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

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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

    • 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?

  • 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


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 Behavior

  • Strategies that do work

    • Administrative interventions

    • Environmental interventions

    • Combinations with other strategies


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

  • 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

  • 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

  • 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 LetterBest Educational Tool


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

  • 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

  • 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


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 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


Cardiac Marker ProfileExample of Excess Testing

  • Cardiac panel from 1998 to 2000

    • Total CK, MB & TnI

    • 0, 6 & 12 hours


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 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


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 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 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 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 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


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 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 Limits100 Cell Manual Diff Count


Labs That Are Band-less

  • Stanford

  • Cleveland Clinic

  • MD Anderson

  • Vanderbilt

  • UCSF

  • SLH

    • 3500 counts/year

    • 640 hours of labor


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 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 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 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 PathwaysExample of Practice Guidelines

  • Nurses & physicians wrote guidelines

  • Pathologists reviewed lab tests

  • Suggestions returned to authors

  • Test utilization monitored before & after


70 Clinical PathwaysImpact on Test Utilization


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


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 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 ContaminationProcedure Change

  • Chlorhexidine blood culture prep

    • One step application

    • Decreased drying time

  • ED trial in August 2002

  • Hospital-wide in May 2003


Blood Culture ContaminationSLH Quarterly Monitor


Blood Culture ContaminationSLH Savings

  • 9740 blood cultures per year

  • Contaminants  from 238 to 135

  • $515,000 hospital cost savings per year


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 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 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 Turnaround Time


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 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-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-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


1995 HCV AlgorithmExample of Optimizing Reflex Testing


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

    • 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

    • 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


    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 Adaptation


    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


    Monoclonal GammopathiesSLH IFE Utilization


    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 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 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 GenotypingSLH Savings

    • Sent to reference lab initially

    • INNO-LiPa HCV II implemented in 2001

    • $55,670 cost savings in 2002


    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


    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 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


    Inpatient Tests per Discharge


    SLH Admitting Physician Satisfaction Survey


    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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