Optimizing Intervention Sequences to Reduce Physician Blood Urea Nitrogen Test Overuse: A Multi-Hospital Analysis

Area of Science:

• Health Services Research
• Quality Improvement Science
• Clinical Laboratory Management

Background:

• Overuse of hospital laboratory testing is a significant quality improvement (QI) priority.
• A multifaceted initiative was developed to reduce blood urea nitrogen (BUN) test ordering across a Canadian province.
• Interventions included system-focused (SF) [electronic medical record (EMR)] and person-focused (PF) [performance audit and education] approaches, or no intervention.

Purpose of the Study:

• To evaluate the impact of sequencing and combining SF and PF interventions on physician BUN test ordering practices.
• To assess the effectiveness of these interventions beyond a single hospital setting.

Main Methods:

• An interrupted time series design with segmented regression analysis was employed.
• Monthly BUN test order counts were analyzed for six hospital Medicine programs over 6-7 years.
• Hospitals were categorized into EMR (n=3) and non-EMR (n=3) groups post-QI initiative.

Main Results:

• Cumulative BUN test ordering reductions ranged from 51% to 95% across hospital programs.
• The most significant reduction (95%) was achieved with a PF followed by SF intervention sequence, coupled with EMR implementation.
• Concurrent PF and SF implementation followed by an additional PF intervention also yielded substantial reductions (93%).
• EMR-equipped hospitals exhibited less monthly data variability compared to non-EMR hospitals.

Conclusions:

• No single intervention sequence or combination yielded identical results, but all approaches led to sustained BUN ordering reductions.
• A sequential PF, SF intervention with EMR implementation, considering workflow, norms, costs, and policy, is crucial for lasting behavioral change.
• Effective implementation requires a holistic approach to ensure broader adaptability and sustained quality improvement in laboratory test utilization.