Uncoordinated Care: Decreasing Unnecessary Lab Work in Patients on Dialysis

Background: The KDOQI clinical practice guidelines recommend avoiding unnecessary venipuncture in patients with end-stage kidney disease (ESKD). Patients on maintenance dialysis have routine blood work. Redundant diagnostics at primary care clinics result in increased frequency of venipuncture, cost of care, and administrative burden. Unfortunately, dialysis unit diagnostics are not consistently available to primary care providers (PCP). We present a quality initiative to identify the extent of this problem and address it through an iterative process of improvement. Methods: A deidentified analytics report included patients with ESKD based on ICD-10 codes who had lab work ordered at our affiliated primary care clinics. Kidney transplant recipients were excluded. Institutional lab components were used to collect information on ambulatory orders redundant with dialysis labs. This included the number of orders over a specified period and the ordering clinic. PCPs completed surveys regarding how they access dialysis labs, if such access would decrease the number of tests ordered, and their familiarity with what routine dialysis studies entail. Education on access to certain dialysis units’ lab results and what labs are routinely ordered was sent by email followed by a repeat survey. Results: Between February 2023 and January 2024, 191 patients with ESKD underwent at least 1536 venipuncture events for redundant testing. The median number of metabolic panels per patient was 5 (IQR 3-11). Initial surveys were completed by 42 of 113 PCPs (37%). 90% could not access dialysis labs and 92% would order less tests with access to these results. Three months post-education, 3 of 20 clinics decreased the number of metabolic panels ordered on ESKD patients by 16.9-41.7%, but no significant change was noted overall. 27 PCPs (24%) completed repeat surveys. 85% still could not access dialysis labs and 83% were not familiar with what these studies entail. Conclusion: Dialysis patients frequently undergo unnecessary diagnostics. Access to dialysis studies and familiarity with dialysis lab monitoring could decrease redundant ordering practices. An estimation of the costs of care is underway. Focus groups and in-person provider education will be held at primary care clinics. Further progress will require collaboration with PCPs, dialysis units, and health system informatics.