Reducing waste: a guidelines-based approach to reducing inappropriate vitamin D and TSH testing in the inpatient rehabilitation setting.
clinical practice guidelines
decision support, computerised
evidence-based medicine
quality improvement
Journal
BMJ open quality
ISSN: 2399-6641
Titre abrégé: BMJ Open Qual
Pays: England
ID NLM: 101710381
Informations de publication
Date de publication:
2019
2019
Historique:
received:
27
02
2019
revised:
27
08
2019
accepted:
09
10
2019
entrez:
22
11
2019
pubmed:
22
11
2019
medline:
14
7
2020
Statut:
epublish
Résumé
Laboratory overutilisation increases healthcare costs, and can lead to overdiagnosis, overtreatment and negative health outcomes. Discipline-specific guidelines do not support routine testing for Vitamin D and thyroid-stimulating hormone (TSH) in the inpatient rehabilitation setting, yet 94% of patients had Vitamin D and TSH tests on admission to inpatient rehabilitation at our institution. Our objective was to reduce Vitamin D and TSH testing by 25% on admission to inpatient Stroke, Spinal Cord Injury, Acquired Brain Injury and Amputee Rehabilitation units. A fishbone framework for root cause analysis revealed potential causes underlying overutilisation of Vitamin D and TSH testing. A series of Plan-Do-Study-Act (PDSA) cycles were introduced to target remediable factors, starting with an academic detailing intervention with key stakeholders that reviewed applicable clinical guidelines for each patient care discipline and the rationale for reducing admission testing. Simultaneously, computerised clinical decision support (CCDS) limited Vitamin D testing to specific criteria. Audit and feedback were used in a subsequent PDSA cycle. Frequency of Vitamin D and TSH testing on admission was the primary outcome measure. The number of electronic admission order caresets containing automatic Vitamin D and/or TSH orders before and after the interventions was the process measure. Rate of Vitamin D supplementation and changes in thyroid-related medication were the balancing measures. After implementation, 2.9% of patients had admission Vitamin D testing (97% relative reduction) and 53% of patients had admission TSH testing (43% relative reduction). Admission order caresets with prepopulated Vitamin D and TSH orders decreased from 100% (n=6) to 0%. The interventions were successful; similar to previous literature, CCDS was more effective than education and audit and feedback interventions alone. The interventions represent >$9000 annualised savings.
Sections du résumé
Background
Laboratory overutilisation increases healthcare costs, and can lead to overdiagnosis, overtreatment and negative health outcomes. Discipline-specific guidelines do not support routine testing for Vitamin D and thyroid-stimulating hormone (TSH) in the inpatient rehabilitation setting, yet 94% of patients had Vitamin D and TSH tests on admission to inpatient rehabilitation at our institution. Our objective was to reduce Vitamin D and TSH testing by 25% on admission to inpatient Stroke, Spinal Cord Injury, Acquired Brain Injury and Amputee Rehabilitation units.
Methods
A fishbone framework for root cause analysis revealed potential causes underlying overutilisation of Vitamin D and TSH testing. A series of Plan-Do-Study-Act (PDSA) cycles were introduced to target remediable factors, starting with an academic detailing intervention with key stakeholders that reviewed applicable clinical guidelines for each patient care discipline and the rationale for reducing admission testing. Simultaneously, computerised clinical decision support (CCDS) limited Vitamin D testing to specific criteria. Audit and feedback were used in a subsequent PDSA cycle. Frequency of Vitamin D and TSH testing on admission was the primary outcome measure. The number of electronic admission order caresets containing automatic Vitamin D and/or TSH orders before and after the interventions was the process measure. Rate of Vitamin D supplementation and changes in thyroid-related medication were the balancing measures.
Results
After implementation, 2.9% of patients had admission Vitamin D testing (97% relative reduction) and 53% of patients had admission TSH testing (43% relative reduction). Admission order caresets with prepopulated Vitamin D and TSH orders decreased from 100% (n=6) to 0%. The interventions were successful; similar to previous literature, CCDS was more effective than education and audit and feedback interventions alone. The interventions represent >$9000 annualised savings.
Identifiants
pubmed: 31750404
doi: 10.1136/bmjoq-2019-000674
pii: bmjoq-2019-000674
pmc: PMC6830472
doi:
Substances chimiques
Vitamin D
1406-16-2
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
e000674Informations de copyright
© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.
Déclaration de conflit d'intérêts
Competing interests: None declared.
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