What happened when lab set sights on parasites

Toward that end, Dr. Pritt and her colleagues not only sought clinician input when developing the algorithm, but also launched ongoing education for them. “We’re a large teaching hospital, so we have trainees coming in every year, so it’s going to be a large undertaking,” she said.

Then, too, she had to grapple with the fact that 80 percent of her laboratory’s intestinal parasite testing volume comes from reference lab clients: “So that’s going to be a big challenge.” She addressed it by attempting to educate the laboratorians at the outside labs, releasing an educational bulletin, a 30-minute educational video, and finally a live televised 60-minute educational program. The result? “Our volumes [of ova-and-parasite testing] actually went up to higher than they had ever been,” she said. Rather than help physicians be more selective in placing specific orders for intestinal parasites, it appears “the educational efforts only served to increase awareness of intestinal parasites and prompt more orders.”

Her conclusion: “Educational efforts are not enough by themselves to sufficiently change ordering practices.” That’s probably for a number of reasons, she said. “We’re not reaching the right people, habits and patterns are hard to break, and every year there’s a regular influx of new trainees and clinicians, not just at my institution but at all of those outreach institutions.” In addition, education is time-consuming. “It’s a lot of effort, and the yield isn’t necessarily sustainable after that initial educational impact. And it turns out, we are not the first persons to see this,” she said, pointing to a 1984 study (Schroeder SA, et al. The failure of physician education as a cost containment strategy. JAMA. 1984;252:225–230).

Fortunately, the literature also held a potential solution: giving clinicians monthly feedback comparing their test-ordering practices with those of their peers, in conjunction with educational efforts resembling those Dr. Pritt had tried. In a 1990 study, doing so resulted in inappropriate test ordering volume falling by at least one-fifth during the intervention period, a reduction that persisted for two years (Bareford D, Hayling A. Inappropriate use of laboratory services: long term combined approach to modify request patterns. BMJ. 1990;301:1305–1307).

“No one ever wants to be the person who isn’t following the guidelines, or isn’t performing up to an expected level,” Dr. Pritt said. “So this actually was pretty powerful. And what I thought was interesting from this paper is they actually said that most of the people, up to a third of the trainees, didn’t even attend the educational conferences, and some of them didn’t even know the algorithms were available. So without the algorithm, without the education, that puts it mostly on the peer feedback that must’ve been driving a lot of this decrease they saw.”

And so, Dr. Pritt said, she and her colleagues planned to begin providing peer performance data in addition to making changes to their test-ordering systems, beginning with the outpatient system that Mayo clinicians use. First, “We’ve tried to put common procedures on the top and additional procedures at the bottom, with the thought that people might be more likely to order the Cryptosporidium and Giardia instead of the parasitic examination [which is lower].”
Second, “I’m going to group these two tests together under the heading of ‘fecal parasite screen for diarrhea,’” she said. “I think people like screens. They like that terminology. It makes them think that’s the first test they should use.” Finally, “We’re now going to say, ‘See guide for testing algorithm,’ with the guide being on the left-hand bar.”

This is a relatively straightforward change to the ordering system, she notes. A more aggressive approach to changing the ordering system with potentially larger impact is to require the ordering clinician to fill in boxes indicating whether the patient has any risk factors for intestinal parasites other than Cryptosporidium or Giardia before allowing them to place an order for the ova-and-parasite exam. She has decided not to pursue this option because of the complexity of parasite risk factors. But “requiring certain pieces of information can be very helpful in other types of tests such as coagulation cascades, in which medication history may be essential for accurate interpretation,” she says.

Dr. Pritt acknowledges that many labs do not have strong IT support and the staff it takes to change an ordering system, and thus she cites other possibilities for the laboratory to gain some control over test ordering: Remove a test from the ordering system altogether (if demographically appropriate) or require a specialist’s approval for testing.

“Now, I think my infectious disease physicians would probably boycott me and protest if I had them approve every single ova-and-parasite test, since it is a high-volume test ordered by family physicians, internal medicine, ED physicians, a whole spectrum of people,” she said. “But again, extrapolating this idea to other areas of the laboratory, I think this could be very appropriate for some special genetics tests, for example.” Small labs might also consider having trainees review every request for an ova-and-parasite test. “Have them call the clinician or look up the medical record, and even cancel at that point if it’s not appropriate.”

Contacted in February, Dr. Pritt said that after making changes to the test-ordering system last August, the laboratory saw an immediate drop in ova-and-parasite test orders. “September is usually our peak volume, but from August to September, we saw our monthly volumes decrease by 100 orders per month, for a total 30 percent decrease compared with volumes seen in September 2011,” she told CAP TODAY. (The peer performance feedback program has not yet been fully rolled out.) She calls the initial results encouraging but says they will monitor to see if the trend is sustained.

The key lesson she learned? “Education is a logical choice. It’s what most of us think of when we want to make a change. We say, ‘Let’s go out and educate everyone.’ It might be easy for a small group, and it might have good short-term impact, but overall it’s probably going to have limited impact and limited long-term staying power.” Instead, she said, education needs to be part of a larger, planned, multipronged approach.

Anne Ford is a writer in Evanston, Ill.