Audit-and-Feedback Utilizing Resident Consensus Standards Reduced Daily Labs

Background The Choosing Wisely campaign recommends that clinicians avoid repetitive laboratory testing in hospitalized patients who have clinical and laboratory stability; however, it is unclear how physicians define laboratory stability, or how they adhere to their own definition. Objective To quantify and compare what internal medicine residents and hospitalists consider a stable complete blood count (CBC) and chemistry panel, and to assess an audit-and-feedback intervention on residents, utilizing resident definitions of lab stability. Methods We used a 2-round consensus survey in 2023 to survey residents and hospitalists to determine consensus definitions of a stable CBC and chemistry panel. We then performed a 21-week audit-and-feedback intervention, providing residents weekly feedback of adherence to their cohort's lab stability definitions. Percent of stable lab panels repeated was compared at baseline, during, and after the intervention. Results In our survey, residents (response rates 55 of 191, 29%; then 32 of 191, 17%) considered smaller day-to-day changes in complete blood count parameters as actionable compared to hospitalists (response rates 47 of 237, 20%; then 59 of 237, 25%). At baseline, residents repeated stable CBCs more often than hospitalists (1060 of 1566, 68% [95% CI, 65-70] vs 52 of 96, 54% [95% CI, 44-64], P=.005). During the intervention, residents repeated fewer stable CBCs (393 of 729, 54% [95% CI, 50-57], P<.001) a reduction sustained at 6-months (635 of 1083, 59% [95% CI, 56-62], P<.001). Conclusions Residents more frequently repeated CBCs that their cohort termed "stable" than did hospitalists. When residents were given feedback on adherence to their cohort's lab stability criteria, there was a sustained reduction in the number of CBCs they ordered.