August 6, 2004

VUMC reduces high-volume diagnostic tests

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Eric G. Neilson, M.D.

VUMC reduces high-volume diagnostic tests

A new study from Vanderbilt University Medical Center sets out a recipe for eliminating a large percentage of inpatient diagnostic testing.

A committee of physician leaders and clinical experts at VUMC has found a safe, simple and relatively painless method for reducing excessive use of high-volume laboratory, radiology and cardiology tests. The dramatic findings were published Monday in the Annals of Internal Medicine.

With health care costs rapidly on the rise, clinicians, insurance companies and policy makers are looking for ways to rid unnecessary costs from the system while maintaining or improving quality and safety.

VUMC pioneer achievements in biomedical informatics have helped put the Medical Center at the forefront of the search for ways to reduce unwanted physician practice variability and excessive use of clinical resources, said the study’s senior author, Eric G. Neilson, M.D., chair of the department of Medicine.

“We’re facing an economic crisis in health care, and payers — insurers, employers, and government — are getting pretty fed up with levels of spending at the bedside,” Neilson said. “Either we’ll do more to manage spending ourselves, or someone will place restrictions on our ability to apply resources to solve patient problems; either way, it’s going to happen. The goal is to do the right thing and only the right thing in patient care. It sounds easy but it isn’t.”

Excessive fear of uncertainty, a litigious society, and want of experience head a long list of causes contributing to the endemic over-use of inpatient diagnostic tests, Neilson said. Researchers have even identified a test addiction disorder among some physicians.

In the mid 1990s, Vanderbilt developed a computer program, called WizOrder, to support clinical decision-making in the hospital. Clinicians use the program to order patient tests and treatments; the program applies clinical logic to issue alerts against any orders that appear unsafe or otherwise inappropriate. The program also furnishes tips about best practice and links to more in-depth presentations of evidence.

Headed by Neilson, the VUMC Resource Utilization Committee pools expertise from across VUMC in a search for ways to reduce excessive use of clinical resources. They’ve focused on WizOrder as a means of influencing practice across the hospital.

In late 1999 and early 2000, the committee changed the way users order certain high-volume tests.

Each morning as they logged into the system, users who had scheduled recurring tests over the next three days got a pop-up message asking if they wanted to continue the testing, cancel the testing, or delay a decision.

Weeks later, some mild constraints were added: users were prevented from placing automatically recurring orders for certain high-volume tests, and common blood chemistry tests that previously could be ordered as a group now had to be ordered separately.

On the ordering screen for common blood chemistry tests, users received a graphical display of results from the previous week.

Among other things, the study looked at orders entered, orders discontinued, net orders (that is, orders entered minus orders discontinued), and quality indicators such as rates of repeated hospital admissions, transfer to intensive care units, mortality and length of stay. The study period extended from 18 months before the start of the pop-up messages to 18 months after the last of the ordering constraints went into use.

The pop-up messages were associated with considerable reduction of some tests, but the ordering constraints and graphical displays that came later brought dramatic overnight reductions.

From before the first intervention to after the last intervention, daily net blood chemistry orders dropped 39 percent (from 1,837 to 1,124), daily net portable chest X-ray orders dropped 23 percent (from 87.0 to 67.1), and daily net electrocardiography orders dropped 28 percent (from 40.0 to 28.7).

There was no negative change in rates of repeated hospital admissions, transfer to intensive care units, mortality, length of stay, or any of the other quality measures included in the study.

As noted by the study authors, the reductions were achieved “without preventing clinicians from ordering the tests they wanted. Our approach was reasonably unobtrusive to the decision makers.”

“Doctors generate 80 percent to 90 percent of the cost in health care,” Neilson said. “We have to take some responsibility for that. It’s not that people don’t need testing, but we must begin to define the boundaries for acceptable levels of testing. It will be best for everyone if we can proceed rationally, without taking measures that would close the door on reasoned inquiry.”

The authors wrote that, if the study were generalized to other hospitals where ordering repeated tests is permissible, up to 25 percent of high-volume testing may be eliminated nationally.

Joining Neilson on the study were Kevin B. Johnson, M.D.; S. Trent Rosenbloom, M.D.; William D. Dupont, Ph.D.; Doug Talbert, Ph.D.; Dario A. Giuse, Dr. Ing.; Allen B. Kaiser, M.D.; and Randolph A. Miller, M.D.

Joining Neilson on the Resource Utilization Committee were Jeffrey Balser, M.D., Ph.D.; R. Daniel Beauchamp, M.D.; Warren E. Beck; Gordon R. Bernard, M.D.; Ian M. Burr, M.D.; Marilyn A. Dubree, R.N.; F. Andrew Gaffney, M.D.; David Head, M.D.; Martha K. Miers; Randolph A. Miller, M.D.; James A. O’Neill, M.D.; C. Wright Pinson, M.D.; David R. Posch; Martin P. Sandler, M.D.; John S. Sergent, M.D.; Gregg T. Tarquinio, Ph.D.

Neilson is the Hugh J. Morgan Professor of Medicine and Cell Biology.