Implementing Evidence-Based Practices into Thrombophilia Order Sets: A Single Institution Quality Improvement Project

Objective: Venous thromboembolic events (VTEs) commonly occur in the inpatient setting often prompting thrombophilia evaluation. Current American Society of Hematology Guidelines support evidence-based testing only in scenarios where management would be affected. With the emergence of the electronic medical record, order sets have become an integral part of the daily workflow for medical practitioners. They were created to enhance evidence-based practices, provide decision-making support and improve providers' efficiency. Electronic order sets must be updated regularly to ensure they reflect the current standard of care in the ever-evolving medical landscape. Most recent ASH guidelines do not support hereditary and acquired thrombophilia testing in the inpatient setting as it is unlikely to change management and creates unnecessary costs. Moreover, testing is recommended only for conditions that have been substantiated to increase the risk of VTEs including factor V Leiden, prothrombin 20210A gene mutation, deficiencies of antithrombin III, protein C, or protein S, and antiphospholipid antibodies compatible with antiphospholipid syndrome. The inpatient thrombophilia order set at our institution included numerous laboratory tests not supported by evidence, resulting in significant financial toxicity without clinical gain. Thrombophilia testing from inpatient admissions from 7/1/2022 to 6/30/2023 totaled $487,462.90. Our group sought to reduce unnecessary testing and implemented an order set to reflect evidence-based practices. The order set prior to our intervention had 18 lab values with a total cost of $4783.48. We created a new evidenced-based order set that cost $2304.00 for a cost differential of $2479.48. We hypothesize a significant cost savings and a reduction in the inaccurate diagnoses of thrombophilia after implementing a guideline-directed order set. Methods: We retrospectively reviewed adult inpatient admissions from 7/1/2022 to 6/30/2023 for thrombophilia workup and calculated the quantity and associated costs of testing. In January 2024, we implemented our revised inpatient thrombophilia order set to reflect guideline supported testing. We present an analysis of associated costs from 2/1/2024-4/30/2024 after the first three months of implementation of the new order set. Results: Thrombophilia testing from inpatient admissions from 7/1/2022 to 6/30/2023 totaled $487,462.90. From 2/1/2023-4/30/23, 257 thrombophilia tests were ordered, totaling $96,828.30. In the first three months after implementation of thrombophilia testing 2/1/2024-4/30/24, 195 number of tests were ordered at a cost of $77,379.10. There were 24% fewer tests ordered at a savings of $19,449.20. Conclusion: After the first three months of implementation of our evidenced-based thrombophilia order set, there was a significant reduction in the number of unnecessary labs tested at our facility. Extrapolated over a year, we anticipate a cost savings nearing $80,000.00. In addition to reduced financial toxicity, using evidence-based testing strategies reduces inaccurate diagnoses and the implications thereof.