A pandemic-related shortage of a mundane item – tubes for collecting blood samples from patients – has caused headaches for health systems around the world.
But it may also have a silver lining: a lesson in how to reduce unnecessary medical testing whether or not there is a shortage, according to a new study.
The shortage of “blue-capped” blood test tubes has given researchers a chance to see whether alerting doctors the moment they place an order could encourage them to order a test only when the results will immediately affect care.
In the new study published in JAMA internal medicine, an alert led to an almost immediate 29% drop in orders for a common test. The reduced level persisted for months.
“This shows that small interventions can make a big difference and suggests that other types of low-value care could benefit from a similar intervention,” said lead author Madison Breeden, MD, an infectious disease researcher at UM. Health who conducted the study during his year as cresident chief of quality and patient safety. She is already exploring whether the approach could reduce unnecessary prescribing of antibiotics.
Breeden and colleagues describe what happened in the spring of 2021 when supply chain and pathology experts at the University of Michigan Health began to worry about a potential shortage of “capped” tubes. blue”. The pandemic had created huge demand for the chemical in the tubes: sodium citrate, which stabilizes blood samples until a lab team can analyze three properties related to blood clotting, called PT, INR and PTT.
After emailing all providers, UM Health added a “best practices alert” to doctors’ electronic test ordering system. They could still order PT/INR/PTT tests, but were asked for “thoughtful restraint in reflexive ordering.”
The alert began appearing a month before the U.S. Food and Drug Administration issued a official notice of shortage and the issue received wide attention. The shortage continues today and moved on to other types of testing.
Researchers looked at what happened for six months after the alert began at UM Health and compared it to data from the previous six months.
“There are very important reasons for ordering this test in certain patients, such as before surgery or when managing certain conditions and treatments,” Breeden explained. “But it can also be part of a standard set of orders that is put in place during an emergency department visit and continues to be ordered repeatedly after the patient is admitted to hospital, even if the results will not change his care.”
For these patients, a single test may be indicated, but not repeat tests.
Busy doctors entering test orders don’t tend to think about the supplies and power of people needed to perform those tests, Breeden notes. In the face of a shortage or strong evidence that a test is often over-ordered, an alert could help prioritize testing for those who need it most.
Canadian experts have in fact flagged PT/INR/PTT testing as a target to reduce unnecessary carethrough the Choosing Wisely program. The same goes for the American Society for Clinical Laboratory Sciencea group of health professionals.
Besides Breeden, the authors of the study are Steven J. Bernstein, MD, MPH, Rodney A. Hayward, MD, and A. Mark Fendrick.
Quoted article:Evaluation of a best practice advisory on ordering prothrombin time, international normalized ratio and partial thromboplastin time tests”, JAMA internal medicine. DOI: 10.1001/jamainternmed.2022.2609