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Residents Save $2M By Eliminating Needless Lab Tests

 |  By John Commins  
   October 21, 2013

Having noticed that "the majority of tests we were ordering… really didn't impact the day-to-day care," a group of neurosurgery residents identified five lab tests that could be eliminated without affecting patient safety. They generated nearly $2 million in savings, including $75,000 in direct costs for their medical center.

 


Seunggu J. Han, MD, is a neurosurgeon
at UCSF

Neurosurgery residents at the University of California San Francisco Medical Center have demonstrated that a reduction by nearly 50% in the use of five common lab tests has no effect on patient care. The reductions generated $1.7 million in savings for payers in fiscal 2011–12, and another $75,000 in decreased direct costs for the medical center, according to a study in Journal of Neurosurgery.

In the one year before the project, the residents identified 45,023 of tests for serum levels of total calcium, ionized calcium, chloride, magnesium, and phosphorus in the neurosurgical service. In fiscal year 2011–2012, this number was reduced 47% to 23,660. The residents' findings were part of an in-house initiative at UCSF that encourages clinicians to identify department-specific cost savings and quality improvements in care delivery.

Seunggu J. Han, MD, a lead researcher among the 18 residents in the project and a neurological surgeon with UCSF, says it makes sense that residents would lead cost savings and quality initiatives because they're often the front-line clinicians with the most contact with patients.

"As a group of residents, we picked up that the majority of tests we were ordering on the neurosurgery service really didn't impact the day-to-day care," Han says. "No clinical decisions were made based on those lab results, whether they were normal or not. The patient's care would not have changed at all whether we had done that test or not. That was the case particularly with those lab tests that we identified."

Han says the high numbers of tests were conducted because UCSF is a high-volume tertiary referral center for neurology that sees more than 2,000 patients a year, many of whom are housed in the intensive care unit, where the assumption is that they are critically ill.

"They are in some ways [critically ill], but probably not in the typical ways that a medicine patient in the ICU would be. They don't tend to have the same gamut of medical problems that the typical internal medicine service would see," he said.

"There is a habit in the ICU setting to order a lot of labs and daily labs just to see if anything is abnormal because there is this assumption that these patients are critically ill and any number of these lab tests can go wrong at any point."

"We were looking at the numbers of labs that we were actually ordering on the service and it is quite an astounding number as a product of the ICU as well as the sheer number of patients that we actually see on the service. You can imagine that compounded with a three-day ICU stay for the typical patient who is getting daily labs. That adds up to be quite a large number," Han said.

The residents worked with an internist who coordinated care with the neurologists and they identified the typical neurology patient and the standard lab tests they'd ordered. Han says they found that the five tests they most frequently ordered came back with normal results "the vast majority of the time. Not only that, but the times they were abnormal we had a very good reason why it was expected and it didn't impact our clinical care. We identified that as a potential area where we could make a significant impact in reducing the lab tests."

Criteria for testing and quality metrics set
Han says the residents weighed the safety of the patient against the need for a test. They didn't want patient care to suffer for lack of a diagnosis. "We were being careful about ordering it on everybody, to really be smarter about who we are ordering it for and almost predicting based on the patients past medical history and their current medical condition who are the patients we should be ordering for and who has the higher likelihood of an abnormal test."

"We met with our hospitalist group and came up with criteria. If the patient meets this criteria that would be the only scenario where would order these tests. We also monitor and have a quality and safety review board that follows all of the general outcomes of these patients including readmission rates and length of hospitalization and length of time in the ICU. Those quality metrics that we followed over time hadn't changed at all throughout this period where we were implementing the new policy of reduced lab orders. We were reassured that we actually had not diminished the quality of the care that we were providing. We didn't see higher rates of complications because a lab test was missed or failed to be ordered or failed to detect an abnormal test."

High expectations vs. unknown factors
While reducing the tests by 47% is an impressive achievement, Han and his fellow residents had pledged to reduce that amount by 50%. "We were just shy of that 50% reduction and the lesson we learned was that it is hard to make changes like this. When you set a goal that takes a lot of effort and foresight and when you are trying to implement these goals there are a lot of unknown elements that you don't always know about going forward," Han says.

"As a group of residents, one of the unknown factors we encountered was there were a lot of lab orders that we don't have control over. On our service the anesthesiologists help us take care of the patients and have the ordering privileges to order any kind of labs on their patients that they deemed appropriate around the operative and perioperative care settings. All the labs they ordered in some ways counted against us but they certainly felt it was an important part of the care so we never argued. That was probably what was included still in that group of 53% of tests that were still being ordered."

Even though they generated nearly $2 million in savings, including the $75,000 in direct costs for the medical center, the residents were not awarded the $400 prize from UCSF. Nonetheless, Han says they are all "very proud of our results."

"We were actually surprised that it wound up calculating out to be a fairly large sum of money," he says. "The medical center did thank us for our efforts at the quality retreat for the medical center they gave us the award for the best quality improvement initiative initiated by physicians."

Impact beyond neurosurgery
Han believes the saving generated by the neurosurgical residents can be replicated throughout hospital care delivery, especially if hospital leaders encourage innovation and problem solving.

"Quality improvement and improving the efficiency of the hospital for every kind of service is an ongoing process. There are always areas to be improved upon and the hospital setting is such a large system and such a big machine that there are bound to be inefficiencies and areas where the quality of care being delivered that could be improved," he says.

"It is an important part of the training process, particularly for residents to get an exposure to this process early and having an eye out for recognizing where there are areas of need for quality improvement and really having the awareness of knowing how to implement a project and monitor the progress and carry it through and seeing its results."

John Commins is a content specialist and online news editor for HealthLeaders, a Simplify Compliance brand.

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