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Published on: May 25, 2017
Reducing Overutilization of Testing for Clostridium difficile Infection in a Pediatric Hospital System: A Quality
J Michael Klatte1, Rangaraj Selvarangan2, Mary Anne Jackson2
1Department of Pediatrics, Baystate Medical Center and Tufts University School of Medicine, Springfield, Massachusetts; and james.klattemd@baystatehealth.org.
Insights
Implementing automatic laboratory declination of inappropriate stool specimens significantly reduced Clostridium difficile testing, leading to substantial cost savings. Physician ordering practices, however, did not show sustained improvement.
Area of Science:
- Clinical diagnostics
- Laboratory medicine
- Infectious disease testing
Background:
- Overuse of Clostridium difficile laboratory testing is a significant issue.
- Nondiarrheal stool specimens and specimens from young children are frequently submitted inappropriately.
Purpose of the Study:
- To reduce Clostridium difficile laboratory testing by decreasing submissions of nondiarrheal stool specimens and specimens from children ≤12 months.
- To determine patient and laboratory cost savings associated with reduced testing.
Main Methods:
- A multifaceted initiative including provider education, computerized order entry modifications, and automatic laboratory declination of inappropriate specimens.
- Run charts and p-charts were used to analyze testing submission and testing rates.
- Cost savings were assessed post-intervention.
Main Results:
- Automatic laboratory declination led to a sustained decrease in tested specimens, from 100% to 53.8%.
- Significant cost savings were achieved: nearly $3600 for the laboratory and ~$32,000 for patients.
- Provider education and order entry modifications did not result in sustained changes in physician ordering practices.
Conclusions:
- Automatic laboratory declination is effective in reducing inappropriate Clostridium difficile testing and generating cost savings.
- While laboratory interventions show success, sustained changes in physician ordering behavior require further strategies.
Objectives:
Study objectives included addressing overuse of Clostridium difficile laboratory testing by decreasing submission rates of nondiarrheal stool specimens and specimens from children ≤12 months of age and determining resultant patient and laboratory cost savings associated with decreased testing.
Methods:
A multifaceted initiative was developed, and components included multiple provider education methods, computerized order entry modifications, and automatic declination from laboratory on testing stool specimens of nondiarrheal consistency and from children ≤12 months old. A run chart, demonstrating numbers of nondiarrheal plus infant stool specimens submitted over time, was developed to analyze the initiative's impact on clinicians' test-ordering practices. A p-chart was generated to evaluate the percentage of these submitted specimens tested biweekly over a 12-month period. Cost savings for patients and the laboratory were assessed at the study period's conclusion.
Results:
Run chart analysis revealed an initial shift after the interventions, suggesting a temporary decrease in testing submission; however, no sustained differences in numbers of specimens submitted biweekly were observed over time. On the p-chart, the mean percentage of specimens tested before the intervention was 100%. After the intervention, the average percentage of specimens tested dropped to 53.8%. Resultant laboratory cost savings totaled nearly $3600, and patient savings on testing charges were ∼$32 000.
Conclusions:
Automatic laboratory declination of nondiarrheal stools submitted for CDI testing resulted in a sustained decrease in the number of specimens tested, resulting in significant laboratory and patient cost savings. Despite multiple educational efforts, no sustained changes in physician ordering practices were observed.
