SALT LAKE CITY - Anyone who's spent a night in a hospital knows the drill: In comes a phlebotomist, 早上的第一件事, 用于实验室测试. Physicians have long recognized that lab testing isn't necessary for all hospitalized patients on a daily basis. Regardless, such tests are often conducted because of routine.
A new paper, authored by University of Utah hospitalists and published in the 医院医学杂志, outlines how the 500-bed academic medical center used a tool developed at the University, 价值驱动成果（VDO）, 减少多余的实验室测试, 这很贵, doesn't improve health outcomes and can harm patients.
“经常, 病人每天早上都需要化验, but that can create a culture where you're ordering tests without really thinking about what you're going to do with the results,第一作者说 Peter Yarbrough, m.s.D., an assistant professor of internal medicine who practices at the VA Salt Lake City Health Care System.
When the VDO tool was used as a part of a multi-faceted quality improvement initiative, 每天订购的测试数量下降了, decreasing lab costs by nearly 10 percent per patient visit. If the approach were applied to all inpatient visits, it was estimated the hospital could potentially save over $1.每年500万.
"The novelty of it is that it's so simple and it could potentially be widely disseminated,资深作家说 Kensaku Kawamoto， M.D., Ph.D., M.H.S.她是生物医学信息学助理教授.
Unnecessary lab testing contributes to the estimated $910 billion wasted each year in U.S. 卫生保健. Beyond costs, lab testing is an important patient safety issue. The sheer number of tests ordered can lead to incidental findings that result in unnecessary follow-up testing and potentially harmful interventions, and early morning blood draws can prevent much needed rest. Vulnerable patients can even develop anemia and associated complications from over-testing.
Yarbrough， Kawamoto和合著者德文·霍顿， M.D.Karli Edholm, m.s.D.波琳娜五世. Kukhareva, M.S., M.P.H. describe in the new paper a 15-month intervention launched in 2013 to address this problem of unnecessary laboratory testing. 当时, 大学刚刚发展了VDO, which allows providers to understand the costs of 卫生保健 by providing actual cost data down to the patient level.
"Prior to VDO, we never had cost information,亚伯勒说. “你所拥有的一切都是指控, and charges are very difficult to interpret as far as how much things really cost."
使用VDO, Yarbrough discovered that lab testing was costing University Hospital about $2 million a year just among patients cared for by hospitalists, who are internal medicine physicians specializing in the care of acutely ill hospitalized patients.
"That number was impressive to me because I saw just how much the common routine tests could add up,亚伯勒说. “大多数测试的成本都不高, but their numbers were so high that the total cost became significant."
With the ultimate goal of changing the culture of routine test ordering into a thoughtful process, a working group analyzed workflows to determine how lab tests were ordered. 有趣的是, they found that it's often one of the least experienced members of the care team, 实习生, 医院里谁负责安排检查.
"The literature would say that 实习生 on the team actually has the greatest influence on what lab tests are ordered and what aren't,亚伯勒说.
The group looked at efforts that had been successful at other institutions and opted to incorporate multiple approaches into a single intervention to determine if the combination would be sustainable. Rounding processes were standardized to include a checklist review for all patients that ensured discussion of labs, 遥测, 疼痛, 中央线, 护理存在, 需要与家人沟通并随访. Decisions about lab tests had to be discussed with more senior members of the team. Third-year medical students were responsible for ensuring that all items were covered daily for each patient.
The results of the interventions over a 15-month period were tangible. 干预组6人,310 hospitalist patient visits were compared to a control group of 25,586次非医院就诊. The interventions reduced the mean cost per day for laboratory testing from $138 to $123 and the mean cost per visit decreased from $618 to $558. There was also a significant reduction in laboratory cost per day, 每次就诊化验室费用, 以及每天的测试次数.
"As we look at how we can conserve our resources as a nation and improve the value that we provide with 卫生保健, it's imperative for us to help get professionals in 卫生保健 systems to be good stewards of resources and to avoid unnecessary diagnostics and interventions,川本说.
The hospitalists continue to use the checklist system, and they consider routine VDO data essential to know how they are doing with lab costs.
"It's one thing to tell somebody that they're ordering too many tests, it's another to quantify it and put dollars and cents to their activity,川本说. "Having the VDO tool allowed for timely feedback to be provided to physicians so they know how they're doing."
“包括教育在内的多方面干预, 舍入检查表实现, 成本反馈, and Financial Incentives Reduces Inpatient Laboratory Costs" by Peter Yarbrough, 波琳娜Kukhareva, 德文·霍顿, Karli Edholm, and Kensaku Kawamoto will be published online in the 医院医学杂志 2016年2月4日