How to Successfully Influence Test Utilization & Improve Laboratory Efficiency

1. 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

2. 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

3. 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

4. Chance of One Test Being Abnormal

5. 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

6. Strategies for Changing Physician Ordering Behavior • Strategies that do work • Administrative interventions • Environmental interventions • Combinations with other strategies

7. 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

8. 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

9. 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

10. 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

11. Clinical Laboratory LetterBest Educational Tool

12. 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

13. 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

14. 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

15. 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

16. 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

17. Vancomycin Orders

18. Cardiac Marker ProfileExample of Excess Testing • Cardiac panel from 1998 to 2000 • Total CK, MB & TnI • 0, 6 & 12 hours

19. 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?

20. 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%

21. Manual WBC Diff Rate

22. 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

23. 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

24. 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

25. 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

26. 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

27. Evaluating Bleeding Risk

28. 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

29. 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

30. Confidence Limits100 Cell Manual Diff Count

31. Labs That Are Band-less • Stanford • Cleveland Clinic • MD Anderson • Vanderbilt • UCSF • SLH • 3500 counts/year • 640 hours of labor

32. 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

33. 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

34. 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+

35. 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

36. Clinical PathwaysExample of Practice Guidelines • Nurses & physicians wrote guidelines • Pathologists reviewed lab tests • Suggestions returned to authors • Test utilization monitored before & after

37. 70 Clinical PathwaysImpact on Test Utilization

38. 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

39. ANA Test Volumes

40. 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

41. 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

42. Blood Culture ContaminationProcedure Change • Chlorhexidine blood culture prep • One step application • Decreased drying time • ED trial in August 2002 • Hospital-wide in May 2003

43. Blood Culture ContaminationSLH Quarterly Monitor

44. Blood Culture ContaminationSLH Savings • 9740 blood cultures per year • Contaminants  from 238 to 135 • $515,000 hospital cost savings per year

45. 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

46. 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

47. 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

48. CMV QT Reagent Wastage

49. CMV QT Turnaround Time

50. 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