High-Value Care | July 27, 2022 | FREE
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Alert decreased coagulation test orders during lab tube shortage, single-center study finds

A best practice advisory delivered through the electronic medical record during a national shortage of laboratory tubes was associated with an immediate decrease in orders for prothrombin time, international normalized ratio, and partial thromboplastin time.

An electronic medical record (EMR)-based alert may have helped decrease coagulation test orders during a national shortage of laboratory tubes, a recent study found.

Researchers at one hospital evaluated a best practice advisory that was instituted on May 15, 2021, during a national shortage of sodium citrate lab tubes. When clinicians ordered a prothrombin time (PT), international normalized ratio (INR), or partial thromboplastin time (PTT) test without other coagulation tests for hospitalized or ED patients, the EMR displayed the message, “There is a national shortage on blue top tubes, and we request thoughtful restraint in reflexive ordering of PT/INR/PTT. Does this patient require PT/INR/PTT measurement?”, and provided guidance on appropriate clinical scenarios. The message required acknowledgment from the clinician, but it did not prohibit the order. In addition, an email detailing the conservation strategies was sent to all physicians. The researchers used an interrupted time-series analysis to assess changes in rates of PT, INR, and PTT testing between six months before and six months after the alert was created. Results were published as a research letter on July 18 by JAMA Internal Medicine.

Daily PT, INR, and PTT tests decreased from a mean 463.8 tests per day before the alert to 329.0 per day after it was instituted (−29.1%; P<0.001). The reduction in testing was −31.4%, assuming that temporal trends before and after were equal, and −26.0% when trends before and after the alert were fitted separately (P<0.001 for both comparisons). The trend for testing was slightly higher after the alert (15 vs. 10 more tests per 100 days before BPA; difference, 5 [95% CI, 0 to 10] tests per 100 days; P=0.07); however, this trend was associated with less than a 10% reduction in the estimated effect size during the six-month follow-up period.

Among other limitations, data were lacking on the clinical indications for the tests that were deferred, the study authors noted. They added that since the alert was implemented when resources were scarce, the findings may not be representative of what a similar intervention could achieve in different circumstances.

“A pandemic-created natural experiment highlighted the effectiveness of a [best practice advisory] added to clinician communication to reduce potentially unnecessary care,” the authors wrote. “As attention to low-value care grows, the addition of EMR-embedded decision-making tools may need to be considered and further evaluated.”