High-Value, Cost-Conscious Care: Iterative Systems-Based Interventions to Reduce Unnecessary Laboratory Testing.

BACKGROUND: Inappropriate testing contributes to soaring healthcare costs within the United States, and teaching hospitals are vulnerable to providing care largely for academic development. Via its "Choosing Wisely" campaign, the American Board of Internal Medicine recommends avoiding repetitive testing for stable inpatients. We designed systems-based interventions to reduce laboratory orders for patients admitted to the wards at an academic facility. METHODS: We identified the computer-based order entry system as an appropriate target for sustainable intervention. The admission order set had allowed multiple routine tests to be ordered repetitively each day. Our iterative study included interventions on the automated order set and cost displays at order entry. The primary outcome was number of routine tests controlled for inpatient days compared with the preceding year. Secondary outcomes included cost savings, delays in care, and adverse events. RESULTS: Data were collected over a 2-month period following interventions in sequential years and compared with the year prior. The first intervention led to 0.97 fewer laboratory tests per inpatient day (19.4%). The second intervention led to sustained reduction, although by less of a margin than order set modifications alone (15.3%). When extrapolating the results utilizing fees from the Centers for Medicare and Medicaid Services, there was a cost savings of $290,000 over 2 years. Qualitative survey data did not suggest an increase in care delays or near-miss events. CONCLUSIONS: This series of interventions targeting unnecessary testing demonstrated a sustained reduction in the number of routine tests ordered, without adverse effects on clinical care.

Nutritional assessments of patients with non-alcoholic fatty liver disease.

BACKGROUND: Obesity is not only associated with nonalcoholic fatty liver disease (NAFLD) but it also adversely affects the progression of other liver diseases. There are limited data regarding the dietary habits of patients with chronic liver disease. METHODS: Nutrition surveys containing 13 different food groups were mailed. Nutrition scores were calculated based on weekly servings. Foods were also divided into USDA food pyramid categories with conversion of each group into calories expended. Clinico-demographic data were available. NAFLD patients were compared to patients with chronic viral hepatitis. RESULTS: A total of 233 subjects were included: age 52.5 +/- 10.0 years, Body mass index (BMI) 28.1 +/- 6.5, MS 24.2%, 31.8% NAFLD, 48.1% hepatitis C virus (HCV), and 20.2% hepatitis B virus (HBV). Six nutrition indices were different among the groups. NAFLD and HCV consumed more low-nutrient food (p = 0.0037 and 0.0011) and more high-sodium food than HBV (p = 0.0052 and 0.0161). Multivariate analysis showed that NAFLD and HCV consumed more high-fat sources of meat/protein than HBV (p = 0.0887 and 0.0626). NAFLD patients consumed less calories from fruits compared to HCV and HBV patients (p = 0.0273 and 0.0023). Nine nutrition indices differed according to BMI. Univariate analysis showed that obese/overweight patients consumed more high-fat sources of meat/protein (p = 0.0078 and 0.0149) and more high-sodium foods (p = 0.0089 and 0.0062) compared to the normal-weight patients. In multivariate analysis, normal-weight patients consumed more fruits than obese (p = 0.0307). Overweight patients also consumed more calories of meat and oil than normal-weight patients (p = 0.0185 and 0.0287). CONCLUSION: NAFLD and HCV patients have similar dietary habits. Patients with HBV have the healthiest dietary habits. Specific dietary interventions should focus on decreasing intake of low-nutrient and high-sodium food, as well as high-fat sources of meat/protein.

Nonalcoholic fatty liver disease: a manifestation of the metabolic syndrome.

Nonalcoholic fatty liver disease (NAFLD) has become the most common form of liver disease, affecting 20% to 30% of the US population. Its clinical manifestations are usually absent or subtle, and it usually comes to medical attention incidentally when aminotransferase levels are found to be elevated or a radiographic study reveals that the liver is fatty. Primary NAFLD is now considered the hepatic manifestation of the metabolic syndrome. The pathogenesis is thought to be a multiple-hit process involving insulin resistance, oxidative stress, apoptosis, and adipokines. In general, the prognosis for simple steatosis is very good; however, nonalcoholic steatohepatitis (NASH) can progress to cirrhosis and hepatocellular carcinoma in 10% to 15% of patients. There is no established treatment for NAFLD except for weight loss and treating each component of the metabolic syndrome.