Implementation of Best Practice Advisories (BPAs) in an 11-hospital safety net system significantly reduced PT/INR and aPTT tests by 18.9% and 19.8%, respectively, in emergency departments, emphasizing the effectiveness of this intervention in minimizing unnecessary test utilization.

The following is a summary of “Reducing low-value ED coags across 11 hospitals in a safety net setting,” published in the November 2023 issue of Emergency Medicine by Walker, et al.

Prothrombin/international normalized ratio and activated partial thromboplastin time (PT/INR and aPTT) are frequently ordered in emergency departments (EDs), although they seldom impact management decisions. Despite numerous quality improvement efforts that have successfully reduced the use of PT/INR and aPTT in well-resourced settings, there’s a gap in evidence for single-intervention approaches within large safety net systems. For a study, researchers sought to evaluate the effectiveness of implementing two Best Practice Advisories (BPAs) in curtailing the usage of PT/INR and aPTT across an expansive safety net system.

Conducted across an 11-hospital safety net system in the United States, this initiative introduced two BPAs discouraging inappropriate PT/INR and aPTT utilization from March 16, 2022, to August 30, 2022. The order rates of PT/INR and aPTT per 100 ED patients were compared pre and post-intervention, both system-wide and at individual hospital levels. 

Complete blood count (CBC) tests served as a control metric, while packed red blood cell transfusions acted as a balancing measure. An interrupted time series regression analysis was employed to discern immediate and longitudinal shifts in test ordering during the intervention phases.

Post-intervention, PT/INR tests displayed an absolute reduction of 4.11 tests per 100 ED visits (95% CI −5.17 to −3.05; a relative decrease of 18.9%). Similarly, aPTT tests witnessed an absolute reduction of 4.03 tests per 100 ED encounters (95% CI −5.10 to −2.97; a relative decrease of 19.8%). Conversely, the control metric, CBC, demonstrated no significant alteration (−0.43, 95% CI −2.83 to 1.96). The response across individual hospitals varied, with relative reductions ranging from 12.1% to 30.5% for PT/INR and 12.1% to 31.4% for aPTT. Regression analysis indicated an immediate decline of 25.7% in PT/INR and 24.7% in aPTT tests post-intervention. However, the rate of test ordering did not show a significant decline compared to the control.

The implementation of BPAs effectively decreased PT/INR and aPTT utilization across 11 EDs within a large urban safety net system. While promising, additional research is essential to determine the efficacy of this intervention in non-safety net settings.

Source: sciencedirect.com/science/article/abs/pii/S0735675723004321