Reducing the Amount of Phlebotomy Ordered for Nonintensive Care Unit Surgical Patients

According to researchers, use of laboratory tests has increased continuously over the past few decades. They add that phlebotomy is a “substantial proportion of hospital expenditure and much of it is unwarranted.” To reduce the number of laboratory tests per patient, hospitals have developed various interventions to reduce the number of laboratory tests per patient, including (1) modifying computerized ordering systems to limit options; (2) not allowing tests to be ordered on a recurring basis, necessitating daily reevaluation; (3) installing pop-up reminders of what seem to be redundant tests; (4) requiring clerical justification for each test ordered by the ordering physician; and (5) unbundling tests so each specific value must be ordered separately. In addition, the researchers noted that no adverse effects have been associated with reducing the number of laboratory tests performed, with no difference in readmission rates, transfers to intensive care units, length of stay, diagnoses, or mortality when laboratory tests have been significantly reduced. The researchers recently conducted a prospective observational study to determine whether making physicians aware of the hospital costs of daily phlebotomy would reduce the amount of phlebotomy ordered for nonintensive care unit surgical patients. The study was conducted at a tertiary care hospital in an urban setting and included all nonintensive care patients on 3 general surgical services. Study results were reported in Archives of Surgery [2011; 146(5):524-527]. The intervention was a weekly announcement made to surgical house staff and attending physicians of the dollar amount charged to nonintensive care patients for laboratory services during the previous week. The primary outcome measure was the dollars charged per patient per day for routine blood work. During an initial observational period of 2 weeks, baseline monitoring of laboratory test ordering occurred. Data were collected by printing a daily patient list for each service. The list included the complete blood cell count and chemistry panel (if obtained) for each patient. The average of the 2 weeks of baseline data in daily charges per patient was $147.73, for a total of $36,875 charged per week on blood cell counts and chemistry panels. Over the course of the intervention (11 weeks), dollars per patient per day decreased, with a correlation coefficient of –0.76 (P=.002). The lowest weekly value reached was $108.11 per patient per day, which was a 27% decrease from baseline. The lowest overall charges per week were $25,311. Over the 11 weeks of the intervention, the total cost savings were $54,967 (totaled consecutively). The researchers noted that there were 2 weeks during the intervention where the costs increased significantly from the previous week. Those weeks coincided with the interns switching services (the population hearing the weekly announcement was different from the prior 4 weeks). Limitations cited by the researchers included the short duration of the study, the lack of follow-up data, and the likelihood that the results of the study may be an underestimate of the cost savings in reducing phlebotomy because gathering data by printing a daily census meant that only a single blood draw could be counted for a given patient for that day, but there were likely patients with >1 blood draw during a 24-hour period. In conclusion, the researchers said “healthcare providers being made aware of the cost of phlebotomy can decrease the amount of these tests ordered and result in significant savings for the hospital.”