The Impact of Peer Management on Test-Ordering Behavior

3 August 2004 | Volume 141 Issue 3 | Pages 196-204

Background: Laboratory testing of hospitalized patients, although essential, can be expensive and sometimes excessive. Attempts to reduce unnecessary testing have often been difficult to implement or sustain.

Objective: Use of peer management through a resource utilization committee (RUC) to favorably modify test-ordering behavior in a large academic medical center.

Design: Interrupted time-series study.

Setting: Medical center with inpatient care provider order entry (CPOE) system and database of ordered tests.

Participants: Predominantly housestaff physicians but all clinical staff (attending physicians, housestaff, medical students, nurses, advance practice nurses, and other clinical staff) at Vanderbilt University Hospital who used CPOE systems.

Intervention: The RUC analyzed the ordering habits of providers during previous years and made 2 interventions by modifying software for the CPOE system. The committee first initiated a daily prompt in the system that asked providers whether they wanted to discontinue tests scheduled beyond 72 hours. After evaluating this first intervention, the committee further constrained testing options by unbundling serum metabolic panel tests (sodium, potassium, chloride, bicarbonate, glucose, blood urea nitrogen, and creatinine tests) into single components and by reducing the ease of repeating targeted tests (including electrolyte, blood urea nitrogen, creatinine, and glucose tests; electrocardiography; and portable chest radiography).

Measurements: Pre- and postintervention volumes of tests; proportion of patients with abnormal targeted chemistry levels after 48 hours; rates of repeated admission, transfer to intensive care units, and mortality; adjusted coefficient of variation for test ordering; and length of stay.

Results: Voluntary reduction of testing beyond 72 hours (first intervention) decreased orders for metabolic panel component tests by 24% (P = 0.02) and electrocardiograms by 57% (P = 0.006) but not orders for portable chest radiographs. Prospective constraints on recurrent test ordering with panel unbundling (second intervention) produced an additional decrease of 51% for metabolic panel component tests (P < 0.001) and 16% for portable chest radiographs (P = 0.03). Incidence of patients with abnormal targeted blood chemistry levels after 48 hours decreased after the intervention (P = 0.02). Postintervention-adjusted coefficients of variation decreased for metabolic panel component tests (P = 0.03) and electrocardiography (P = 0.04). Rates of (adjusted) monthly readmission, transfers to intensive care units, hospital length of stay, and mortality were unchanged.

Limitations: Other activities occurring during the time period of the interventions might have influenced some test-ordering behaviors, and we assessed effects on only a limited number of commonly ordered tests.

Conclusions: Peer management reduced provider variability by addressing the imperfect ability of clinicians to rescind testing in a timely manner. Hospitals with growing health care costs can improve their resource utilization through peer management of testing behaviors by using CPOE systems.

*For a list of members of the Resource Utilization Committee, see Appendix.

Editors' Notes Context Can simple electronic aids help physicians reduce unnecessary, costly test ordering? Contribution In this interrupted time-series study from a large academic hospital, a committee of peer leaders selected ways to use their care provider order entry (CPOE) system to reduce unnecessary test ordering. Computer prompts questioning repetitive orders for routine tests and unbundling of tests within metabolic panel tests both reduced test orders. Patient readmission rates, length of stay, transfer to intensive care units, and mortality rates remained stable. Implications Peer-designed interventions using CPOE systems can improve provider test-ordering behavior. –The Editors

 

Author and Article Information

From Vanderbilt University School of Medicine, Nashville, Tennessee.

Acknowledgments: The authors thank Dale Plummer Jr. for his extensive help with the statistical analyses.

Grant Support: By the Vanderbilt-Ingram Cancer Center biostatistics core through the National Cancer Institute Cancer Center (grants P30 CA-68485 and CA-50468) (Dr. Dupont) and by the National Library of Medicine (LM-06226) (Dr. Miller).

Potential Financial Conflicts of Interest:Consultancies: S.T. Rosenbloom (McKesson); Honoraria: R.A. Miller (Vanderbilt University); Royalties: D. Talbert (Vanderbilt University), D.A. Giuse (Vanderbilt University), R.A. Miller (Vanderbilt University).

Requests for Single Reprints: Eric G. Neilson, MD, Department of Medicine, Vanderbilt University School of Medicine, D-3100 Medical Center North, 21st Avenue South and Garland Avenue, Nashville, TN 37232; e-mail, eric.neilson{at}vanderbilt.edu.

Current Author Addresses: Drs. Neilson and Kaiser: Department of Medicine, Vanderbilt University School of Medicine, D-3100 Medical Center North, 21st Avenue South and Garland Avenue, Nashville, TN 37232-2358.

Drs. Miller and Giuse: Department of Biomedical Informatics, Vanderbilt University School of Medicine, 2209 Garland Avenue, Lower Level Eskind Biomedical Library, Nashville, TN 37232-8340.

Dr. Dupont: Department of Biostatistics, Vanderbilt University School of Medicine, 21st Avenue South and Garland Avenue, S-2323 Medical Center North, Nashville, TN 37232-2158.

Drs. Johnson and Rosenbloom: Departments of Biomedical Informatics and Pediatrics, Vanderbilt University School of Medicine, 2209 Garland Avenue, 402 Eskind Biomedical Library, Nashville, TN 37232-8340.

Dr. Talbert: Department of Computer Science, Software Automation and Intelligence Lab, Tennessee Technological University, PO Box 5101, Cookeville, TN 38505.

Author Contributions: Conception and design: E.G. Neilson, S.T. Rosenbloom, R.A. Miller.

Analysis and interpretation of the data: E.G. Neilson, K.B. Johnson, S.T. Rosenbloom, W.D. Dupont, A. Kaiser, R.A. Miller.

Drafting of the article: E.G. Neilson, K.B. Johnson, S.T. Rosenbloom, W.D. Dupont, R.A. Miller.

Critical revision of the article for important intellectual content: E.G. Neilson, K.B. Johnson, W.D. Dupont, D.A. Giuse, A. Kaiser, R.A. Miller.

Final approval of the article: E.G. Neilson, K.B. Johnson, S.T. Rosenbloom, W.D. Dupont, D. Talbert, D.A. Giuse, A. Kaiser, R.A. Miller.

Provision of study materials or patients: D.A. Giuse.

Statistical expertise: K.B. Johnson, S.T. Rosenbloom, W.D. Dupont.

Administrative, technical, or logistic support: D. Talbert.

Collection and assembly of data: E.G. Neilson, S.T. Rosenbloom, D. Talbert, D.A. Giuse, A. Kaiser, R.A. Miller.