Background: Routine inpatient laboratory testing is a well-recognized area of healthcare waste and was highlighted by the American Board of Internal Medicine Choosing Wisely campaign as a practice that should be questioned. Multifaceted quality improvement interventions, especially those that incorporate interventions beyond education, are more successful at achieving sustainable change.
Study design: Retrospective, controlled, interrupted time series study.
Setting: University of Utah, academic general internal medicine hospitalist service.
Synopsis: The intervention group, a teaching hospitalist service, received targeted education, cost feedback comparing individual provider performance, and divisional financial incentives. Additionally, a standardized rounding checklist was implemented and completed by rotating medical students. The control group included all non-hospitalist services. Approximately 20% of the 31,896 encounters measured in pre-intervention and post-intervention periods took place in the intervention group. Lab cost per day was reduced from $138 to $123 in the intervention group (P<0.001), while cost per day was non-significantly increased in the control group from $130 to $132 (P=0.37). Limitations of this study include the fact that the University of Utah already prioritizes high-value care and utilizes a local tool to provide individual cost and ordering feedback to providers as well as the financial incentives. Additionally, the use of medical students to implement the rounding checklist may not be feasible in many practice settings.
Bottom line: An approach of targeted education, direct provider feedback, consistent use of a rounding checklist, and financial incentives may decrease lab utilization.
Citation: Yarbrough PM, Kukhareva PV, Horton D, Edholm K, Kawamoto K. Multifaceted intervention including education, rounding checklist implementation, cost feedback, and financial incentives reduces inpatient laboratory costs [published online ahead of print February 4, 2016]. J Hosp Med. doi:10.1002/jhm.2552.
aVL ST-Depression Differentiates Inferior Stemi from Pericarditis
This retrospective analysis showed that any aVL ST-depression helps to distinguish inferior myocardial infarctions from pericarditis.
Citation: Bischof JE, Worrall C, Thompson P, Marti D, Smith SW. ST depression in lead aVL differentiates inferior ST-elevation myocardial infarction from pericarditis. Am J Emerg Med. 2016;34(2):149-154.