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Impact of Weekly Feedback on Test Ordering Patterns
Christine Minerowicz, MD; Nicole Abel, MD; Krystal Hunter, MBA; Kathryn C. Behling, MD, PhD; Elizabeth Cerceo, MD; and Charlene Bierl, MD, PhD
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Impact of Weekly Feedback on Test Ordering Patterns

Christine Minerowicz, MD; Nicole Abel, MD; Krystal Hunter, MBA; Kathryn C. Behling, MD, PhD; Elizabeth Cerceo, MD; and Charlene Bierl, MD, PhD
Providing a weekly feedback report significantly influences the test ordering behavior of internal medicine residents and reduces laboratory overutilization.
Although we were able to calculate the reduction in charges achieved by our intervention, we cannot directly translate the fewer tests performed into dollars saved for the laboratory or reduced healthcare costs for capitated inpatients. For example, more than 4000 fewer magnesium levels were ordered in the post intervention group. While we did not track order sets, it is likely that most of the magnesium levels ordered were in conjunction with other tests. The economics of performing or not performing a magnesium level is negligible when a tube of blood is already drawn for another test, such as an electrolyte panel, because laboratory overhead costs are fixed (ie, there is no additional material required, no additional phlebotomist or laboratory technician time needed) and the reagents to perform the test are inexpensive. In contrast, the reduction in nearly 3000 manual differentials performed by laboratory technicians and occasional pathologist review has the potential for far greater impact on the daily operations of the laboratory in terms of personnel allocation.

Caution must be exercised before extrapolating our data hospitalwide. The same level of impact may not be seen in medical services that do not routinely manage critically ill patients or require extensive diagnostic evaluation with the same frequency as that performed by our internal medicine residents. Additionally, attending physicians may be too entrenched in their ordering habits or may have already attenuated their test volume to a fairly efficient level due to practice experience. Therefore, they may not achieve the same level of success using our intervention.

Finally, the downstream effects of our study remain to be seen, as we continue to provide the weekly feedback reports to the internal medicine residents. Reduced testing may lead some to fear delayed or missed diagnoses. However, Wang et al demonstrated that reduced testing (range = 7% to 40% of all chemistry tests) in the coronary care unit did not alter length of stay, readmission to the intensive care unit, hospital morbidity, hospital mortality, or ventilator days.9 We do not know if reducing unnecessary testing will become an integral part of the residents’ ordering behaviors as they move beyond their training or if the mindfulness will fade once the weekly feedback reports disappear.

CONCLUSIONS
We conclude that providing internal medicine residents with weekly feedback regarding test-ordering patterns resulted in a significant reduction in the total number of laboratory tests ordered over time. These data suggest that there may be utility in expanding the use of these weekly feedback reports to other specialties and to nonresident physicians, as well as in expanding the reports to include other areas of patient care such as transfusion medicine. 

Author Affiliations: Department of Pathology, Rutgers Robert Wood Johnson Medical School (CM), New Brunswick, NJ; Department of Medicine (NA), Cooper Research Institute—Biostatistics Group (KH), Department of Pathology (KCB, CB), Division of Hospital Medicine (EC), Cooper University Hospital, Camden, NJ; Department of Biomedical Sciences, Cooper Medical School of Rowan University (KCB), Camden, NJ.

Source of Funding: None.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (CB, EC); acquisition of data (CB, CM); analysis and interpretation of data (CB, CM, KH, EC, KCB, NA); drafting of the manuscript (CB, CM, EC, NA); critical revision of the manuscript for important intellectual content (CB, CM, KH, EC, KCB, NA); statistical analysis (CB, KH, KCB); administrative, technical, or logistic support (CB, KH); and supervision (CB, EC).

Address correspondence to: Charlene Bierl, MD, PHD, Department of Pathology, P037, 1 Cooper Plz, Camden, NJ, 08103. E-mail: Bierl-charlene@Cooperhealth.edu.
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