CCL Featured Stories, Homepage Featured Stories, Recommendations from the Choosing Wisely® Initiative
Choosing Wisely®: Duplicate Orders
Changes in the U.S. healthcare system continually shift medical practices toward a focus on value: ordering tests, initiating treatments, and providing therapies that are known to improve patient health outcomes. Hospital organizations facing increasing pressure to deliver high-quality services at lower costs must reconsider long-standing practices that may in fact be unnecessary. Among those are daily or standing orders for inpatients.
At Cleveland Clinic, we have implemented decision support tools in the electronic order entry system to assist clinicians in avoiding unnecessary testing.(1,2) These initiatives began with restrictions on same-day orders and have been expanded to include restrictions of molecular genetic test orders to once-per-lifetime, as well as some intermediate interval restrictions (e.g., HbA1C may be ordered only once within 30 days).
A current initiative focuses on limiting standing orders, as recommended by several professional organizations through the Choosing Wisely® initiative:
- Don’t perform serial blood counts on clinically stable patients. (3)
- Don’t perform repetitive CBC and chemistry testing in the face of clinical and lab stability. (4)
- Don’t order diagnostic tests at regular intervals (such as every day), but rather in response to specific clinical questions. (5)
“Above and beyond decreasing the cost of care, which is very important these days, these initiatives decrease unnecessary phlebotomy, with should have a positive impact on iatrogenic anemia and the sequelae thereof (i.e., poor wound healing and increased infection rates),” notes Dr. Gary W. Procop, Medical Director of the Enterprise Test Utilization Committee at Cleveland Clinic.
“Additionally, it is often underappreciated that unnecessary tests (i.e., those tests with a low pre-test probability of being positive) are more likely to produce a false-positive reaction than a truly positive reaction. False-positive test results have a number of negative impacts on patient care, patient satisfaction, and patient experience. False-positive results often lead to repeat testing, and sometimes to additional radiologic studies and other work-ups.”
- Procop GW, Keating C, Stagno P, Kottke-Marchant K, Partin M, Tuttle R, et al. Reducing duplicate testing: a comparison of two clinical decision support tools. Am J Clin Pathol. 2015 May;143(5):623-626.
- Procop GW, Yerian LM, Wyllie R, Harrison AM, Kottke-Marchant K. Duplicate laboratory test reduction using a clinical decision support tool. Am J Clin Pathol. 2014 May;141(5):718-723.
- American Association of Blood Banks. Choosing Wisely® web site. http://www.choosingwisely.org/clinician-lists/american-association-blood-banks-serial-blood-counts-on-clinically-stable-patients. Accessed November 29, 2016.
- Society of Hospital Medicine – Adult Hospital Medicine. Choosing Wisely® web site. http://www.choosingwisely.org/clinician-lists/society-hospital-medicine-adult-repetitive-cbc-chemistry-testing. Accessed November 29, 2016.
- Critical Care Societies Collaborative – Critical Care. Choosing Wisely® web site. http://www.choosingwisely.org/clinician-lists/critical-care-societies-collaborative-regular-diagnostic-tests. Accessed November 29, 2016.
- Choosing Wisely®: an initiative of the American Board of Internal Medicine Foundation. http://www.choosingwisely.org
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