An Educational and Administrative Intervention to Promote Rational Laboratory Test Ordering on an Academic General Medicine Service

Published:September 09, 2016DOI:



      Overuse of clinical laboratory testing in the inpatient setting is a common problem. The objective of this project was to develop an inexpensive and easily implemented intervention to promote rational laboratory use without compromising resident education or patient care.


      The study comprised of a cluster-randomized, controlled trial to assess the impact of a multifaceted intervention of education, guideline development, elimination of recurring laboratory orders, unbundling of laboratory panels, and redesign of the daily progress note on laboratory test ordering. The population included all patients hospitalized “general medicine” was duplicated during 2 consecutive months on a general medicine teaching service within a 999-bed tertiary care hospital in Boston, Massachusetts. The primary outcome was the total number of commonly used laboratory tests per patient day during 2 months in 2008. Secondary outcomes included a subgroup analysis of each individual test per patient day, adverse events, and resident and nursing satisfaction.


      A total of 5392 patient days were captured. The intervention produced a 9% decrease in aggregate laboratory use (rate ratio, 0.91; P = .021; 95% confidence interval, 0.84-0.98). Six instances of delayed diagnosis of acute kidney injury and 11 near misses were reported in the intervention arm.


      A bundled educational and administrative intervention promoting rational ordering of laboratory tests on a single academic general medicine service led to a modest but significant decrease in laboratory use. To our knowledge, this was the first study to examine the daily progress note as a tool to limit excessive test ordering. Unadjudicated near misses and possible harm were reported with this intervention. This finding warrants further study.


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        • Peabody F.W.
        The physician and the laboratory.
        Boston Med Surg J. 1922; 187: 324-327
        • Griner P.F.
        • Liptzin B.
        Use of the laboratory in a teaching hospital: implications for patient care, education, and hospital costs.
        Ann Intern Med. 1971; 75: 157-163
      1. Editorial: Routine laboratory tests–the physician's responsibility.
        N Engl J Med. 1966; 274: 222
        • van Walraven C.
        • Naylor C.D.
        Do we know what inappropriate laboratory utilization is? A systematic review of laboratory clinical audits.
        JAMA. 1998; 280: 550-558
        • Bates D.W.
        • Goldman L.
        • Lee T.H.
        Contaminant blood cultures and resource utilization. the true consequences of false-positive results.
        JAMA. 1991; 265: 365-369
        • Chant C.
        • Wilson G.
        • Friedrich J.O.
        Anemia, transfusion, and phlebotomy practices in critically ill patients with prolonged ICU length of stay: a cohort study.
        Crit Care. 2006; 10: R140
        • Salisbury A.C.
        • Reid K.J.
        • Alexander K.P.
        • et al.
        Diagnostic blood loss from phlebotomy and hospital-acquired anemia during acute myocardial infarction.
        Arch Intern Med. 2011; 171: 1646-1653
        • Thavendiranathan P.
        • Bagai A.
        • Ebidia A.
        • Detsky A.S.
        • Choudhry N.K.
        Do blood tests cause anemia in hospitalized patients? The effect of diagnostic phlebotomy on hemoglobin and hematocrit levels.
        J Gen Intern Med. 2005; 20: 520-524
        • Eisenberg J.M.
        Physician utilization: the state of research about physicians' practice patterns.
        Med Care. 2002; 40: 1016-1035
        • Axt-Adam P.
        • van der Wouden J.C.
        • van der Does E.
        Influencing behavior of physicians ordering laboratory tests: a literature study.
        Med Care. 1993; 31: 784-794
        • Solomon D.H.
        • Hashimoto H.
        • Daltroy L.
        • Liang M.H.
        Techniques to improve physicians' use of diagnostic tests: a new conceptual framework.
        JAMA. 1998; 280: 2020-2027
        • Kobewka D.M.
        • Ronksley P.E.
        • McKay J.A.
        • Forster A.J.
        • van Walraven C.
        Influence of educational, audit and feedback, system based, and incentive and penalty interventions to reduce laboratory test utilization: a systematic review.
        Clin Chem Lab Med. 2015; 53: 157-183
        • Iwashyna T.J.
        • Fuld A.
        • Asch D.A.
        • Bellini L.M.
        The impact of residents, interns, and attendings on inpatient laboratory ordering patterns: a report from one university's hospitalist service.
        Acad Med. 2011; 86: 139-145
        • Kellerman S.E.
        • Herold J.
        Physician response to surveys. A review of the literature.
        Am J Prev Med. 2001; 20: 61-67
        • Kroenke K.
        • Hanley J.F.
        • Copley J.B.
        • et al.
        Improving house staff ordering of three common laboratory tests. Reductions in test ordering need not result in underutilization.
        Med Care. 1987; 25: 928-935
        • May T.A.
        • Clancy M.
        • Critchfield J.
        • et al.
        Reducing unnecessary inpatient laboratory testing in a teaching hospital.
        Am J Clin Pathol. 2006; 126: 200-206
        • Neilson E.G.
        • Johnson K.B.
        • Rosenbloom S.T.
        • et al.
        The impact of peer management on test-ordering behavior.
        Ann Intern Med. 2004; 141: 196-204
        • Sussman E.
        • Goodwin P.
        • Rosen H.
        Administrative change and diagnostic test use. the effect of eliminating standing orders.
        Med Care. 1984; 22: 569-572