Agreement Between Serum Assays Performed in ED Point-of-Care and Hospital Central Laboratories.

INTRODUCTION: Point-of-care (POC) testing allows for more time-sensitive diagnosis and treatment in the emergency department (ED) than sending blood samples to the hospital central laboratory (CL). However, many ED patients have blood sent to both, either out of clinical custom, or because clinicians do not trust the POC values. The objective of this study was to examine the level of agreement between POC and CL values in a large cohort of ED patients. METHODS: In an urban, Level I ED that sees approximately 120,000 patients/year, all patients seen between March 1, 2013, and October 1, 2014, who had blood sent to POC and CL labs had levels of agreement measured between serum sodium, potassium, blood urea nitrogen (BUN), creatinine, and hematocrit. We extracted data from the hospital's clinical information system, and analyzed agreement with the use of Bland-Altman plots, defining both 95% confidence intervals (CIs) and more conservative CIs based on clinical judgment. RESULTS: Out of 163,661 patients seen during the study period, 14,567 had blood samples sent both for POC and CL analysis. Using clinical criteria, the levels of agreement for sodium were 98.6% (within 5mg/dL), for potassium 90.7% (0.5 mmol/L), for BUN 89.0% (within 5 mg/dL), for creatinine 94.5% (within 0.3 mg/dL), for hematocrit 96.5% (within 5 g/dL). CONCLUSION: Agreement between POC and CL values is excellent. Restricting the analysis to clinically important levels of agreement continues to show a high level of agreement. The data suggest that sending a serum sample to the hospital CL for duplicate assays is unnecessary. This may result in substantial savings and shorter ED lengths of stay.

Exit Survey of Senior Residents: Cost Conscious but Uninformed.

Background Cost awareness, to ensure physician stewardship of limited resources, is increasingly recognized as an important skill for physicians. The Accreditation Council for Graduate Medical Education has made cost awareness part of systems-based practice, a core competency of resident education. However, little is known about resident cost awareness. Objective We sought to assess senior resident self-perceived cost awareness and cost knowledge. Methods In March 2014, we conducted a cross-sectional survey of all emergency medicine, internal medicine, obstetrics and gynecology, orthopaedic surgery pediatrics, and medicine-pediatrics residents in their final year at Yale-New Haven Hospital. The survey examined attitudes toward health care costs and residents' estimates of order prices. We considered resident price estimates to be accurate if they were between 50% and 200% of the Connecticut-specific Medicare price. Results We sent the survey to 84 residents and received 47 completed surveys (56% response rate). Although more than 95% (45 of 47) felt that containing costs is the responsibility of every clinician, and 49% (23 of 47) agreed that cost influenced their decision when ordering, only 4% (2 of 47) agreed that they knew the cost of tests being ordered. No residents accurately estimated the price of a complete blood count with differential, and only 2.1% (1 of 47) were accurate for a basic metabolic panel. The overall accuracy of all resident responses was 25%. Conclusions In our study, many trainees exit residency with self-identified deficiencies in knowledge about costs. The findings show the need for educational approaches to improve cost awareness among trainees.

Impact of laboratory cost display on resident attitudes and knowledge about costs.

AIM: Cost awareness has been proposed as a strategy for curbing the continued rise of healthcare costs. However, most physicians are unaware of the cost of diagnostic tests, and interventions have had mixed results. We sought to assess resident physician cost awareness following sustained visual display of costs into electronic health record (EHR) order entry screens. STUDY DESIGN: We completed a preintervention and postintervention web-based survey. Participants were physicians in internal medicine, paediatrics, combined medicine and paediatrics, obstetrics and gynaecology, emergency medicine, and orthopaedic surgery at one tertiary co are academic medical centre. Costs were displayed in the EHR for 1032 unique laboratory orders. We measured attitudes towards costs and estimates of Medicare reimbursement rates for 11 common laboratory and imaging tests. RESULTS: We received 209 survey responses during the preintervention period (response rate 71.1%) and 194 responses during the postintervention period (response rate 66.0%). The proportion of residents that agreed/strongly agreed that they knew the costs of tests they ordered increased after the cost display (8.6% vs 38.2%; p<0.001). Cost estimation accuracy among residents increased after the cost display from 24.0% to 52.4% for laboratory orders (p<0.001) and from 37.7% to 49.6% for imaging orders (p<0.001). CONCLUSIONS: Resident cost awareness and ability to accurately estimate laboratory order costs improved significantly after implementation of a comprehensive EHR cost display for all laboratory orders. The improvement in cost estimation accuracy for imaging orders, which did not have costs displayed, suggested a possible spillover effect generated by providing a cost context for residents.