Improving Cost and Quality By Using New Approach to Common Blood Tests

From the FieldBy Mark Safalow, MD, FHM
Hospitalist and Physician Advisor at Middlesex Hospital

From the Field is a series of guest blogs that offer perspectives from those working in the health care field.

blood.PNGHealthcare is changing, and we can all sense it and feel it.  It is not only the elephant sitting in the room, but the one that is perched on the roof of the hospital.   As providers, we know it is there.  The roof bows in, but we often choose not to look.

However, change is pervasive. It is unavoidable. Those who ignore to see that elephant just above them will not survive in the current healthcare environment.

The biggest metamorphosis is in the form of value based careWe, as a nation, are transitioning from fee-for-volume and service to fee-for-value and quality.  Reimbursement is affected, and Medicare dollars are at stake. Hospitals and private offices will survive by accepting these changes.  This is a win-win situation, as it benefits patients by improving quality, and also benefits the healthcare system by decreasing cost and the overall burden that cannot be sustained.

For example, spending more money on healthcare and ordering more tests does not equal better quality care. And that’s where I come in as a Hospitalist and Physician Advisor at Middlesex Hospital. It made perfect sense to implement an important quality improvement project to our institution.  The elephant was there, but providers were myopic. So I decided to bring Choosing Wisely to Middlesex.

The Choosing Wisely Campaign is a national movement. For those of us practitioners who receive multiple journals on a weekly basis, it is near impossible to not see an article pertaining to Choosing Wisely.  Articles may use the words, “waste in medicine” or “things we do for no reason,” but they are all essentially about making sound medical choices.

Some practitioners still living in a box may not have heard of Choosing Wisely, but they are certainly aware of the waste in medicine and the lack of communication between providers and patients.  Most also know the statistics: One third of tests and interventions ordered are not medically necessary, and in fact, may cause harm. 

To me, this number is mind-blowing. To think that one out of every three of my orders may be unnecessary. Even, as I write this blog, a Cleveland Clinical Journal of Medicine that just came in the mail has a feature article titled, “Are We Causing Anemia By Ordering Unnecessary Blood Tests.”

This is an area where we are making some extraordinary changes and Middlesex Hospital. In March of 2015, I heard a group from Vanderbilt discuss their success with reducing daily blood work.  They improved patient satisfaction and safety, and drove down cost.  It was a compelling lecture, and it was my motivation to bringing this campaign to Middlesex Hospital.

Being the voice of change was not easy, and there were some bumps along the road.  In my naiveté, I had assumed that we would be up and running within a couple of months.  Of course, this is a hospital, and nothing happens that quickly.

So after discussions with the Connecticut Choosing Wisely Collaborative, meetings with administrators and providers, and multiple committee and subcommittee meetings, our campaign went live in November of 2015.

We began our campaign focusing on reducing common daily blood tests, specifically, CBC, BMP, and CMP.   Once this was decided upon, with the assistance of our IT and statistics department, we obtained a baseline, specifically, the number of these common lab tests ordered per patient, per day, per hospitalist. 

The average prior to initiating the campaign was 1.27.  With aggressive education, via emails, live lectures, and flyers by each computer on the medical floors, that number was driven down to 1.05 after 15 weeks, or a 17% drop from baseline.

Providers were starting to ask themselves important questions: Is this test necessary? Will this test change my management? Will this test lead to more unnecessary tests? 

Providers and patients were collaborating, and the results showed.  After 15 weeks, a lab alert was created reminding providers if a CBC was ordered even if there was no significant change from the prior day.  And yes, we were sensitive to alert fatigue, but after two weeks of this alert, the number of tests ordered per patient, per day dropped to 0.75, or a 41% drop from baseline.

We have now been sustained at a 50% drop from baseline.  This has been accomplished with the hard work from multiple people, from providers to IT folks to the marketing department.  Hospitalists now receive transparent report cards demonstrating their baseline number and their current number, compared to their peers.  These report cards are to be rolled out soon to our Family Practice residents and then ultimately, to the rest of the medical staff.

I hope that Middlesex Hospital has set an example for other hospitals in Connecticut and the rest of the nation to build a Choosing Wisely Campaign.  Accepting change and letting go of old practices is a challenge, but one that is necessary to move forward. I challenge you to not ignore that giant elephant in the room.

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