一项由住院医师主导的多学科倡议，旨在安全减少每日实验室检查。

A Multidisciplinary Housestaff-Led Initiative to Safely Reduce Daily Laboratory Testing.

作者信息

Iams Wade, Heck Josh, Kapp Meghan, Leverenz David, Vella Michael, Szentirmai Eszter, Valerio-Navarrete Irene, Theobald Cecelia, Goggins Kathryn, Flemmons Kevin, Sponsler Kelly, Penrod Cody, Kleinholz Patricia, Brady Donald, Kripalani Sunil

机构信息

W. Iams is chief resident in internal medicine, Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee. J. Heck was chief resident in radiology and musculoskeletal radiology fellow, Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee, at the time of implementation and writing. M. Kapp is chief resident in pathology, Department of Pathology, Vanderbilt University Medical Center, Nashville, Tennessee. D. Leverenz is a third-year internal medicine resident, Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee. M. Vella is a fourth-year general surgery resident, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee. E. Szentirmai is a fourth-year medical student, School of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee. I. Valerio-Navarrete is data analyst, Department of Informatics, Vanderbilt University Medical Center, Nashville, Tennessee. C. Theobald is assistant professor of medicine, Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee. K. Goggins is research coordinator, Department of Internal Medicine and Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, Tennessee. K. Flemmons is assistant professor of medicine, Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee. K. Sponsler is assistant professor of medicine, Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee. C. Penrod is a pediatric emergency medicine fellow, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee. P. Kleinholz is chief resident in neurology, Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee. D. Brady is professor of medicine and designated institutional official, Office of Graduate Medical Education,

出版信息

Acad Med. 2016 Jun;91(6):813-20. doi: 10.1097/ACM.0000000000001149.

DOI:10.1097/ACM.0000000000001149

PMID:27028031

Abstract

PURPOSE

Provision of high-value care is a milestone in physician training. The authors evaluated the effect of a housestaff-led initiative on laboratory testing rates.

METHOD

Vanderbilt University Medical Center's Choosing Wisely steering committee, led by housestaff with faculty advisors, sought to reduce unnecessary daily basic metabolic panel (BMP) and complete blood count (CBC) testing on inpatient general medicine and surgical services. Intervention services received a didactic session followed by regular data feedback with goal rates and peer comparison. Testing rates during January 1, 2013-February 9, 2015, were compared on intervention services and control services using a difference-in-differences analysis and an interrupted time-series analysis with segmented linear regression.

RESULTS

Compared with concurrent controls, the mean number of BMP tests per patient day decreased by an additional 0.23 (95% CI 0.17-0.29) on medical housestaff and 0.15 (95% CI 0.09-0.21) on hospitalist intervention services. Daily CBC tests decreased by an additional 0.28 (95% CI 0.23-0.33) on medical housestaff, 0.08 (95% CI 0.03-0.13) on hospitalist, and 0.12 (95% CI 0.05-0.20) on surgical housestaff intervention services. Patients with lab-free days (0 labs ordered in 24 hours) increased by an additional 4.1 percentage points (95% CI 2.1-6.1) on medical housestaff and 9.7 percentage points (95% CI 6.6-12.8) on hospitalist intervention services. There were no adverse changes in length of stay or intensive care unit transfer, in-hospital mortality, or 30-day readmission rates.

CONCLUSIONS

A housestaff-led intervention utilizing education and data feedback with goal setting and peer comparison resulted in safe, significant reductions in daily laboratory testing rates.

摘要

目的

提供高价值医疗服务是医师培训中的一个里程碑。作者评估了一项由住院医师主导的举措对实验室检查率的影响。

方法

范德堡大学医学中心的“明智选择”指导委员会由住院医师在教员顾问的带领下，试图减少内科和外科住院患者不必要的每日基础代谢指标（BMP）和全血细胞计数（CBC）检查。干预科室接受了一次教学课程，随后是定期的数据反馈，包括目标率和同行比较。使用差异分析和带有分段线性回归的中断时间序列分析，比较了2013年1月1日至2015年2月9日期间干预科室和对照科室的检查率。

结果

与同期对照组相比，内科住院医师干预科室每位患者每天的BMP检查平均次数额外减少了0.23（95%置信区间0.17 - 0.29），住院医师干预科室减少了0.15（95%置信区间0.09 - 0.21）。内科住院医师干预科室的每日CBC检查额外减少了0.28（95%置信区间0.23 - 0.33），住院医师干预科室减少了0.08（95%置信区间0.03 - 0.13），外科住院医师干预科室减少了0.12（95%置信区间0.05 - 0.20）。在内科住院医师干预科室，无实验室检查日（24小时内未开具任何实验室检查）的患者比例额外增加了4.1个百分点（95%置信区间2.1 - 6.1），住院医师干预科室增加了9.7个百分点（95%置信区间6.6 - 12.8）。住院时间、转入重症监护病房的情况、住院死亡率或30天再入院率均无不良变化。