Can a mindful approach to ordering investigations reduce inappropriate testing?

Appropriate resource allocation in the healthcare setting should be a factor to consider in all clinical encounters. It is the guiding principle behind the group Choosing Wisely Canada, which was created in 2014 in response to the growing need to cut down on unnecessary testing and medical procedures which represent 30% of all interventions performed across the country. Testing is not only expensive from a systems point of view, but may also put patients in harm’s way when you consider the implications of a test and its result for the individual receiving it: false positives, inherent risks and side-effects, and the anxiety that precedes any medical procedure. Choosing Wisely puts out excellent recommendations for all medical specialties ranging from family practice to rheumatology and is involved in nearly 350 quality improvement (QI) research projects to study the effects of guideline implementation on clinical practice and outcomes. But what more can you do on an individual basis as a healthcare professional to ensure judicious allocation of health resources? Researchers at the McGill Clinical Practice Assessment Unit supervised an observational study on the effectiveness of “trainee-led daily time-outs” with regards to cutting down on needless lab testing.

McGill medical trainees led this project at the Royal Victoria Hospital on a 26-bed teaching unit, with the intention of decreasing unnecessary lab tests using a “mindfulness-based laboratory reduction” approach. This involved 3 actions; first conversations held at QI rounds reminding the team about the dangers of needless testing with discussions revolving around the CanMED roles, second restricting physicians’ ability to pre-emptively order labs ahead of time to 2 days inclusively, and third implementation of daily time-out sessions where all labs sent for the next day could be carefully examined and a decision could be made as to whether these were necessary and/or appropriate.

When results of the study were examined, it was found that costs related to testing of individual admitted patients were reduced from 117$ to 66$. These calculations were made using data from 985 patients, reflecting a total of 50, 657$ saved on behalf of the hospital! Staff who participated in this project were found to have a 32% reduction of test-related costs per patient following the intervention. Additionally, the duration of hospitalization was reduced for those patients included in the study.//It’s important to remember that while this data is interesting, it is drawn from a very select patient population at a single institution. That being said, similar time-out procedures such as those carried out in the immediate pre-op period to confirm patient ID have strong evidence to support their usefulness in preventing medical error. And it’s only intuitive that taking these kinds of team pauses has the potential to optimize patient care and satisfaction in that care. It would be interesting to see how a larger scale project might be conducted across a handful of teaching hospitals, perhaps with a QI curricula that could consistently be used at each center.//Ultimately, it’s projects like these that remind us that a mindful approach should be integrated as much as possible in clinical decision-making at all levels, for the sake of allocating resources in a just manner and for the sake of delivering safe and evidence-based care.

This article was written by Madison Le Gallee, a second year medical student at McGill University and a member of the McGill Med Mindfulness team.

Reference: McDonald EG, Saleh RR, Lee TC. Mindfulness-based laboratory reduction: reducing utilization through trainee-led daily ‘time-outs’. Am J Med. 2017;130:e241-e244. – PubMed

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