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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? Laboratory Efficiency

  • 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? Laboratory Efficiency

  • 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 Laboratory EfficiencyBeing Abnormal


Strategies for changing physician ordering behavior
Strategies for Changing Physician Ordering Behavior Laboratory Efficiency

  • 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 Laboratory Efficiency

  • Strategies that do work

    • Administrative interventions

    • Environmental interventions

    • Combinations with other strategies


Lundberg s principles jama 1998 280 2036
Lundberg’s Principles Laboratory EfficiencyJAMA 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 Laboratory Efficiency

  • 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 Laboratory Efficiency

  • 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 Laboratory Efficiency

  • 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 Letter Laboratory EfficiencyBest Educational Tool


Analyzing the problem
Analyzing the Problem Laboratory Efficiency

  • 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 Laboratory Efficiency

  • 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 Laboratory Efficiency

  • 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 Laboratory Efficiency

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 Monitoring Laboratory EfficiencyExample 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 Laboratory Efficiency


Cardiac marker profile example of excess testing
Cardiac Marker Profile Laboratory EfficiencyExample 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 Profile Laboratory EfficiencyExample 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 Counts Laboratory EfficiencyExample 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 Laboratory Efficiency


Wbc differential counts slh outcomes
WBC Differential Counts Laboratory EfficiencySLH 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 Tests Laboratory EfficiencyExample 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 Tests Laboratory EfficiencyExample 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 Tests Laboratory EfficiencySLH 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 Time Laboratory EfficiencyExample 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 Laboratory Efficiency


Bleeding time slh outcomes
Bleeding Time Laboratory EfficiencySLH 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 Count Laboratory EfficiencyExample 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 Limits Laboratory Efficiency100 Cell Manual Diff Count


Labs that are band less
Labs That Are Band-less Laboratory Efficiency

  • Stanford

  • Cleveland Clinic

  • MD Anderson

  • Vanderbilt

  • UCSF

  • SLH

    • 3500 counts/year

    • 640 hours of labor


Blood bank serology examples of obsolete tests
Blood Bank Serology Laboratory EfficiencyExamples 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 Serology Laboratory EfficiencyExamples 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 Serology Laboratory EfficiencyExamples 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 Serology Laboratory EfficiencySLHCost 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 Pathways Laboratory EfficiencyExample 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 Pathways Laboratory EfficiencyImpact on Test Utilization


Anti nuclear antibody example of reference range change
Anti-nuclear Antibody Laboratory EfficiencyExample 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 Laboratory Efficiency


Anti nuclear antibody outcomes
Anti-nuclear Antibody Laboratory EfficiencyOutcomes

  • 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 Contamination Laboratory EfficiencyExample 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 Contamination Laboratory EfficiencyProcedure 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 Contamination Laboratory EfficiencySLH Quarterly Monitor


Blood culture contamination slh savings
Blood Culture Contamination Laboratory EfficiencySLH 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 Policy Laboratory EfficiencyExample 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 Policy Laboratory EfficiencySLH 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 Quantitation Laboratory EfficiencyExample 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 Laboratory Efficiency


Cmv qt turnaround time
CMV QT Turnaround Time Laboratory Efficiency


Urine cultures example of improved tat
Urine Cultures Laboratory EfficiencyExample 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 Laboratory Efficiency @ 48 vs. 24 Hours


Urine culture slh benefits
Urine Culture Laboratory EfficiencySLH 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-up Laboratory EfficiencyExample 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-up Laboratory EfficiencyLab 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 Laboratory Efficiency


1995 hcv algorithm example of optimizing reflex testing
1995 HCV Algorithm Laboratory EfficiencyExample of Optimizing Reflex Testing


1995 hcv algorithm inefficiency identified
1995 HCV Algorithm Laboratory EfficiencyInefficiency 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 Laboratory Efficiency


    1997 hcv algorithm1
    1997 HCV Algorithm Laboratory Efficiency

    • 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 Laboratory Efficiency

    • 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 Laboratory Efficiency


    Thyroid testing example of optimized reflex testing
    Thyroid Testing Laboratory EfficiencyExample 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 Laboratory Efficiency


    Thyroid cascade adaptation
    Thyroid Cascade Adaptation Laboratory Efficiency


    Monoclonal gammopathies example of optimized reflex testing
    Monoclonal Gammopathies Laboratory EfficiencyExample 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



    Monoclonal gammopathies slh ife utilization
    Monoclonal Gammopathies Laboratory EfficiencySLH IFE Utilization


    Esoteric send out requests
    Esoteric Send Out Requests Laboratory Efficiency

    • 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 Fibrosis Laboratory EfficiencyExampleof 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 Genotyping Laboratory EfficiencyExample 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 Genotyping Laboratory EfficiencySLH 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 Surgery Laboratory EfficiencyExample 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



    Benefits of decreased transfusion
    Benefits of Decreased Transfusion Laboratory Efficiency

    • 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 Testing Laboratory EfficiencyPatient 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 Laboratory Efficiency


    Inpatient tests per discharge
    Inpatient Tests per Discharge Laboratory Efficiency



    Summary of the slh approach
    Summary of the SLH Approach Laboratory Efficiency

    • 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