Eve Rittenberg

What proportion of common diagnostic tests appear redundant

PURPOSE To identify ancillary tests for which there are criteria defining the earliest interval at which a repeat test might be indicated, to determine how often each test is repeated earlier than these intervals and, if repeated, provides useful information. SUBJECTS AND METHODS We performed a retrospective cohort study of 6,007 adults discharged from a large teaching hospital during a 3-month period in 1991. We measured the proportion of commonly performed diagnostic tests that were redundant, and their associated charges. RESULTS Of the 6,007 patients discharged, 5,289 (88%) had at least one of 12 target tests performed. Overall, 78,798 of the target tests were performed during the study period, of which 22,237 (28%) were repeated earlier than test-specific predefined intervals. This percentage varied substantially by test (range, 2% to 62%). To assess how many early repeats were justified, we performed chart reviews in a random sample stratified by test. For two tests, nearly all the initial results in the sample were abnormal, and all repeats were considered justified. Of early repeats following a normal initial result for the remaining 10 tests, chart review found no clinical indication for 92%, and a weighted mean of 40% appeared redundant. Overall, 8.6% of these 10 tests appeared redundant; if these were not performed, the annual charge reductions would be

A randomized trial of a computer-based intervention to reduce utilization of redundant laboratory tests

930,000 at our hospital, although the impact on costs would be much smaller. CONCLUSIONS For some tests, an important proportion are repeated too early to provide useful clinical information. Most such tests might be eliminated using computerized reminder systems.

Improving Response to Critical Laboratory Results with Automation: Results of a Randomized Controlled Trial

PURPOSE To determine the impact of giving physicians computerized reminders about apparently redundant clinical laboratory tests. SUBJECTS AND METHODS We performed a prospective randomized controlled trial that included all inpatients at a large teaching hospital during a 15-week period. The intervention consisted of computerized reminders at the time a test was ordered that appeared to be redundant. Main outcome measures were the proportions of clinical laboratory orders that were canceled and the proportion of the tests that were actually performed. RESULTS During the study period, there were 939 apparently redundant laboratory tests among the 77,609 study tests that were ordered among the intervention (n = 5,700 patients) and control (n = 5,886 patients) groups. In the intervention group, 69% (300 of 437) of tests were canceled in response to reminders. Of 137 overrides, 41% appeared to be justified based on chart review. In the control group, 51% of ordered redundant tests were performed, whereas in the intervention group only 27% of ordered redundant tests were performed (P <0.001). However, the estimated annual savings in laboratory charges was only

How promptly are inpatients treated for critical laboratory results

35,000. This occurred because only 44% of redundant tests performed had computer orders, because only half the computer orders were screened for redundancy, and because almost one-third of the reminders were overridden. CONCLUSIONS Reminders about orders for apparently redundant laboratory tests were effective when delivered. However, the overall effect was limited because many tests were performed without corresponding computer orders, and many orders were not screened for redundancy.

Gender and Utilization of Ancillary Services

Objective: To evaluate the effect of an automatic alerting system on the time until treatment is ordered for patients with critical laboratory results. Design: Prospective randomized controlled trial. Intervention: A computer system to detect critical conditions and automatically notify the responsible physician via the hospitals paging system. Patients: Medical and surgical inpatients at a large academic medical center. One two-month study period for each service. Main outcomes: Interval from when a critical result was available for review until an appropriate treatment was ordered. Secondary outcomes were the time until the critical condition resolved and the frequency of adverse events. Methods: The alerting system looked for 12 conditions involving laboratory results and medications. For intervention patients, the covering physician was automatically notified about the presence of the results. For control patients, no automatic notification was made. Chart review was performed to determine the outcomes. Results: After exclusions, 192 alerting situations (94 interventions, 98 controls) were analyzed. The intervention group had a 38 percent shorter median time interval (1.0 hours vs. 1.6 hours, P = 0.003; mean, 4.1 vs. 4.6 hours, P = 0.003) until an appropriate treatment was ordered. The time until the alerting condition resolved was less in the intervention group (median, 8.4 hours vs. 8.9 hours, P = 0.11; mean, 14.4 hours vs. 20.2 hours, P = 0.11), although these results did not achieve statistical significance. The impact of the intervention was more pronounced for alerts that did not meet the laboratorys critical reporting criteria. There was no significant difference between the two groups in the number of adverse events. Conclusion: An automatic alerting system reduced the time until an appropriate treatment was ordered for patients who had critical laboratory results. Information technologies that facilitate the transmission of important patient data can potentially improve the quality of care.

Trauma-Informed Care — Reflections of a Primary Care Doctor in the Week of the Kavanaugh Hearing

OBJECTIVE The purpose of the study is to determine how frequently critical laboratory results (CLRs) occur and how rapidly they are acted upon. A CLR was defined as a result that met either the critical reporting criteria used by the laboratory at Brigham and Womens Hospital or other, more complex criteria. DESIGN This is a retrospective cohort study in a large academic tertiary-care hospital. MEASUREMENTS The proportion of chemistry and hematology results obtained in a 13-day period that met the hospital laboratorys critical reporting criteria were calculated. The charts of a stratified random sample of patients with CLRs due to sodium, potassium, and glucose were reviewed to determine the time interval until an appropriate treatment was ordered and the time interval until the critical condition was resolved. RESULTS In 13 days, 1938 of 201,037 laboratory results (0.96%, or 0.44 per patient-day) met the hospitals critical reporting criteria. In the chart review, 222 CLRs were included in the stratified random sample, and 99 of these met the inclusion criteria. Among these 99 CLRs, the median time interval until an appropriate treatment was ordered was 2.5 hours. This interval was 1.8 hours when the CLR met the laboratorys criteria and a phone call was made, and 2.8 hours when the CLR met more complex criteria not requiring a phone call (p = 0.07). For 27 (27%) of the CLRs, an appropriate treatment was ordered only after five or more hours. The median time until the condition resolved was 14.3 hours: 12.0 hours for CLRs that met the hospitals criteria and 20.9 hours for the CLRs that met the more complex criteria (p = 0.006). CONCLUSION Although CLRs meeting the hospitals criteria were reported promptly by the laboratory, treatment delays were still common. Results that did not meet the hospitals critical criteria but still represented serious clinical situations were more often associated with treatment delays. Difficulty communicating critical results directly to the responsible caregiver is the likely cause of some delays in treatment. New communications methods, including computer-based technologies, should be explored and tested for their potential to reduce treatment delays and improve clinical care.

Identifying adverse drug events: development of a computer-based monitor and comparison with chart review and stimulated voluntary report.

OBJECTIVE: To determine whether gender is associated with the use of ancillary services in hospitalized patients.DESIGN: A retrospective study of laboratory and radiology tests ordered for medical and surgical inpatients over 16-month and 20-month periods, respectively. Obstetric patients were excluded.MEASUREMENTS AND MAIN RESULTS: Number of clinical laboratory and radiology tests per admission, their associated charges, and total charges per admission were measured. In crude analyses, women had 16.5% fewer clinical laboratory tests (p < .0001) with 18.8% lower associated charges (p < .0001) and 24.4% fewer radiology tests (p < .0001) with 15.6% lower associated charges (p < .0001) than men. Total changes for the admission were lower for women in both the clinical laboratory study period (

Identifying hospital admissions due to adverse drug events using a computer-based monitor.

16,178 vs

Predicting Clostridium difficile Stool Cytotoxin Results in Hospitalized Patients with Diarrhea

18,912, p < .0001) and the radiology study period (

Reminders for Redundant Tests: Results of a Randomized Controlled Trial.

14,621 vs