Clinical pathology selected abstracts

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Editor: Deborah Sesok-Pizzini, MD, MBA, chief medical officer, Labcorp Diagnostics, Burlington, NC, and adjunct professor, Department of Clinical Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia.

Evaluation of a laboratory stewardship intervention targeted at cardiac and thoracic surgical services

November 2023—Among the many reasons unnecessary laboratory tests are ordered in a hospital are preselected orders on order sets, clinician habits, and trainee concerns. Laboratory tests are among the highest volume procedures performed in inpatient hospital care. Excessive use of these tests can lead to patient discomfort as a result of unnecessary phlebotomy and contribute to iatrogenic anemia and increased risk of bloodstream infections. It can also contribute to the rising cost of medical care. Many laboratory stewardship programs have been developed to improve how clinicians order and use lab tests. These efforts often focus on modifying the computerized provider order-entry (CPOE) system and can be used in conjunction with education and feedback to drive change. This approach is particularly appealing for academic medical centers seeking to illustrate the importance of delivering high-value care while reducing unnecessary laboratory use. The authors conducted a study in which they selected the thoracic and cardiac surgery service lines at an academic quaternary care hospital, both of which have high levels of laboratory use, for a multilevel laboratory stewardship intervention to decrease unnecessary lab testing. They designed a multilevel intervention for the study that included five components: stakeholder engagement, provider education, CPOE modification, performance feedback, and culture change supported by leadership. The primary outcome of the study was laboratory tests ordered per patient day. The secondary outcomes were number of blood draws per patient day, total lab-associated costs, length of stay, discharge to a nursing facility, 30-day readmission, and death. A difference-in-difference analytic approach was employed to evaluate the outcome measures in the intervention period. Other surgical services were used as controls. For the primary outcome of laboratory tests ordered per patient day, the authors found that 1.5 to two fewer tests were ordered per patient day for the thoracic and cardiac surgery services, and an estimated 20,000 fewer tests were performed during the intervention period. Of interest, blood draws per patient day decreased significantly on the thoracic surgery service but not on the cardiac surgery service. Furthermore, lengths of stay, deaths, and 30-day readmissions did not change significantly across services in the postintervention period, suggesting that the interventions did not have a measurable adverse impact on patient outcomes. The authors concluded that a multilevel intervention based on stakeholder engagement, provider education, CPOE modification, performance feedback, and deliberate culture change improves laboratory test ordering across thoracic and cardiac surgery services. They noted that a partnership between laboratory and clinical services that order high volumes of lab tests can be an effective strategy for developing a robust laboratory stewardship program.

Mathias PC, Khor S, Harris K, et al. Evaluation of a multilevel laboratory stewardship intervention targeted to cardiac and thoracic surgical services at an academic medical center. Arch Pathol Lab Med. 2023;147:957–963.

Correspondence: Dr. Patrick C. Mathias at pcm10@uw.edu