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Original Investigation |

Impact of Providing Fee Data on Laboratory Test Ordering:  A Controlled Clinical Trial

Leonard S. Feldman, MD; Hasan M. Shihab, MBChB, MPH; David Thiemann, MD; Hsin-Chieh Yeh, PhD; Margaret Ardolino, RN, MS; Steven Mandell, MS; Daniel J. Brotman, MD
JAMA Intern Med. 2013;173(10):903-908. doi:10.1001/jamainternmed.2013.232.
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Importance Inpatient care providers often order laboratory tests without any appreciation for the costs of the tests.

Objective To determine whether we could decrease the number of laboratory tests ordered by presenting providers with test fees at the time of order entry in a tertiary care hospital, without adding extra steps to the ordering process.

Design Controlled clinical trial.

Setting Tertiary care hospital.

Participants All providers, including physicians and nonphysicians, who ordered laboratory tests through the computerized provider order entry system at The Johns Hopkins Hospital.

Intervention We randomly assigned 61 diagnostic laboratory tests to an “active” arm (fee displayed) or to a control arm (fee not displayed). During a 6-month baseline period (November 10, 2008, through May 9, 2009), we did not display any fee data. During a 6-month intervention period 1 year later (November 10, 2009, through May 9, 2010), we displayed fees, based on the Medicare allowable fee, for active tests only.

Main Outcome Measures We examined changes in the total number of orders placed, the frequency of ordered tests (per patient-day), and total charges associated with the orders according to the time period (baseline vs intervention period) and by study group (active test vs control).

Results For the active arm tests, rates of test ordering were reduced from 3.72 tests per patient-day in the baseline period to 3.40 tests per patient-day in the intervention period (8.59% decrease; 95% CI, −8.99% to −8.19%). For control arm tests, ordering increased from 1.15 to 1.22 tests per patient-day from the baseline period to the intervention period (5.64% increase; 95% CI, 4.90% to 6.39%) (P < .001 for difference over time between active and control tests).

Conclusions and Relevance Presenting fee data to providers at the time of order entry resulted in a modest decrease in test ordering. Adoption of this intervention may reduce the number of inappropriately ordered diagnostic tests.

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Figures

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Figure 1. Computerized provider order entry example. AM indicates morning; Heme-8, complete blood count; Lab/LAB, laboratory; STAT, immediately.

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Figure 2. Change in total charges (in US dollars) from baseline to intervention periods. BMP indicates basic metabolic panel; iCa, ionized calcium; CMP, comprehensive metabolic panel.

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