Desai Ruchi, Zhang Ray, Shah Nainesh, Bacalao Maria, Galous Haidy, Karp David R, Bajaj Puneet
Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA.
Department of Pathology, UT Southwestern Medical Center, Dallas, TX, USA.
J Gen Intern Med. 2025 May 28. doi: 10.1007/s11606-025-09632-1.
Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are two laboratory tests often ordered simultaneously to assess for inflammation. Studies show that CRP is superior to ESR, and co-ordering ESR and CRP increases expenditures and phlebotomy without demonstrable patient benefit.
Our quality improvement project aimed to reduce ESR/CRP co-ordering and total ESR orders in a safety-net health setting (health system 1) and a university setting (health system 2) within an academic medical center.
DESIGN/INTERVENTIONS: Using plan, do, study, act (PDSA) methodology, we developed education and electronic health record (EHR) interventions, which included education to all rheumatology providers, targeted education to rheumatology providers with the highest ESR/CRP co-orders, removal of ESR from the rheumatology order set at health system 2, and implementation of a non-intrusive clinical decision support (CDS) change at both hospitals.
We compared ESR/CRP co-orders, ESR-only orders, and CRP-only orders between pre- and post-intervention periods, as well as weekly average orders per 1000 patient days in the inpatient setting and per 1000 patient encounters in the outpatient setting and rheumatology clinics.
In health system 1, average weekly ESR/CRP co-orders decreased by 25%, ESR-only orders decreased by 26%, and CRP-only orders increased by 11%. In health system 2, average weekly ESR/CRP co-orders decreased by 36%, ESR-only orders decreased by 47%, and CRP-only orders increased by 65%. Most of the change was seen in the outpatient setting, with >80% reduction in ESR/CRP co-ordering by the rheumatology division in both health systems. Using ESR and CRP Medicare reimbursement rates, estimated payer savings system-wide were $59,354.33 over 1 year.
Specialty-led and targeted educational interventions and non-intrusive simple EHR CDS changes are effective in reducing redundant laboratory testing to provide higher value care.
红细胞沉降率（ESR）和C反应蛋白（CRP）是常用于同时评估炎症的两项实验室检查。研究表明，CRP优于ESR，同时开具ESR和CRP会增加费用和静脉穿刺次数，且未给患者带来明显益处。
我们的质量改进项目旨在减少一所学术医疗中心内的安全网医疗机构（医疗系统1）和大学医疗机构（医疗系统2）中ESR/CRP同时开具的情况以及ESR的总开具次数。
设计/干预措施：我们采用计划-实施-研究-改进（PDSA）方法，制定了教育和电子健康记录（EHR）干预措施，包括对所有风湿病医疗服务提供者进行教育，对ESR/CRP同时开具率最高的风湿病医疗服务提供者进行针对性教育，在医疗系统2的风湿病医嘱集中删除ESR，并在两家医院实施非侵入性临床决策支持（CDS）变更。
我们比较了干预前后ESR/CRP同时开具的情况、仅开具ESR的情况和仅开具CRP的情况，以及住院环境中每1000个患者日和门诊环境及风湿病诊所中每1000次患者就诊的每周平均开具次数。
在医疗系统1中，每周ESR/CRP同时开具的平均次数下降了25%，仅开具ESR的次数下降了26%，仅开具CRP的次数增加了11%。在医疗系统2中，每周ESR/CRP同时开具的平均次数下降了36%，仅开具ESR的次数下降了47%，仅开具CRP的次数增加了65%。大部分变化出现在门诊环境中，两个医疗系统的风湿病科ESR/CRP同时开具的情况减少了80%以上。根据ESR和CRP的医疗保险报销率，估计全系统支付方在1年内节省了59354.33美元。
由专科主导的针对性教育干预措施和非侵入性的简单EHR CDS变更可有效减少冗余的实验室检查，从而提供更高价值的医疗服务。
