The Impact of an Electronic Expensive Test Notification.
TL;DR: Although this passive CDST was passive (ie, could be overridden at the point of order entry) and was associated with a relatively low abandonment rate, it achieved a considerable cost savings each year since each abandoned test saved the institution $1,000 or more.
Abstract: Objectives The impact of clinical decision support tools (CDSTs) that display test cost information has been variable. Methods We retrospectively analyzed the 3-year impact of a passive CDST that notified providers when the test order cost was $1,000 or more. We determined the most common expensive tests ordered, the frequency with which providers abandoned the order after notification, and the costs saved through this intervention. Results The average monthly abandonment rate was 12.5% (2014), 12.9% (2015), and 14.3% (2016). The cost savings from tests not performed for this 3-year period was $696,007. Molecular hematopathology assays were the most frequently ordered tests, with variable abandonment rates. Conclusions Although this CDST was passive (ie, could be overridden at the point of order entry) and was associated with a relatively low abandonment rate, it achieved a considerable cost savings each year since each abandoned test saved the institution $1,000 or more.
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Journal Article•
TL;DR: In the majority of studies, charge information changed ordering and prescribing behavior as mentioned in this paper, but no analysis or synthesis of these studies has been conducted; however, the authors of this paper aim to determine the type and quality of charge display studies that have been published and synthesize this information in the form of a literature review.
Abstract: ABSTRACTBACKGROUNDWhile studies have been published in the last 30 years that examine the effect of charge display during physician decision-making, no analysis or synthesis of these studies has been conducted.OBJECTIVEWe aimed to determine the type and quality of charge display studies that have been published; to synthesize this information in the form of a literature review.METHODSEnglish-language articles published between 1982 and 2013 were identified using MEDLINE, Web of Knowledge, ABI-Inform, and Academic Search Premier. Article titles, abstracts, and text were reviewed for relevancy by two authors. Data were then extracted and subsequently synthesized and analyzed.RESULTSSeventeen articles were identified that fell into two topic categories: the effect of charge display on radiology and laboratory test ordering versus on medication choice. Seven articles were randomized controlled trials, eight were pre-intervention vs. post-intervention studies, and two interventions had a concurrent control and intervention groups, but were not randomized. Twelve studies were conducted in a clinical environment, whereas five were survey studies. Of the nine clinically based interventions that examined test ordering, seven had statistically significant reductions in cost and/or the number of tests ordered. Two of the three clinical studies looking at medication expenditures found significant reductions in cost. In the survey studies, physicians consistently chose fewer tests or lower cost options in the theoretical scenarios presented.CONCLUSIONSIn the majority of studies, charge information changed ordering and prescribing behavior.
51 citations
TL;DR: An overview of the tools available within the EHR to improve decision making throughout the entire laboratory testing process, from test order to clinical action is provided.
16 citations
14 Jan 2020
TL;DR: The transition to a value-based payment system offers pathologists the opportunity to play an increased role in population health by improving outcomes and safety as well as reducing costs.
Abstract: The transition to a value-based payment system offers pathologists the opportunity to play an increased role in population health by improving outcomes and safety as well as reducing costs. Although laboratory testing itself accounts for a small portion of health-care spending, laboratory data have significant downstream effects in patient management as well as diagnosis. Pathologists currently are heavily engaged in precision medicine, use of laboratory and pathology test results (including autopsy data) to reduce diagnostic errors, and play leading roles in diagnostic management teams. Additionally, pathologists can use aggregate laboratory data to monitor the health of populations and improve health-care outcomes for both individual patients and populations. For the profession to thrive, pathologists will need to focus on extending their roles outside the laboratory beyond the traditional role in the analytic phase of testing. This should include leadership in ensuring correct ordering and interpretation of laboratory testing and leadership in population health programs. Pathologists in training will need to learn key concepts in informatics and data analytics, health-care economics, public health, implementation science, and health systems science. While these changes may reduce reimbursement for the traditional activities of pathologists, new opportunities arise for value creation and new compensation models. This report reviews these opportunities for pathologist leadership in utilization management, precision medicine, reducing diagnostic errors, and improving health-care outcomes.
14 citations
TL;DR: Clinical decision support tools that involve improving test utilization should be jointly overseen by a laboratory stewardship committee and the hospital informatics team, as well as the associated committees.
4 citations
01 Sep 2020
TL;DR: Findings suggest opportunities exist to better guide ordering practices for respiratory pathogen testing, including limiting repeat testing, with the goal of optimization of clinical yield, and diagnostic stewardship.
Abstract: Background Upper respiratory tract infections are common, and the ability to accurately and rapidly diagnose the causative pathogen has important implications for patient management. Methods We evaluated the test-ordering practices for 2 commonly utilized nucleic acid amplification tests (NAATs) for the detection of respiratory pathogens: the Xpert Flu Assay for influenza A/B (Flu assay) and the Biofire FilmArray respiratory panel assay (RP assay), which detects 20 different targets. Our study examined repeat testing; that is, testing within 7 days from an initial test. Results Our study found that repeat testing is common for each of the individual assays: 3.0% of all Flu assays and 10.0% of all RP assays were repeat testing. Of repeat testing, 8/293 (2.7%) of repeat Flu assays and 75/1257 (6.0%) of RP assays resulted diagnostic gains, i.e., new detections. However, for the RP assay, these new detections were not always clinically actionable. The most frequently discrepant organisms were rhinovirus/enterovirus (28/102, 27.5%), followed by respiratory syncytial virus (12/102, 11.8%) and coronavirus OC43 (11/102, 10.8%). Furthermore, there were 3,336 instances in which a patient was tested using both a Flu assay and RP assay, of which only 44 (1.3%) had discrepant influenza results. Conclusions Our findings suggest opportunities exist to better guide ordering practices for respiratory pathogen testing, including limiting repeat testing, with the goal of optimization of clinical yield, and diagnostic stewardship.
4 citations
Cites background from "The Impact of an Electronic Expensi..."
...(30) demonstrated that a passive clinical decision support tool could prevent some unnecessary testing....
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References
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TL;DR: A differential diagnosis for why physicians do not follow practice guidelines is offered, as well as a rational approach toward improving guideline adherence and a framework for future research are offered.
Abstract: ContextDespite wide promulgation, clinical practice guidelines have had limited
effect on changing physician behavior. Little is known about the process and
factors involved in changing physician practices in response to guidelines.ObjectiveTo review barriers to physician adherence to clinical practice guidelines.Data SourcesWe searched the MEDLINE, Educational Resources Information Center (ERIC),
and HealthSTAR databases (January 1966 to January 1998); bibliographies; textbooks
on health behavior or public health; and references supplied by experts to
find English-language article titles that describe barriers to guideline adherence.Study SelectionOf 5658 articles initially identified, we selected 76 published studies
describing at least 1 barrier to adherence to clinical practice guidelines,
practice parameters, clinical policies, or national consensus statements.
One investigator screened titles to identify candidate articles, then 2 investigators
independently reviewed the texts to exclude articles that did not match the
criteria. Differences were resolved by consensus with a third investigator.Data ExtractionTwo investigators organized barriers to adherence into a framework according
to their effect on physician knowledge, attitudes, or behavior. This organization
was validated by 3 additional investigators.Data SynthesisThe 76 articles included 120 different surveys investigating 293 potential
barriers to physician guideline adherence, including awareness (n = 46), familiarity
(n = 31), agreement (n = 33), self-efficacy (n = 19), outcome expectancy (n
= 8), ability to overcome the inertia of previous practice (n = 14), and absence
of external barriers to perform recommendations (n = 34). The majority of
surveys (70 [58%] of 120) examined only 1 type of barrier.ConclusionsStudies on improving physician guideline adherence may not be generalizable,
since barriers in one setting may not be present in another. Our review offers
a differential diagnosis for why physicians do not follow practice guidelines,
as well as a rational approach toward improving guideline adherence and a
framework for future research.
6,378 citations
"The Impact of an Electronic Expensi..." refers background in this paper
...However, there is general agreement that laboratory testing is overused, provides little clinical utility when ordered without clear indication, and may, in some cases, be detrimental to patient care.(4,5) The elimination of unnecessary testing is a means by which health care systems can reduce cost while improving patient care, patient satisfaction, and quality....
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TL;DR: Michael Porter discusses how to achieve universal coverage in a way that will support, rather than impede, a fundamental reorientation of the delivery system around value for patients.
Abstract: Michael Porter writes that the only way to truly contain costs in health care is to improve outcomes. He discusses how we can achieve universal coverage in a way that will support, rather than impede, a fundamental reorientation of the delivery system around value for patients.
858 citations
"The Impact of an Electronic Expensi..." refers background in this paper
...Increasing emphasis on value-based care encourages health care providers to develop evidence-based, best-practice approaches for patient care that maintain or improve the quality of care while decreasing waste and lowering costs.(1) This shift from volume to value has necessitated a reassessment of all components of medical service lines to ensure that each component provided is truly necessary and contributes to positive patient outcomes....
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Royal Hospital for Women1, Birkbeck, University of London2, University of Oxford3, National Drug and Alcohol Research Centre4, University of New South Wales5, Australian National University6, Canberra Hospital7, Boston Children's Hospital8, Wollongong Hospital9, Illawarra Health & Medical Research Institute10
TL;DR: A neonatal diagnostic code of NAS is strongly associated with poor and deteriorating school performance and parents must be identified early and provided with support to minimize the consequences of poor educational outcomes.
Abstract: BACKGROUND AND OBJECTIVES: Little is known of the long-term, including school, outcomes of children diagnosed with Neonatal abstinence syndrome (NAS) (International Statistical Classification of Disease and Related Problems [10th Edition], Australian Modification, P96.1). METHODS: Linked analysis of health and curriculum-based test data for all children born in the state of New South Wales (NSW), Australia, between 2000 and 2006. Children with NAS (n = 2234) were compared with a control group matched for gestation, socioeconomic status, and gender (n = 4330, control) and with other NSW children (n = 598 265, population) for results on the National Assessment Program: Literacy and Numeracy, in grades 3, 5, and 7. RESULTS: Mean test scores (range 0–1000) for children with NAS were significantly lower in grade 3 (359 vs control: 410 vs population: 421). The deficit was progressive. By grade 7, children with NAS scored lower than other children in grade 5. The risk of not meeting minimum standards was independently associated with NAS (adjusted odds ratio [aOR], 2.5; 95% confidence interval [CI], 2.2–2.7), indigenous status (aOR, 2.2; 95% CI, 2.2–2.3), male gender (aOR, 1.3; 95% CI, 1.3–1.4), and low parental education (aOR, 1.5; 95% CI, 1.1–1.6), with all Ps CONCLUSIONS: A neonatal diagnostic code of NAS is strongly associated with poor and deteriorating school performance. Parental education may decrease the risk of failure. Children with NAS and their families must be identified early and provided with support to minimize the consequences of poor educational outcomes.
219 citations
TL;DR: A committee of peer leaders selected ways to use their care provider order entry (CPOE) system to reduce unnecessary test ordering, and computer prompts questioning repetitive orders for routine tests and unbundling of tests within metabolic panel tests both reduced test orders.
Abstract: The authors studied the effect of a computer-based medical order entry system on unnecessary test ordering. Two strategies reduced test orders: computer prompts that questioned repetitive orders fo...
151 citations
TL;DR: Early results of bundled payments are promising, but preserving access to care for patients with high comorbidity burdens and those requiring more complex care is a lingering concern.
Abstract: The purpose of this review was to evaluate the literature regarding bundle payment reimbursement models for total joint arthroplasty (TJA). From an economic standpoint, TJA are cost-effective, but they represent a substantial expense to the Centers for Medicare & Medicaid Services (CMS). Historically, fee-for-service payment models resulted in highly variable cost and quality. CMS introduced Bundled Payments for Care Improvement (BPCI) in 2012 and subsequently the Comprehensive Care for Joint Replacement (CJR) reimbursement model in 2016 to improve the value of TJA from the perspectives of both CMS and patients, by improving quality via cost control. Early results of bundled payments are promising, but preserving access to care for patients with high comorbidity burdens and those requiring more complex care is a lingering concern. Hospitals, regardless of current participation in bundled payments, should develop care pathways for TJA to maximize efficiency and patient safety.
123 citations
"The Impact of an Electronic Expensi..." refers background in this paper
...The implementation of new legislation (eg, Medicare Access and Chip Reauthorization Act of 2015) and the bundling of payments for particular diagnoses and procedures similarly encourage review of each aspect of the health care delivery process to reduce unnecessary costs while preserving or improving quality.(2,3) The importance of laboratory-based testing for the diagnosis and management of patients is well established....
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