How to successfully influence test utilization improve laboratory efficiency
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How to Successfully Influence Test Utilization & Improve Laboratory Efficiency. Fred V. Plapp, Cynthia Essmyer, Anne Byrd & Marjorie Zucker Saint Luke’s Health System Kansas City. Why Be Concerned About Excessive Testing?. Increased laboratory costs

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How to successfully influence test utilization improve laboratory efficiency

How to Successfully Influence Test Utilization & Improve Laboratory Efficiency

Fred V. Plapp, Cynthia Essmyer, Anne Byrd & Marjorie Zucker

Saint Luke’s Health System

Kansas City


Why be concerned about excessive testing

Why Be Concerned About Excessive Testing?

  • Increased laboratory costs

    • Once operational efficiencies are maximized, reducing unnecessary testing is the only way to significantly reduce costs

  • Payer pressure

    • Continued squeeze on reimbursement

    • Required documentation of utilization


Why be concerned about test utilization

Why Be Concerned About Test Utilization?

  • Increased potential for direct & indirect harm

    • Increased number of false & weak positives

    • Follow-up increases cost, worry, discomfort, risk

      • Confirmatory tests

      • Specialist referrals

      • Invasive procedures

    • Unnecessary postponement of procedure

    • Attention diverted from primary problem


Chance of one test being abnormal

Chance of One Test Being Abnormal


Strategies for changing physician ordering behavior

Strategies for Changing Physician Ordering Behavior

  • Reviewed 49 articles between 1966 & 1998

    JAMA 1998;280:2020

  • Strategies that do not work by themselves

    • Physician consensus building

    • Test guideline dissemination

    • Traditional education

    • Utilization audits

    • Informing physicians of lab charges


Strategies for changing physician ordering behavior1

Strategies for Changing Physician Ordering Behavior

  • Strategies that do work

    • Administrative interventions

    • Environmental interventions

    • Combinations with other strategies


Lundberg s principles jama 1998 280 2036

Lundberg’s PrinciplesJAMA 1998;280:2036

  • Know the right thing to do

  • Confer w/ respected physician leaders

  • Implement changes administratively

  • Educate through writing & conferences

  • Weather the storm

  • Remain open to communication

  • Enjoy the success of more effective service


Examples of environmental interventions

Examples of Environmental Interventions

  • Test requisition redesign

    • Preferred tests & cascades emphasized

    • Outmoded tests less obvious or omitted

    • Large panels restricted

  • Optimized testing & reporting

    • Rapid turnaround times

    • Minimal number of laboratory errors

    • Immediate & easy access to test results

    • Merged out & inpatient test results


Examples of administrative interventions

Examples of Administrative Interventions

  • Administrative policy changes

    • Pathologist approval for special tests

    • Pathologist approval of send out tests

    • Test intervals, frequencies & reflex policy

  • Financial feedback

    • Review of CPT codes denied payment

    • Decision support systems


Examples of educational interventions

Examples of Educational Interventions

  • Clinical Laboratory Letter

    • Test recommendations & algorithms

  • Clinical pathways

    • Practice guidelines w/ standardized testing

  • Timely pathology consults

  • Physician feedback

    • Test utilization by service or peer group


Clinical laboratory letter best educational tool

Clinical Laboratory LetterBest Educational Tool


Analyzing the problem

Analyzing the Problem

  • High test volume & diverse test menu

    • 2 million tests performed per year

    • >300 different tests offered

  • No single project would be effective

  • Multi-pronged long term strategy was required


Arriving at a solution

Arriving at a Solution

  • Pathologists & staff continuously monitor testing trends within their areas of expertise

  • Targeted tests with following characteristics:

    • High volume

    • Expensive

    • Difficult to perform

    • Questionable medical benefit

    • Unusual number of abnormal results


Action plan

Action Plan

  • Lab collaborated with:

    • Hospital departments & patient care committees

    • Nursing and medical staffs

  • Pathologists discussed proposals with:

    • Key physicians

    • Entire medical departments

    • Hospital Performance Improvement committee

  • Clinical Laboratory Letter

    • Published test utilization data & algorithms


Types of projects undertaken

Excessive Tests

Obsolete Tests

Clinical Pathways

Reference Ranges

Wastage

Turnaround Time

Algorithms & Reflex Testing

Send Out Tests

In-sourcing Tests

Transfusion

Error Rate

Types of Projects Undertaken


Vancomycin monitoring example of excess testing

Vancomycin MonitoringExample of Excess Testing

  • Clinical pharmacologists noted too many drug levels ordered in 1994

    • Peak & trough levels ordered together

    • Little scientific evidence supporting peak

  • Lab & Pharmacy educated medical staff

    • Presented at medical staff meetings

    • Published data in Clinical Laboratory Letter

    • Deleted peak from computer order screens


Vancomycin orders

Vancomycin Orders


Cardiac marker profile example of excess testing

Cardiac Marker ProfileExample of Excess Testing

  • Cardiac panel from 1998 to 2000

    • Total CK, MB & TnI

    • 0, 6 & 12 hours


Cardiac marker profile example of excess testing1

Cardiac Marker ProfileExample of Excess Testing

  • ACC & AHA guideline revision in 2000

  • Panel  to MB & TnI at 0, 3, & 6 h

  • Eliminated >23,000 CK per year

    • $3450/y decrease in reagent costs

    • $805,000/y decrease in payer charges

    • Faster TAT – 1 vs 2 analyzers

  • Time to discontinue MB?


Wbc differential counts example of excess testing

WBC Differential CountsExample of Excess Testing

  • Manual diff rate was 40% in 1999

  • Installed Coulter Gen-S in 2000

  • Continually re-examined reflex criteria

    • Eliminated Immature Gran band 1 flag

    • Eliminated diff if WBC <0.8

    • No flags on high RBC, Hb, Hct, MCV, RDW

    • Set neutrophil flag to 12.0 & 90%


Manual wbc diff rate

Manual WBC Diff Rate


Wbc differential counts slh outcomes

WBC Differential CountsSLH Outcomes

  • Avoid 15,000 manual diffs per year

  • CAP average time = 11 minutes/slide

  • Save 2750 hours of labor per year

    • >1 FTE

  • Expect rate to  further in 2004

    • New analyzer

    • Eliminate band counts


Rapid bacterial antigen tests example of an obsolete test

Rapid Bacterial Antigen TestsExample of an Obsolete Test

  • Introduced in 1980s for Dx of bacterial meningitis

    • H flu

    • N meningitidis

    • E coli

    • S pneumo

    • GBS


Rapid bacterial antigen tests example of an obsolete test1

Rapid Bacterial Antigen TestsExample of an Obsolete Test

  • Clinical utility questioned today

    • Not sensitive enough to rule out bacterial origin

    • Not specific enough to direct antibiotic therapy

    • Improved empiric antibiotic Rx available


Rapid bacterial antigen tests slh outcome

Rapid Bacterial Antigen TestsSLH Outcome

  • Pathologist reviewed 22 cases over 3 months

    • 50% ordered inappropriately

  • Reviewed guidelines w/ ED physicians

  • Published in Clinical Laboratory Letter

  • Monitored utilization for 1y after guidelines

    • Total number of orders decreased 75%

  • Discontinued in Oct 2001


Bleeding time example of an obsolete test

Bleeding TimeExample of an Obsolete Test

  • Poor perioperative screening test

  • Poor diagnostic test

  • Poor clinical reproducibility

    • Technical & patient factors

  • Discontinuation not associated w/ adverse outcome

    • Clin Chem 2001;47:1204-11


Evaluating bleeding risk

Evaluating Bleeding Risk


Bleeding time slh outcomes

Bleeding TimeSLH Outcomes

  • BT discontinued June 2003

  • Eliminated 425 manual tests per year

  • Time savings of 212 hours per year

  • Labor savings of $31,875 per year

  • Payer charges decreased $108,375


Band neutrophil count example of an obsolete test

Band Neutrophil CountExample of an Obsolete Test

  • Previously considered mainstay in lab diagnosis of bacterial infection

  • Recently clinical utility questioned

    • Subjective band ID criteria

    • Imprecision & sampling errors

    • Accurate 5 part automated diff

    • ANC = better predictor of infection


Confidence limits 100 cell manual diff count

Confidence Limits100 Cell Manual Diff Count


Labs that are band less

Labs That Are Band-less

  • Stanford

  • Cleveland Clinic

  • MD Anderson

  • Vanderbilt

  • UCSF

  • SLH

    • 3500 counts/year

    • 640 hours of labor


Blood bank serology examples of obsolete tests

Blood Bank SerologyExamples of Obsolete Tests

  • Recipient testing policies adopted

    • Immediate spin crossmatch

    • Routine use of anti-IgG

    • Elutions on +DAT only if Tx w/in 3 mo

  • Donor testing

    • Anti-A,B to confirm group O units

    • Rh type confirmed only on Rh units


Blood bank serology examples of obsolete tests1

Blood Bank SerologyExamples of Obsolete Tests

  • Recipient tests eliminated

    • Anti-A,B testing on recipients

    • Autocontrol

    • Weak D testing including moms

    • Reading Ab screen after immediate spin

    • Antigen typing for insignificant Ab


Blood bank serology examples of obsolete tests2

Blood Bank SerologyExamples of Obsolete Tests

  • Cord blood test policies

    • ABO & Rh typing only if mom is Group O or Rh negative

    • No elution if DAT+


Blood bank serology slh cost savings

Blood Bank SerologySLHCost Savings

  • >1900 hours of labor per year

  • >23,100 tubes per year

  • 90 vials of anti-D per year

  • 48 vials of anti-A and B

  • Numerous elutions

    • Only performed 11 in 2003


Clinical pathways example of practice guidelines

Clinical PathwaysExample of Practice Guidelines

  • Nurses & physicians wrote guidelines

  • Pathologists reviewed lab tests

  • Suggestions returned to authors

  • Test utilization monitored before & after


70 clinical pathways impact on test utilization

70 Clinical PathwaysImpact on Test Utilization


Anti nuclear antibody example of reference range change

Anti-nuclear AntibodyExample of Reference Range Change

  • Reported ANA >1:40 as positive

    before 1995

  • Referrals & follow-up tests ordered

    • <5% positive if ANA <1:160

  • Discussed with rheumatologists

  • Changed cutoff to 1:160 in June 95

  • Started testing at 1:160 dilution


Ana test volumes

ANA Test Volumes


Anti nuclear antibody outcomes

Anti-nuclear AntibodyOutcomes

  • Positive ANA rate decreased 14%

  • Follow-up testing eliminated

    • Payer charges  $99,925 per year

    • Referrals & diagnostic procedures avoided

    • Eliminated >500 manual tests per year


Blood culture contamination example of decreased wastage

Blood Culture ContaminationExample of Decreased Wastage

  • Contamination w/ skin flora causes

    • Unnecessary antibiotic administration

    • Additional cultures & other lab tests

    • Increased length of stay

    • Increased hospital cost of ~$5000/case

  • ASM goal is contamination rate <3%

    • ED usually have higher rates


Blood culture contamination procedure change

Blood Culture ContaminationProcedure Change

  • Chlorhexidine blood culture prep

    • One step application

    • Decreased drying time

  • ED trial in August 2002

  • Hospital-wide in May 2003


Blood culture contamination slh quarterly monitor

Blood Culture ContaminationSLH Quarterly Monitor


Blood culture contamination slh savings

Blood Culture ContaminationSLH Savings

  • 9740 blood cultures per year

  • Contaminants  from 238 to 135

  • $515,000 hospital cost savings per year


Specimen in lab policy example of decreased wastage

Specimen in Lab PolicyExample of Decreased Wastage

  • Worked with Blood Conservation Team to reduce iatrogenic blood loss

  • SIL Policy implemented

    • Stored blood specimens for 2 weeks

    • Publicized in Lab Letter & Nursing publications

    • Avoided redrawing patients for add on tests


Specimen in lab policy slh outcomes

Specimen in Lab PolicySLH Outcomes

  • 11,244 requests for tests on SIL

  • $51,726 savings in labor & supplies

  • Avoided 11,244 venipunctures

  • Conserved 71,428 mL of blood

    • Equivalent to 140 units of RBCs


Cmv pcr quantitation example of decreased wastage

CMV PCR QuantitationExample of Decreased Wastage

  • Cobas Amplicor CMV QT - Oct 2001

  • Initially performed on M,W,F schedule

    • Not enough specimens to use complete kit

    • Unused reagents had to be discarded

      • Wastage cost $5000 per month

  • Flexible schedule introduced Jan 2003

    • Run whenever have 9 specimens

    • Monitored wastage & TAT


Cmv qt reagent wastage

CMV QT Reagent Wastage


Cmv qt turnaround time

CMV QT Turnaround Time


Urine cultures example of improved tat

Urine CulturesExample of Improved TAT

  • Literature recommended 24 hour incubation

  • Discussed with Infectious Disease physicians

  • Published in Laboratory Letter

  • Procedure changed on Sep 1, 1995

  • Repeated monitor in June 96 & Sep 98


Urine culture results @ 48 vs 24 hours

Urine Culture Results @ 48 vs. 24 Hours


Urine culture slh benefits

Urine CultureSLH Benefits

  • No change in true positive rate

  • 6100 fewer contaminants per year

    • Payer cost savings of $88,740 per year

    • Fewer contaminants worked up

    • Fewer repeat cultures submitted

  • Faster turnaround time

    • Antibiotic Rx optimized more quickly

  • Lab workload  by 120 plates per day


Diarrhea work up example of optimizing reflex testing

Diarrhea Work-upExample of Optimizing Reflex Testing

  • Questionable value for inpatients

  • Reviewed >200 inpatient O&P & stool cultures

    • No enteric pathogens detected

    • Ordered for 3 consecutive days

    • Payers billed $234,375 w/o pathogen

    • 20% exams on inpatients admitted >3d


Diarrhea work up lab policy change

Diarrhea Work-upLab Policy Change

  • New nosocomial diarrhea policy

  • >3 days after admission

    • Substituted C. diff toxin for O&P

  • <3 days after admission

    • Substituted Giardia screen for O&P

    • Payer cost savings >$400,000/year

    • Reagent & labor savings of $11,592 per year

    • Specimen held for 7 days


Diarrhea algorithm

Diarrhea Algorithm


1995 hcv algorithm example of optimizing reflex testing

1995 HCV AlgorithmExample of Optimizing Reflex Testing


1995 hcv algorithm inefficiency identified

1995 HCV AlgorithmInefficiency Identified

PCR if RIBA positive or indeterminate

  • Most RIBA were Indeterminate

  • 66% had RIBA & PCR performed

  • Shared data with GI & ID physicians

  • Changed algorithm in 1997


  • 1997 hcv algorithm

    1997 HCV Algorithm


    1997 hcv algorithm1

    1997 HCV Algorithm

    • Financial Impact

      • PCR had better sensitivity & specificity

        • Fewer RIBA performed

      • Based on 1997 test volumes

        • Payer charges decreased $63,000

        • Laboratory costs decreased $39,000


    1997 hcv algorithm limitations

    1997 HCV Algorithm Limitations

    • PCR QT had limited dynamic range

      • Not as sensitive as PCR QL

      • 25% cases exceeded linearity

    • TaqMan RT PCR conversion

      • Much wider dynamic range

        • Eliminated need for PCR QL

        • Eliminated repeat testing

          • $23,000 per year cost savings


    2003 hcv algorithm

    2003 HCV Algorithm


    Thyroid testing example of optimized reflex testing

    Thyroid TestingExample of Optimized Reflex Testing

    • 3 Lab Letters recommended cascade

      • Feb 96, Apr 98 & Feb 99

      • Screen w/ TSH

      • Follow-up w/ fT4

    • 85% of patients have normal TSH

      • No further testing required


    Thyroid cascade

    Thyroid Cascade


    Thyroid cascade adaptation

    Thyroid Cascade Adaptation


    Monoclonal gammopathies example of optimized reflex testing

    Monoclonal GammopathiesExample of Optimized Reflex Testing

    • Physicians able order IFE w/o prior SPE

    • Most patients did not have monoclonal

    • IFE more expensive than SPE

    • Established reflex testing

      • Lab supply savings of $6000 per year

      • Payer charges decreased $17,800 per year


    Lab evaluation of monoclonal gammopathies

    Lab Evaluation of Monoclonal Gammopathies


    Monoclonal gammopathies slh ife utilization

    Monoclonal GammopathiesSLH IFE Utilization


    Esoteric send out requests

    Esoteric Send Out Requests

    • Esoteric test expenses increasing

      • HHV-6, FISH, NK cells, CF, HCV genotypes

    • CLS & pathologists review requests

      • Consult with ordering physician

      • In source if feasible

    • Annual cost savings of $200,000/year


    Cystic fibrosis example of in sourcing a test

    Cystic FibrosisExampleof In-sourcing a Test

    • ACOG & ACMG recommendation

      • March 2001

      • Offer screening to pregnant couples

    • Sent to reference lab initially

    • Roche CF Gold in November 2002

      • $40,000 cost savings in 2003


    Hcv genotyping example of in sourcing a test

    HCV GenotypingExample of In-sourcing a Test

    • 6 HCV genotypes recognized

    • Genotype determines therapy

      • Type 1 requires 48 months

      • Types 2 & 3 require 24 months

    • Interferon Rx very expensive


    Hcv genotyping slh savings

    HCV GenotypingSLH Savings

    • Sent to reference lab initially

    • INNO-LiPa HCV II implemented in 2001

    • $55,670 cost savings in 2002


    Open heart surgery example of transfusion review

    Open Heart SurgeryExample of Transfusion Review

    • OHS transfused ~one third of components

    • Pathologist analyzed blood usage each year

      • Surgeon specific usage

      • Reviewed with CTS team

      • Evaluated risk factors, meds,practice variations

    • Published transfusion guidelines & risks

    • Presented to medical & house staff


    Average number of units transfused per ohs case

    Average Number of Units Transfused per OHS Case


    Benefits of decreased transfusion

    Benefits of Decreased Transfusion

    • 1000 OHS cases performed each year

    • $600,000 cost savings per year

    • Transfusion reaction risks decreased

    • Blood Bank workload decreased

    • Nursing time for transfusion decreased


    Poc blood glucose testing patient identification errors

    POC Blood Glucose TestingPatient Identification Errors

    • Manual Patient ID entry

      • 12,000 tests per month

      • 9.7% average error rate

      • ~450 unidentified results per month

    • PI project in December 2002

      • Accu-Chek Inform & RALS Plus

      • Barcoded armbands


    Glucose meter id errors

    Glucose Meter ID Errors


    Inpatient tests per discharge

    Inpatient Tests per Discharge


    Slh admitting physician satisfaction survey

    SLH Admitting Physician Satisfaction Survey


    Summary of the slh approach

    Summary of the SLH Approach

    • Target problems that are solvable

    • Collect & analyze data from your own lab

    • Present the data to influential physicians

      • These experts are the lab’s best advocates

    • Communicate changes to medical staff

      • Lab newsletter is a very effective educational tool

    • Monitor impact of changes


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