Reminding surgical staff of phlebotomy costs appears to affect utilization

(Press-News.org) Surgical house staff and attending physicians who are reminded about the charges for ordering daily blood drawing for routine blood work appear to reduce the amount of routine blood tests ordered and the charges for these laboratory tests, according to a report in the May issue of Archives of Surgery, one of the JAMA/Archives journals.

"The use of laboratory tests has been rapidly increasing over the past few decades to the point where phlebotomy is a substantial proportion of hospital expenditure, and much of it is unwarranted," state the authors. As background, they note that some institutions have modified computer systems to limit the opportunity for clinicians to order redundant tests. They also point to other studies associating these practices with cost savings and no adverse effects on readmission rates, transfer to the intensive care unit, length of stay, diagnoses, or mortality.

Elizabeth A. Stuebing, M.D., M.P.H., of the University of Miami , and Thomas J. Miner, M.D., from Brown University in Providence , R.I. , conducted a study at a Rhode Island Hospital . For nonintensive care unit patients among three general surgical services, the authors obtained daily phlebotomy data, as well as associated charges for these tests, and calculated the amount spent on blood draws and laboratory tests per patient and as a whole. The researchers then made a weekly announcement, for 11 weeks, to surgical house staff and attending physicians about total charges as well as charges per patient per day averaged over the previous week.

The baseline per-patient daily charges were calculated as $147.73, for an initial total of $36,875 charged per week for routine laboratory tests, including blood counts and chemistry panels. During the intervention, the lowest per-patient daily phlebotomy charge was $108.11, a decrease of 27 percent from baseline, and the lowest overall weekly charge was $25,311. At the end of the 11-week study period, the researchers calculated that $54,967 had been saved. The only two weeks in which charges increased to a great extent from the prior week were the same times in which interns rotated in and out of the unit.

The authors reported that the intervention was successful and the costs of implementing it were negligible. "We focused on simply providing the economic implications of wasteful ordering habits, specifically regarding phlebotomy," they write. "This study successfully showed that even without technical and time-consuming interventions, test ordering behavior can be greatly reduced by making health care providers aware of costs."

(Arch Surg. 2011;146[5]:524-527. Available pre-embargo to the media at www.jamamedia.org.)

Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

Commentary: Is That Laboratory Test Necessary?

In a related commentary, A. Benedict Cosimi, M.D., from Massachusetts General Hospital in Boston, writes, "Stuebing and Miner are to be commended for attempting to reduce the volume of unnecessary phlebotomy orders on their surgical units by increasing the cost consciousness of the caregivers." Cosimi commends Stuebing and Miner for offering "convincing evidence that cost consciousness can provide a potent weapon for reducing some of the wasteful medical spending that contributes to our overall health care bill, which currently is twice as much per person as that of most industrialized countries."

### (Arch Surg. 2011;146[5]:527. Available pre-embargo to the media at www.jamamedia.org.)

Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

To contact Elizabeth A. Stuebing, M.D., M.P.H., call Omar Montejo at 305-243-5654 or e-mail omontejo@miami.edu.

For more information, contact JAMA/Archives Media Relations at 312/464-JAMA (5262) or e-mail mediarelations@jama-archives.org.