Reducing waste: a guidelines-based approach to reducing inappropriate vitamin D and TSH testing in the inpatient rehabilitation setting

[摘要] Background Laboratory overutilisation increaseshealthcare costs, and can lead to overdiagnosis,overtreatment and negative health outcomes. Disciplinespecific guidelines do not support routine testing forVitamin D and thyroid-stimulating hormone (TSH) inthe inpatient rehabilitation setting, yet 94% of patientshad Vitamin D and TSH tests on admission to inpatientrehabilitation at our institution. Our objective was toreduce Vitamin D and TSH testing by 25% on admission toinpatient Stroke, Spinal Cord Injury, Acquired Brain Injuryand Amputee Rehabilitation units.Methods A fishbone framework for root cause analysisrevealed potential causes underlying overutilisation ofVitamin D and TSH testing. A series of Plan-Do-StudyAct (PDSA) cycles were introduced to target remediablefactors, starting with an academic detailing interventionwith key stakeholders that reviewed applicable clinicalguidelines for each patient care discipline and therationale for reducing admission testing. Simultaneously,computerised clinical decision support (CCDS) limitedVitamin D testing to specific criteria. Audit and feedbackwere used in a subsequent PDSA cycle. Frequency ofVitamin D and TSH testing on admission was the primaryoutcome measure. The number of electronic admissionorder caresets containing automatic Vitamin D and/orTSH orders before and after the interventions was theprocess measure. Rate of Vitamin D supplementation andchanges in thyroid-related medication were the balancingmeasures.Results After implementation, 2.9% of patients hadadmission Vitamin D testing (97% relative reduction) and53% of patients had admission TSH testing (43% relativereduction). Admission order caresets with prepopulatedVitamin D and TSH orders decreased from 100% (n=6) to0%. The interventions were successful; similar to previousliterature, CCDS was more effective than education andaudit and feedback interventions alone. The interventionsrepresent >$9000 annualised savings.

[学科分类] 药学