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BACKGROUND Inappropriate laboratory testing is a contributor to waste in healthcare. OBJECTIVE To evaluate the impact of a multifaceted laboratory reduction intervention on laboratory costs. DESIGN A retrospective, controlled, interrupted time series (ITS) study. SETTING University of Utah Health Care, a 500‐bed academic medical center in Salt Lake City, Utah. POPULATION All patients 18 years or older admitted to the hospital to a service other than obstetrics, rehabilitation, or psychiatry. INTERVENTION Multifaceted quality‐improvement initiative in a hospitalist service including education, process change, cost feedback, and financial incentive. MEASUREMENTS Primary outcomes of lab cost per day and per visit. Secondary outcomes of number of basic metabolic panel (BMP), comprehensive metabolic panel (CMP), complete blood count (CBC), and prothrombin time/international normalized ratio tests per day; length of stay (LOS); and 30‐day readmissions. RESULTS A total of 6310 hospitalist patient visits (intervention group) were compared to 25,586 nonhospitalist visits (control group). Among the intervention group, the unadjusted mean cost per day was reduced from $138 before the intervention to $123 after the intervention (P < 0.001), and the unadjusted mean cost per visit decreased from $618 to $558 (P = 0.005). The ITS analysis showed significant reductions in cost per day, cost per visit, and the number of BMP, CMP, and CBC tests per day (P = 0.034, 0.02, <0.001, 0.004, and <0.001). LOS was unchanged and 30‐day readmissions decreased in the intervention group. CONCLUSION A multifaceted approach to laboratory reduction demonstrated a significant reduction in laboratory cost per day and per visit, as well as common tests per day at a major academic medical center. Journal of Hospital Medicine 2016;11:348–354. © 2016 Society of Hospital Medicine

Although electronic telemetry ordering changes can produce decreases in hospital-wide telemetry monitoring, a multifaceted intervention may lead to an even larger decline in utilization rates. Whether these changes are durable cannot be ascertained from our study.

Background The first Multi-center Medication Reconciliation Quality Improvement Study (MARQUIS1) demonstrated that implementation of a medication reconciliation best practices toolkit decreased total unintentional medication discrepancies in five hospitals. We sought to implement the MARQUIS toolkit in more diverse hospitals, incorporating lessons learned from MARQUIS1. Methods MARQUIS2 is a pragmatic, mentored implementation QI study which collected clinical and implementation outcomes. Sites implemented a revised toolkit, which included interventions from these domains: 1) best possible medication history (BPMH)-taking; 2) discharge medication reconciliation and patient/caregiver counseling; 3) identifying and defining clinician roles and responsibilities; 4) risk stratification; 5) health information technology improvements; 6) improved access to medication sources; 7) identification and correction of real-time discrepancies; and, 8) stakeholder engagement. Eight hospitalists mentored the sites via one site visit and monthly phone calls over the 18-month intervention period. Each site’s local QI team assessed opportunities to improve, implemented at least one of the 17 toolkit components, and accessed a variety of resources (e.g. implementation manual, webinars, and workshops). Outcomes to be assessed will include unintentional medication discrepancies per patient. Discussion A mentored multi-center medication reconciliation QI initiative using a best practices toolkit was successfully implemented across 18 medical centers. The 18 participating sites varied in size, teaching status, location, and electronic health record (EHR) platform. We introduce barriers to implementation and lessons learned from MARQUIS1, such as the importance of utilizing dedicated, trained medication history takers, simple EHR solutions, clarifying roles and responsibilities, and the input of patients and families when improving medication reconciliation.

SYNOPSIS Compared to younger patients, older patients with atrial fibrillation (AF) have an increased risk of stroke and systemic embolism1, 2. For the majority of patients, oral anticoagulation (OAC) remains the most effective way to reduce this risk. While vitamin K antagonists (VKAs) have been used for decades, the more recent development of non-vitamin K dependent oral anticoagulants (NOACs) provides clinicians with broader selection of anticoagulants for stroke prevention in older AF patients. In this review, we discuss stroke risk-stratification tools for clinical decision making, review pharmacologic options for the prevention of stroke, and highlight several practical considerations to the use of these agents in older adults.