A GROUP of New York City hospitals found a way to reduce the repeated use of inflammatory marker testing in non-ICU COVID-19 hospitalized patients.
In a study in the Journal of Hospital Medicine, researchers with New York City Health + Hospitals, a public safety-net system that includes 11 hospitals, targeted four tests that were being overused in non-ICU covid patients: C-reactive protein (CRP), ferritin, lactate dehydrogenase (LDH) and procalcitonin. The health system’s System High-Value Care Council created the list of overused tests. (It chose to not focus on markers for D-dimer and troponin.)
To reduce the use of those four tests when admitting covid patients, the health system made two changes to an ordering section for inflammatory markers. That ordering section appeared in both the health system’s general admission order set and its covid admission order set. Changes included:
Researchers added a “nonintrusive, informational nudge statement” to the health system’s Epic EHR. The statement explained that the council was recommending that inflammatory markers be checked on admission for covid patients, but that they should not be repeated unless there was clinical change or deterioration—with the exception of D-dimers. (Researchers noted that D-dimer testing was being used at that time to anticoagulate covid patients.)
The health system created a one-day “forcing function” that allowed physicians to order the four tests for only one day per entry. Previously, the health system had allowed the tests to be ordered for up to three consecutive days.
After the changes were made, researchers saw a clear reduction in use of the markers. The study found an 18% decrease in CRP testing, a 38% decrease in ferritin testing and a 30% decrease in LDH testing.
Researchers noted that despite seeing an overall reduction in the use of three of the four tests, there was significant variation in those reductions across the system’s 11 hospitals. The use of LDH testing, for example, went from a 35% increase to a 51% decrease.
The study found no clear patterns in the use of inflammatory marker tests when comparing hospitals by size or by their status as a trauma center. Researchers concluded that variations in use of the tests were most likely based on local practice patterns.
The authors also noted how quickly the use of routine inflammatory marker testing in covid patients went from being very useful to not recommended over the course of the pandemic. In the early days of the pandemic, they said, the markers greatly helped diagnose covid patients. As more was known about covid, however, the tests could be detrimental to patient care.
After the changes were made to the EHR, the study looked at more than 7,383 patient encounters between January 2021 and March 2022.