Reducing Unnecessary Phlebotomy Testing Using a Clinical Decision Support System.

INTRODUCTION: Reducing unnecessary tests reduces costs without compromising quality. We report here the effectiveness of a clinical decision support system (CDSS) on reducing unnecessary type and screen tests and describe, estimated costs, and unnecessary provider ordering. METHODS: We used a pretest posttest design to examine unnecessary type and screen tests 3 months before and after CDSS implementation in a large academic medical center. The clinical decision support system appears when the test order is initiated and indicates when the last test was ordered and expires. Cost savings was estimated using time-driven activity-based costing. Provider ordering before and after the CDSS was described. RESULTS: There were 26,206 preintervention and 25,053 postintervention specimens. Significantly fewer unnecessary type and screen tests were ordered after the intervention (12.3%, n = 3,073) than before (14.1%, n = 3,691; p < .001) representing a 12.8% overall reduction and producing an estimated yearly savings of $142,612. Physicians had the largest weighted percentage of unnecessary orders (31.5%) followed by physician assistants (28.5%) and advanced practice nurses (11.9%). CONCLUSIONS: The CDSS reduced unnecessary type and screen tests and annual costs. Additional interventions directed at providers are recommended. The clinical decision support system can be used to guide all providers to make judicious decisions at the time of care.

Reducing Phlebotomy Utilization With Education and Changes to Computerized Provider Order Entry.

INTRODUCTION: Daily phlebotomy is often a standard procedure in hospitalized patients. Recently, this practice has begun receiving attention as a potential target for efforts focused on eliminating overuse. Several organizations have published their efforts in this arena. Interventions have included education, feedback, and changes to computerized provider order entry (CPOE) but have yielded mixed results. METHODS: A quality improvement initiative to reduce the utilization of daily phlebotomy was conducted at a 505-bed Academic Medical Center. This project involved a combination of educational interventions and changes to CPOE. The primary end point evaluated was the daily performance of complete blood counts (CBCs) and basic metabolic profiles (BMPs) on medical and surgery units relative to the corresponding hospital census. RESULTS: Over the course of this project from August 1, 2013, to September 23, 2016, there was a 15.2% reduction in CBCs (p < .001 for linear trend) and 13.1% reduction in BMPs. DISCUSSION: Our results suggest that layering multimodal interventions that involve both "hard-wired" changes to CPOE and education and performance feedback can result in decreased utilization of phlebotomy.

Genome-Wide Profiling of RNA from Dried Blood Spots: Convergence with Bioinformatic Results Derived from Whole Venous Blood and Peripheral Blood Mononuclear Cells.

Genome-wide transcriptional profiling has emerged as a powerful tool for analyzing biological mechanisms underlying social gradients in health, but utilization in population-based studies has been hampered by logistical constraints and costs associated with venipuncture blood sampling. Dried blood spots (DBS) provide a minimally invasive, low-cost alternative to venipuncture, and in this article we evaluate how closely the substantive results from DBS transcriptional profiling correspond to those derived from parallel analyses of gold-standard venous blood samples (PAXgene whole blood and peripheral blood mononuclear cells [PBMC]). Analyses focused on differences in gene expression between African-Americans and Caucasians in a community sample of 82 healthy adults (age 18-70 years; mean 35). Across 19,679 named gene transcripts, DBS-derived values correlated r = .85 with both PAXgene and PBMC values. Results from bioinformatics analyses of gene expression derived from DBS samples were concordant with PAXgene and PBMC samples in identifying increased Type I interferon signaling and up-regulated activity of monocytes and natural killer (NK) cells in African-Americans compared to Caucasian participants. These findings demonstrate the feasibility of DBS in field-based studies of gene expression and encourage future studies of human transcriptome dynamics in larger, more representative samples than are possible with clinic- or lab-based research designs.

Impact of an educational intervention on the frequency of daily blood test orders for hospitalized patients.

OBJECTIVES: During hospitalizations, blood is drawn for diagnostic laboratory tests to help guide patient care. Often, blood tests continue to be ordered even in the face of clinical and laboratory stability. Blood draws are painful and costly, and they may be associated with anemia. We hypothesized that provider education could reduce the frequency of daily blood tests ordered for hospitalized patients. METHODS: During a 2-month intervention period, internal medicine providers were educated through flyers displayed in providers' offices and periodic email communications reminding them to order daily blood tests only if the results would change patient care. Two-month preintervention data from 982 patients and 2-month postintervention data from 988 patients were analyzed. The primary outcome measured was the number of daily blood tests ordered per patient per day. RESULTS: Mean orders of CBC decreased from 1.46 to 1.37 tests per patient per day (P < .05) after the intervention. Basic metabolic panel orders were reduced from 0.91 to 0.83 tests per patient per day (P < .05). Cost analyses showed a reduction of $6.33 per patient day based on the decrease in the number of daily laboratory tests ordered. CONCLUSIONS: Provider education and reminders can reduce the frequency of daily blood tests ordered by providers for hospitalized patients. This can decrease health care costs and may reduce the risk of complications such as anemia.

Cost analysis of strategies to reduce blood culture contamination in the emergency department: sterile collection kits and phlebotomy teams.

OBJECTIVE: Blood culture collection practices that reduce contamination, such as sterile blood culture collection kits and phlebotomy teams, increase up-front costs for collecting cultures but may lead to net savings by eliminating downstream costs associated with contamination. The study objective was to compare overall hospital costs associated with 3 collection strategies: usual care, sterile kits, and phlebotomy teams. DESIGN: Cost analysis. SETTING: This analysis was conducted from the perspective of a hospital leadership team selecting a blood culture collection strategy for an adult emergency department (ED) with 8,000 cultures drawn annually. METHODS: Total hospital costs associated with 3 strategies were compared: (1) usual care, with nurses collecting cultures without a standardized protocol; (2) sterile kits, with nurses using a dedicated sterile collection kit; and (3) phlebotomy teams, with cultures collected by laboratory-based phlebotomists. In the base case, contamination rates associated with usual care, sterile kits, and phlebotomy teams were assumed to be 4.34%, 1.68%, and 1.10%, respectively. Total hospital costs included costs of collecting cultures and hospitalization costs according to culture results (negative, true positive, and contaminated). RESULTS: Compared with usual care, annual net savings using the sterile kit and phlebotomy team strategies were $483,219 and $288,980, respectively. Both strategies remained less costly than usual care across a broad range of sensitivity analyses. CONCLUSIONS: EDs with high blood culture contamination rates should strongly consider evidence-based strategies to reduce contamination. In addition to improving quality, implementing a sterile collection kit or phlebotomy team strategy is likely to result in net cost savings.

Erythrocytapheresis compared with whole blood phlebotomy for the treatment of hereditary haemochromatosis.

BACKGROUND: Hereditary haemochromatosis may result in severe organ damage which can be prevented by therapy. We studied the possible advantages and disadvantages of erythrocytapheresis as compared with phlebotomy in patients with hereditary haemochromatosis. MATERIALS AND METHODS: In a prospective, randomised, open-label study, patients with hereditary haemochromatosis were randomised to bi-weekly apheresis or weekly whole blood phlebotomy. Primary end-points were decrease in ferritin levels and transferrin saturation. Secondary endpoints were decrease in haemoglobin levels, discomfort during the therapeutic procedure, costs and technicians' working time. RESULTS: Sixty-two patients were included. Thirty patients were randomised to apheresis and 32 to whole blood phlebotomy. Initially, ferritin levels declined more rapidly in the apheresis group, and the difference became statistically highly significant at 11 weeks; however, time to normalisation of ferritin level was equal in the two groups. We observed no significant differences in decline of transferrin saturation, haemoglobin levels or discomfort. The mean cumulative technician time consumption until the ferritin level reached 50 µg/L was longer in the apheresis group, but the difference was not statistically significant. The cumulative costs for materials until achievement of the desired ferritin levels were three-fold higher in the apheresis group. CONCLUSION: Treatment of hereditary haemochromatosis with erythrocytapheresis instead of whole blood phlebotomy results in a more rapid initial decline in ferritin levels and a reduced number of procedures per patient, but not in earlier achievement of target ferritin level. The frequency of discomfort was equally low with the two methods. The costs and, probably, technician time consumption were higher in the apheresis group.

Erythrocytapheresis versus phlebotomy in the initial treatment of HFE hemochromatosis patients: results from a randomized trial.

BACKGROUND: Standard treatment of newly diagnosed HFE hemochromatosis patients is phlebotomy. Erythrocytapheresis provides a new therapeutic modality that can remove up to three times more red blood cells per single procedure and could thus have a clinical and economic benefit. STUDY DESIGN AND METHODS: To compare the number of treatment procedures between erythrocytapheresis and phlebotomy needed to reach the serum ferritin (SF) target level of 50 µg/L, a two-treatment-arms, randomized trial was conducted in which 38 newly diagnosed patients homozygous for C282Y were randomly assigned in a 1:1 ratio to undergo either erythrocytapheresis or phlebotomy. A 50% decrease in the number of treatment procedures for erythrocytapheresis compared to phlebotomy was chosen as the relevant difference to detect. RESULTS: Univariate analysis showed a significantly lower mean number of treatment procedures in the erythrocytapheresis group (9 vs. 27; ratio, 0.33; 95% confidence interval [CI], 0.25-0.45; Mann-Whitney p < 0.001). After adjustments for the two important influential factors initial SF level and body weight, the reduction ratio was still significant (0.43; 95% CI, 0.35-0.52; p < 0.001). Cost analysis showed no significant difference in treatment costs between both procedures. The costs resulting from productivity loss were significantly lower for the erythrocytapheresis group. CONCLUSION: Erythrocytapheresis is highly effective treatment to reduce iron overload and from a societal perspective might potentially also be a cost-saving therapy.

Therapeutic phlebotomy procedures and their impact on a rural hospital's red blood cell inventory and fiscal stature.

BACKGROUND: Therapeutic phlebotomy (TP) programs offer an important community service and often provide financial and donor unit resources for the hospital. This study assessed the financial impact and red blood cell (RBC) inventory contribution of a small, rural hospital-based TP program. STUDY DESIGN AND METHODS: TP procedures over 13 months were evaluated at a 142-bed rural hospital. The hospital had a Food and Drug Administration variance for a hereditary hemochromatosis (HH) donor program. The revenue for the non-HH therapeutic phlebotomies and the savings attained for units added to RBC inventory from allogeneic eligible HH donors were compiled. RESULTS: During the study, 84 patients were involved in the TP program. Of the 62 HH patients, 43 met eligibility requirements for allogeneic donations resulting in 207 donor units collected for the blood bank inventory and a savings of $21,000 in blood costs. Additionally, 22 non-HH patients underwent 183 TP procedures earning the hospital over $15,000 in net revenue. CONCLUSION: The TP program at this small, rural 142-bed hospital provided a financial gain of $36,000 during the 13-month study period. The HH donor program contributed approximately 4% to the RBC inventory. The TP program at this small, rural 142-bed hospital proved to be financially lucrative and provided a community service to patients.

Surgical vampires and rising health care expenditure: reducing the cost of daily phlebotomy.

OBJECTIVE: To determine whether simply being made continually aware of the hospital costs of daily phlebotomy would reduce the amount of phlebotomy ordered for nonintensive care unit surgical patients. DESIGN: Prospective observational study. SETTING: Tertiary care hospital in an urban setting. PARTICIPANTS: All nonintensive care unit patients on 3 general surgical services. INTERVENTION: A weekly announcement to surgical house staff and attending physicians of the dollar amount charged to nonintensive care unit patients for laboratory services during the previous week. MAIN OUTCOME MEASURE: Dollars charged per patient per day for routine blood work. RESULTS: At baseline, the charges for daily phlebotomy were $147.73/patient/d. After 11 weeks of residents being made aware of the daily charges for phlebotomy, the charges dropped as low as $108.11/patient/d. This had a correlation coefficient of -0.76 and significance of P = .002. Over 11 weeks of intervention, the dollar amount saved was $54,967. CONCLUSION: Health care providers being made aware of the cost of phlebotomy can decrease the amount of these tests ordered and result in significant savings for the hospital.

Improving the blood collection process using the active-phlebotomist phlebotomy system.

BACKGROUND: Because the number of patients requiring phlebotomy varies significantly at different times throughout the day, it is difficult to control wait times during peak times. We tried to solve this problem by changing from the conventional fixed-phlebotomist phlebotomy system (CFPPS), in which the phlebotomist waits for patients at a fixed location to the active-phlebotomist phlebotomy system (APPS), in which a phlebotomist goes to patients actively. We compared the productivity of these two systems. METHODS: After changing the system at our hospital, we measured the waiting time before seeing phlebotomy staff and compared it to a comparable hospital that uses CFPPS. We reviewed the phlebotomy count recorded in the laboratory information system before and after the system change. RESULTS: After the system change, the average waiting time for phlebotomy was 2.34 min (median 1 min) and the waiting time was less than 5 min in all time slots, except 7:00 to 7:30 a.m. The new system significantly decreased the waiting time. In addition, the maximum number of patients seen by a phlebotomist during the peak time was higher in the APPS. CONCLUSION: The APPS enhanced the productivity of the phlebotomist and reduced waiting time with limited human resources in a Korean hospital.

Electrolyte orders in the neuroscience intensive care unit: worth the value or waste?

BACKGROUND: To assess the value of the practice of obtaining frequent electrolyte measurements in patients with extended stay in a neuroscience intensive care unit (NICU). METHODS: We identified consecutive patients 18 years or older, admitted to the NICU between January 1 and July 31, 2009 with length of stay ≥ 5 days. We collected potassium, sodium, magnesium, ionized calcium, phosphorus laboratory measurements and hemoglobin levels, and recorded electrolyte replacement orders and red blood cell transfusions. Average laboratory costs were estimated. RESULTS: 93 patients were included in the study (54 men, mean age 54 years, range 18-85 years). Mean length of stay was 10.4 days (range 5-36 days). Sodium and potassium were the electrolytes most frequently measured (averages of 14.1 and 13.1 per patient, respectively). More than 75% of the results were within normal range for all electrolytes measured and critical values were extremely uncommon. The number of phlebotomies for electrolyte measurements was strongly associated with the degree of hemoglobin drop (P < 0.0001). Electrolyte panels were ordered much more often than individual electrolytes with average cost exceeding $2200 per patient. Replacing half of these electrolyte panels with single sodium or potassium orders would have resulted in savings greater than $100,000 in our population. CONCLUSIONS: Electrolytes measurements are very frequent in the NICU, but results are most often normal and only exceptionally critical. The phlebotomies required for these tests significantly worsen hemoglobin levels. A more conservative use of electrolyte measurements can result in reduction of blood loss and substantial cost savings.

Blood product collection and supply: a matter of money?

BACKGROUND: Previous studies have shown that countries with a low or medium Human Development Index (HDI) transfuse far fewer blood products than countries with a high HDI. HDI comprises both economical and non-economical elements. We considered the hypothesis that non-economical, cultural differences may be additional factors in understanding blood donation and blood supply differences. METHODS: We quantified the explained variance, r(2), in: the number of donors, the number of whole blood collections and the number of red blood cell units supplied to hospitals for 25 European countries. Candidate predictors were Hofstede's cultural dimensions, the demographic factor Old Age Dependency Ratio and the three components of HDI: Gross National Income, Life Expectancy and the Educational Development Index. RESULTS: The cultural dimension Power Distance was the best sole predictor of whole blood collection (r(2) = 56.8%) and the number of donors (r(2) = 25.1%). The Educational Development Index best predicted the number of red blood cell units (r(2) = 45.0%). Multivariable models including the cultural dimension Power Distance and the Educational Development Index gave the best results in predicting the number of whole blood collections and red blood cell units supplied and, to a lesser extent, the number of donors, with adjusted r(2) values of 63.6%, 51.9% and 28.6%, respectively. In contrast, Gross National Income made no significant predictive contribution to any of the multivariable models. Neither did the other cultural dimensions, Life Expectancy or Old Age Dependency Ratio. CONCLUSION: The effects of education level and cultural aspects should be taken into account as influencers on donation behaviour. The concept of power distance, in particular, presents a challenge to blood donor managers in cross-cultural and multi-cultural donor management contexts.

Impact of blood cultures drawn by phlebotomy on contamination rates and health care costs in a hospital emergency department.

We conducted a prospective comparison of blood culture contamination rates associated with dedicated phlebotomists and nonphlebotomy staff in the emergency department (ED) at Parkland Memorial Hospital in Dallas, TX. In addition, hospital charges and lengths of stay were determined for patients with negative, false-positive, and true-positive blood culture results. A total of 5,432 blood culture collections from two ED areas, the western wing of the ED (ED west) and the nonwestern wing of the ED (ED nonwest), were evaluated over a 13-month period. Phlebotomists drew 2,012 (55%) of the blood cultures in ED west while nonphlebotomy staff drew 1,650 (45%) in ED west and 1,770 (100%) in ED nonwest. The contamination rates of blood cultures collected by phlebotomists were significantly lower than those collected by nonphlebotomists in ED west (62/2,012 [3.1%] versus 122/1,650 [7.4%]; P < 0.001). Similar results were observed when rates between phlebotomists in ED west and nonphlebotomy staff in ED nonwest were compared (62/2,012 [3.1%] versus 100/1,770 [5.6%]; P < 0.001). Comparison of median patient charges between negative and false-positive episodes ($18,752 versus $27,472) showed $8,720 in additional charges per contamination event while the median length of stay increased marginally from 4 to 5 days. By utilizing phlebotomists to collect blood cultures in the ED, contamination rates were lowered to recommended levels, with projected reductions in patient charges of approximately $4.1 million per year.

Cost-effectiveness of FDA variance for blood collection from individuals with hereditary hemochromatosis at a 398-bed hospital-based donor center.

Hereditary hemochromatosis (HH) is treated by therapeutic phlebotomy to reduce excess body iron. This 398-bed, hospital-based donor center wanted to determine whether there was a financial advantage to requesting FDA approval to allow transfusion of blood components from eligible individuals with HH. Donor center records from 2008 were reviewed to identify all therapeutic phlebotomy patients with a diagnosis of HH. HH patients were contacted and asked to complete the AABB Uniform Donor History Questionnaire (UDHQ) to determine their eligibility as potential allogeneic blood donors. Financial ramifications attributable to loss of revenue from the therapeutic phlebotomies($100/collection) were compared with the potential gain in revenue from collecting units for transfusion ($429/collection) in a 12-month period. Nineteen HH patients were identified and screened for allogeneic eligibility. Seventeen patients (89%) met the eligibility criteria for allogeneic donors, and two patients (11%) did not. Retrospective review of donor records indicated that a total of 60 units were collected from these HH patients from January 2008 through December 2008. Fifty-five of the 60 units collected (92%) were eligible for allogeneic use, potentially generating gross revenue of $23,595. After deducting expenses for infectious disease testing and loss of revenue for the nonqualified therapeutic phlebotomies, the net revenue from the collection of 55 RBC units that could have potentially been used for allogeneic transfusion was $20,345. In contrast, the current revenue generated by the collection of 60 therapeutic phlebotomies was only $6,000. In 2008, using eligible HH individuals as allogeneic blood donors would have resulted in an increase in revenue of $14,345 for our blood center.This study demonstrates that even at a medium-size, hospital-based donor center, obtaining a variance from the FDA to establish an HH blood donor program is a cost-effective endeavor, which does not compromise donor or patient safety.

Evaluation of at-home phlebotomy for iron overload: feasibility and satisfaction of patients and healthcare workers.

OBJECTIVE: This study aimed to evaluate at-home phlebotomy and the satisfaction of iron-overload patients and healthcare workers with the procedure. METHODS: Forty-two patients underwent at-home phlebotomy between 2003 and 2006. The phlebotomy was performed by the patient's nurse, who was trained by the private healthcare firm that also took charge of the disposal of the blood products. Data concerning these phlebotomies were collected via telephone interviews with all 42 patients, as well as 35 nurses and 40 primary-care physicians. The Limousin Regional Health Observatory processed the data collection. RESULTS: Ninety percent (38/42) of the patients, 80% (28/35) of the nurses and 67% (27/40) of the primary-care physicians responded. For 80% of the patients, phlebotomy volume and frequency were as prescribed. Patients chose home phlebotomy for personal reasons, or because of the limited availability of French Blood Establishment facilities (68%), or in response to being offered it by their hospital physician (32%). For 81.6% of the patients, at-home phlebotomy was more satisfactory than phlebotomy in hospital or at the French Blood Establishment and, for 84%, the constraints required were fully acceptable. The nurses considered that these homecare procedures were within their area of responsibility (100%), but felt that the remuneration was insufficient (65%). Ninety-six percent of the primary-care physicians said they were correctly informed, but only 40% felt that they were truly committed to the procedure. CONCLUSION: At-home phlebotomy is feasible, less costly than institutional phlebotomy and improves patient comfort.

Blood, sweat, and tears: embedding biological samples in social science research on children.

In the first decade of the 21st Century, calls for interdisciplinary research are commonplace. Yet, relatively few papers discuss how to complete such research successfully. In this paper, I describe the details of data collection focused on five, six and seven-year old children. The project examined the effect of environmental contaminants on children's educational outcomes. It included a primary caregiver interview, a skill test with the child, and a venous blood draw from the child to test for lead, mercury, cadmium, arsenic, nicotine, and cotinine. This paper describes key issues and the solutions I adopted. Challenges discussed here include navigating the Institutional Review Board Process, analyzing the blood, obtaining the supplies needed to draw blood, banking blood for future research, hiring a phlebotomist, and recruiting subjects. While not all details will apply directly to other research projects, this paper provides some perspective on the current realities facing social scientists who decide to collect biological samples.