Bates et al., 1999, The USA (28) | RCT | 4 months | A tertiary care hospital | Inpatients at the hospital | CG: 5886 patients IG:5700 patients | CPOE reminder: In the intervention group, if a test had previously been ordered within its test-specific interval, the physician received a reminder that the test had been performed recently or was pending; the result was showed if available. For the control group, duplication was determined in exactly the same way, but there was no reminder. | Delivering reminders about orders for apparently redundant laboratory tests were effective. However, since many tests were conducted without corresponding computer orders and many orders were not screened for duplication overall effect was limited. |
Boon-Falleur et al., 1995, The United Kingdom (31) | Before-after | 6 months | A pediatric liver disease unit | Patients with liver transplant | Before: 42 patients After: 175 patients | A rule-based expert system allows static and dynamic requesting rules to be defined for different clinical classifications of patients. The static rules allow the definition of "baseline" proposals within a precise time schedule. Dynamic rules allow the system to react to results of previously ordered tests. The attending physician may accept or amend the system's proposals by adding or removing requests to the proposed schedule. | The clinicians’ perspective was that the system would increase the total benefits in clinical resources use, improve the management of laboratory data, and save time for doing laboratory ancillary tasks. |
Bridges et al., 2014, The USA (34) | Before-after | 6 months | A tertiary care hospital | Patient admitted to the department of medicine | Before: 674 patients After: 692 patients | The intervention consisted of displaying a computerized alert informing that the clinician is ordering a recently ordered test. | Computerized alerts may be effective in reducing redundant laboratory tests and enhancing efficiency of healthcare system. |
Dalal et al., 2017, The USA (35) | Before-after | 6 months | A teaching hospital | All TSH, T3, and T4 ordered in Department of Medicine | Before: 2611 tests After: 2454 tests | A clinical algorithm for CDS and Hard Stops were incorporated into the EMR to decline ordering freeT3 or freeT4 without an abnormal TSH, also certain exceptions were predefined. In addition, if the TSH was abnormal a reflex rule was triggered and could automatically order freeT3 and freeT4. | By a clinical decision support about when to order TFTs, they observed a decrease in the number of unnecessary tests ordered. |
Eaton et al., 2018, The USA (36) | Time-series | 30 months | Hospital | Inpatient population admitted to general medicine service | Before: 14193 patients After: 13751 patients | Educational guide, nonintrusive ordering message, and noon conference. Appropriate indications for selected tests were incorporated into text accompanying the laboratory orders in hospital’s HER. Physicians could ignore the text and proceed with the order. | Nonintrusive CDSS do not have significant effect on utilization of laboratory test. |
Gottheil et al., 2016, Canada (30) | Time series | 12 months | A tertiary care hospital | Erythrocyte Sedimentation Rate orders | Not mentioned | Educational content and CDSS: a series of appropriateness criteria for Erythrocyte Sedimentation Rate was incorporated into CDSS. | Their quality improvement initiative could reduce inappropriate Erythrocyte Sedimentation Rate testing by computerized CDS. |
Klatte et al., 2016, The USA (37) | Time series | 12 months | A tertiary hospital, a 53-bed satellite facility | Specimens from children ≤ 12 months | 485 specimens | Educational intervention, an evidence-based algorithm for appropriate clostridium difficile ordering, and CPOE requiring clinicians to mandatory complete 2 extra fields. nondiarrheal stool were automatically declined by laboratory, unless in cases with severe ileus or toxic megacolon. | Their CDSS intervention resulted in a sustained drop in the number of specimens tested, which saved laboratory and patient cost significantly. They observed no sustained change in clinicians’ ordering practices in spite of multiple educational efforts. |
Levick et al., 2013, The USA (38) | Time series | 6 months | Three not-for-profit hospitals | Patients with B-Type Natriuric Peptide test | 41306 patients | CPOE with embedded CDS: The CDS intervention is an expert rule that searches the system for a B-Type natriuric peptide lab value for the patient. An advisory alert was indicated to the ordering clinician if there was a value for the test and it was within the current hospital stay. | Using CDSS alerts has the potential for improving care, but should be used judiciously and in the appropriate environment. |
Lippi et al., 2015, Italy (32) | Before-after | 6 months | A teaching hospital | A variety of tests requests including C reactive protein, TSH, ferritin, brain natriuretic peptide, etc | 3539 test requests | CDSS: an electronic alert is automatically triggered by a potentially inappropriate test request. The alert contains a detailed explanation of the specific rule for appropriateness of the test. | A CDSS alert may be effective to decrease the inappropriateness of laboratory test orders, generate significant cost saving and educate physicians to use laboratory resources more efficiently. |
Nicholson et al., 2017, The USA (39) | Before-after non-equivalent control group | 26 months | A tertiary-care pediatric hospital | Children < 36 months of age | Before: 141 patients After: 55 patients | An alert advising against ordering C. difficile tests in infants and young children based on the American Academy of Pediatrics recommendations. Physicians could override it optionally. | The average monthly testing rate for C. difficile for children < 35 months old decreased without complication after the use of a CPOE alert in those who tested positive for C.difficile. |
Niès et al., 2010, France (33) | Time series | 36 months | A university teaching hospital | Patients with hepatitis B antigen test | Before: 2888 patients After: 1572 patients | CDSS: The alert is triggered when one of the targeted serological tests for hepatitis B virus is selected to be ordered. The Serology-CDSS stores a record of its execution each time a physician selects a viral serology test order. An alert is displayed if the most recent result of the targeted laboratory test for the patient is less than 90 days old. | After CDSS implementation an immediately decrease was observed in the proportion of unnecessarily duplicate tests. CDSS alerts could also improve compliance rate. |
Quan et al., 2019, The USA (40) | Before-after | 24 months | An academic hospital | Patients with C. difficile infection test | Before: 284 tests After: 268 tests | Clinicians were required to verify the determined criteria for appropriate ordering of C. difficile infection test. A warning email was sent to the physicians ordering the test without appropriate approval. | The protocol increased appropriate testing as well as decreasing hospital-onset standardized infection ratio of C. difficile infection. |
Procop et al., 2014, The USA (41) | Time series | 24 months | The Cleveland Clinic | more than 1000 tests of all patients | Not mentioned | CDSS: This tool informs the provider that the test being ordered is a duplicate. It also block unnecessary duplicate test orders during the computerized physician order entry | Real-time interaction between the laboratory and the physician through CDS tools could decrease duplicate orders. It saves healthcare costs and should also increase patient satisfaction and well-being. |
Rosenbloom et al., 2005, The USA (42) | Time series | 5 years | An academic inpatient tertiary care facility | Clinicians at a university hospital | 194,192 patients | The CDSS exhorted users to discontinue unnecessary tests recurring more than 72 hours into the future 2) Education regarding appropriate indications for testing. 3) CDS and CPOE systems targeted only magnesium ordering, displayed recent results, limited testing to one instance per order, summarized indications for testing, and required users to select an indication | A clinical decision support intervention intended to regulate testing increased test order rates as an unintended result of decision support. |
Rudolf et al., 2017, The USA (43) | Time series | 36 months | A tertiary care teaching hospital | Laboratory tests | 61644 laboratory test ordes | Alert in the CPOE system: the alert appeared in the CPOE each time an order with frequency greater than one occurrence was selected. The justification for the order was also captured by the CPOE, as providers were required to select one of three approved indications for the daily laboratory test or manually enter another indication. | Our experience suggests auditing and continued feedback are additional crucial components to changing ordering behavior. Curtailing daily orders alone may not be a sufficient strategy to reduce in-laboratory costs |
Samuelson at al., 2015, The USA (44) | Before-after | 16 months | Two academic medical hospitals | Patients evaluated for heparin-induced thrombocytopenia | Before: 265 patients After: 146 patients | CDSS: A decision-support tool required providers to calculate the 4Ts (heparin-induced thrombocytopenia risk) score prior to ordering laboratory-based tests for anti-PF4/heparin antibody enzyme-linked immunosorbent assay testing | Our study demonstrates that a clinical decision support tool embedded within the electronic ordering process can decrease unnecessary testing for heparin-induced thrombocytopenia. |