Evaluating the long-term effects of a data-driven approach to reduce variation in emergency department pathology investigations: study protocol for evaluation of the NSW Health Pathology Atlas of variation

Abstract

IntroductionVariation in test ordering is a major issue in Australia and globally with significant financial and clinical impacts. There is currently a lack of research identifying and remediating variation in the use of pathology tests in emergency departments (EDs). In 2019, NSW Health Pathology introduced the Pathology Atlas of Variation that uses a data-driven tool (the Atlas Analytical Model) to investigate test order variation across New South Wales (NSW) and engage with local health districts (LHDs) to reduce variation. The objectives of this study are to evaluate whether this data-driven approach is associated with: (1) a reduction in test order variation; (2) improvements in patient outcomes and (3) cost benefits, for the five most frequent ED presentations.Methods and analysisThis is a large multisite study including 45 major public hospitals across 15 LHDs in NSW, Australia. The Atlas Analytical Model is a data analytics and visualisation tool capable of providing analytical insights into variation in pathology investigations across NSW EDs, which will be used as feedback to inform LHDs efforts to reduce variation. Interrupted time series analyses using 2 years pre Atlas (2017–2018) and 2 years post Atlas (2021–2022) data will be conducted. Study data will be obtained by linking hospital and laboratory databases. Funnel plots will be used to identify EDs with outlying pathology test ordering practices. The outcome measures include changes in test ordering practices, ED length of stay, hospital admission and cost benefits (total pathology costs per ED encounter).Ethics and disseminationThe study has received ethical approval from the NSW Population and Health Service Research Ethics Committee (reference, 2019/ETH00184). The findings of the study will be published in peer-reviewed journals and disseminated via presentations at conferences. We will also engage directly with key stakeholders to disseminate the findings and to inform policies related to pathology testing in the ED.

Diagnostic Informatics—The Role of Digital Health in Diagnostic Stewardship and the Achievement of Excellence, Safety, and Value

“…They can deliver key outcome-based measures of diagnostic utilization such as patient outcome or hospital admissions, which can be used to evaluate the impact of key interventions (e.g., electronic decision support). This is the premise underlying key initiatives like the New South Wales (NSW) Health Pathology Atlas of Variation (in collaboration with the NSW Emergency Care Institute and NSW eHealth Integrated Care), designed to create a statewide quality improvement project ( 10 ).…”

The NSW Pathology Atlas of Variation: Part II—The Association of Variation in Emergency Department Laboratory Investigations With Outcomes for Patients Presenting With Chest Pain

“…Fourth, the presenting problem, a triage nurse-entered data field, has some limitations, as outlined previously. 13,35 Although most of the presenting problem terminologies used to indicate chest pain are consistent across the study hospitals, there were some free-text terminologies and discrepancies in the use of the free texts across hospitals. 13,35 Fifth, information extracted from routinely collected administrative and clinical databases may sometimes be inaccurate owing to potential data entry errors.…”

“…12 In an effort to reduce variation in laboratory investigations across EDs in New South Wales (NSW), the most populous state in Australia, NSW Health Pathology recently introduced a statewide project called the NSW Pathology Atlas of Variation. 13 The NSW Pathology Atlas of Variation aims to investigate the variation that exists across NSW and to engage with local health districts within the state to reduce variation where it may be unwarranted. As part of this large project, the current study sought to evaluate variation in ED laboratory investigations and its association with patient operational outcomes specifically in patients presenting with undifferentiated chest pain.…”

The NSW Pathology Atlas of Variation: Part I—Identifying Emergency Departments With Outlying Laboratory Test–Ordering Practices

“…The current study was undertaken as part of a larger NSW Pathology Atlas of Variation project, for which the study protocol is available elsewhere. 50 The objectives of the current study were to identify EDs with outlying laboratory test-ordering practices for patients presenting with undifferentiated abdominal pain and chest pain across 44 Australian EDs.…”

“…Although most of the entries are consistent across the study hospitals and there were only a few missing values for this data field, there were some free-text entries and inconsistencies in them. 50,64 In our previous pilot trial from 4 hospitals (unpublished data), of the 381,744 presenting problem entries indicating abdominal pain, 83.5%, 10.4%, 1.3%, and 0.8% were entered as "pain, abdominal," "pain-abdominal," "pain, epigastric," and "abdominal pain," respectively, whereas other terminologies such as "abdo pain," "lower abdominal pain," "central abdominal pain," "RLQ abdo pain," "RUQ abdo pain," and "UPPER abdominal pain" accounted for approximately 4% of the entries for abdominal pain. We observed similar variations in the use of terminologies indicating chest pain (eg, "pain, chest," "chest pain," "pain-chest").…”