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A Utilization Management Intervention to Reduce Unnecessary Testing in the Coronary Care Unit
Thomas J. Wang, MD;
Elizabeth A. Mort, MD;
Paul Nordberg, MS;
Yuchiao Chang, PhD;
Mary E. Cadigan, RN;
Laura Mylott, PhD, RN;
Lillian V. Ananian, RN;
B. Taylor Thompson, MD;
Michael Fessler, MD;
William Warren, MD;
Amy Wheeler, MD;
Mark Jordan, MD;
Michael A. Fifer, MD
Arch Intern Med. 2002;162:1885-1890.
Background There have been no studies of interventions to reduce test utilization
in the coronary care unit.
Objective To determine whether a 3-part intervention in a coronary care unit could
decrease utilization without affecting clinical outcomes.
Methods Practice guidelines for routine laboratory and chest radiographic testing
were developed by a multidisciplinary team, using evidence-based recommendations
when possible and expert opinion otherwise. These guidelines were incorporated
into the computer admission orders for the coronary care unit at a large teaching
hospital, and educational efforts were targeted at the house staff and nurses.
Utilization during the 3-month intervention period was compared with utilization
during the same 3 months in the prior year. The hospital's medical intensive
care unit, which did not receive the specific intervention, provided control
data.
Results During the intervention period, there were significant reductions in
utilization of all chemistry tests (from 7% to 40%). Reductions in ordering
of complete blood counts, arterial blood gas tests, and chest radiographs
were not statistically significant. After controlling for trends in the control
intensive care unit, however, the reductions in arterial blood gas tests (P = .04) and chest radiographs (P<.001)
became significant. The reductions in potassium, glucose, calcium, magnesium,
and phosphorus testing, but not other chemistries, remained significant. The
estimated reduction in expenditures for "routine" blood tests and chest radiographs
was 17% (P<.001). There were no significant changes
in length of stay, readmission to intensive care, hospital mortality, or ventilator
days.
Conclusion The utilization management intervention was associated with significant
reductions in test ordering without a measurable change in clinical outcomes.
From the Department of Medicine (Drs Wang, Mort, Thompson, Fessler,
Warren, Wheeler, Jordan, and Fifer), Clinical Care Management Unit (Drs Mort
and Chang and Mr Nordberg), and the Department of Nursing (Mss Cadigan and
Ananian and Dr Mylott), Massachusetts General Hospital, Boston.
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