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Major reductions in unnecessary aspartate aminotransferase and blood urea nitrogen tests with a quality improvement initiative
  1. Rachel Strauss1,
  2. Alex Cressman2,
  3. Mark Cheung3,
  4. Adina Weinerman4,
  5. Suzanne Waldman1,
  6. Edward Etchells4,
  7. Alireza Zahirieh5,
  8. Piero Tartaro6,
  9. Jeremy Rezmovitz7,
  10. Jeannie Callum1
  1. 1Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
  2. 2Division of Internal Medicine, University of Toronto, Toronto, Ontario, Canada
  3. 3Division of General Internal Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
  4. 4Division of General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
  5. 5Department of Nephrology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
  6. 6Department of Gastroenterology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
  7. 7Department of Family and Community Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
  1. Correspondence to Dr Jeannie Callum, Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada; jeannie.callum{at}sunnybrook.ca

Abstract

Background/context Unnecessary laboratory testing leads to considerable healthcare costs. Aspartate aminotransferase (AST), commonly ordered with alanine aminotransferase (ALT) and blood urea nitrogen (BUN), commonly ordered with creatinine (Cr), often add little value to patient management at significant cost. We undertook a choosing wisely based quality improvement initiative to reduce the frequency of testing.

Objectives To reduce the ratio of AST/ALT and BUN/Cr to less than 5% for all inpatient and outpatient test orders.

Measures Absolute number and ratio of AST/ALT and BUN/Cr; AST, ALT, BUN and Cr tests per 100 hospital days; projected annualised cost savings and monthly acute inpatient bed days.

Improvements We created guidelines for appropriate indications of AST and BUN testing, provided education with audit and feedback and removed AST and BUN from institutional order sets.

Impact/results The ratios of AST/ALT and BUN/Cr decreased significantly over the study period (0.37 to 0.14, 0.57 to 0.14, respectively), although the goal of 0.05 was not achieved due to a delay in adopting the choosing wisely strategies during the study time period by some inpatient units. The number of tests per 100 hospital days decreased from 20 to 7 AST (95% CI 19 to 20.5, 5.6 to 8.7, p<0.001) and from 72 to 17 BUN (95% CI 70 to 73.4, 16.6 to 22.9, p<0.001). The initiative resulted in a projected annualised cost savings of C$221 749.

Discussion A significant decrease in the AST/ALT and BUN/Cr ratios can be achieved with a multimodal approach and will result in substantial healthcare savings.

  • quality improvement
  • laboratory medicine
  • educational outreach, academic detialing

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Footnotes

  • Contributors RS, AC, CMC, PT, AZ, JC, AW, EE and JR planned and carried out interventions. SW extracted data from the laboratory information system. RS and JC performed data analyses. RS, AC and JC wrote the manuscript with input from all authors.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Data are available upon reasonable request.

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