Clinician-friendly tactics slash unwarranted testing

Kevin B. O’Reilly

January 2014—A child born recently at Broward Health Medical Center was definitively diagnosed, without testing, as having a significant genetic abnormality. A medical resident eager to put his education into practice ordered genetic testing for the newborn, two normal siblings, and the child’s parents.

The tests would have cost the hospital up to $10,000—each.

The testing would help the uninsured family understand its future options, the resident told the lab leadership at Broward Health, a five-hospital safety-net health system in South Florida.

The medical center’s laboratory director, pathologist Fred Reineke, MD, and Leo Serrano, Broward Health’s corporate director of laboratory services, pointed out that the testing was not needed for the child as it would not change the treatment plan. The two siblings were in normal health and showed no signs of the genetic abnormality, rendering the tests pointless for them. The testing for the parents might be indicated, but could be done on an outpatient basis once the family had enrolled in Medicaid.

No, the resident persisted. Once discharged, the family was set to head home—for Haiti.

“Doctor, we’re glad to order these tests for you,” Serrano says he told the resident. “And we’ll send you the bill because Broward Health can’t afford to eat the costs.”

Unsurprisingly, that proposition proved dissuasive to the resident.

The wide-ranging effort to cut unneeded lab testing at Broward Health is not usually so dramatic, but the case highlights what Serrano says is a central tenet of the system’s wildly successful initiative that slashed nearly $900,000 in costs from July 2012 to July 2013.

“The magic question to throw out there is: Is this test going to make a difference in the patient’s outcome or in the way you treat the patient?” Serrano says. “That’s the mindset we have to establish.”

What the laboratory leadership at Broward Health has learned, and is eager to share with their colleagues around the country, is that a top-down approach to tackling inappropriate testing will not succeed.

Yes, the Broward strategy contains the major elements typically included in lab-use reduction initiatives: an optimized computerized physician order-entry system, evidence-based test-ordering algorithms, and test formularies. But the essential component to making it all work has been putting much of the say-so over how the initiative has rolled out into the hands of the physicians who do the test-ordering. Collaboration, not dictation, is the watchword.

“By involving the medical staff from day one and having them be the decision makers, we’ve gotten good buy-in,” says Ronald Giffler, MD, a pathologist and Broward Health system’s corporate laboratory medical director.

Broward’s accomplishment comes as new research confirms the pervasiveness of pointless lab testing across medicine. A recently published meta-analysis of 15 years’ worth of studies that examined 46 of the 50 most commonly used lab tests found that 20 percent of the 1.6 million tests were ordered unnecessarily. And somewhat surprisingly, the overuse rate was 44 percent during initial testing, compared with just seven percent in repeat testing, said the study, published Nov. 15, 2013 in PLOS ONE (8[11]:e78962.doi:10.1371/journal.pone.0078962).

“The mantra that you keep hearing when you talk about inappropriate lab testing is: ‘Oh, yes, of course it’s about inappropriate repeat testing and it’s bankrupting medicine,’” says Ramy Arnaout, MD, DPhil, the study’s senior author and assistant professor in the Department of Pathology at Beth Israel Deaconess Medical Center and Harvard Medical School.

“We were able to take all of this inappropriate testing and split it apart to reveal this landscape,” Dr. Arnaout says. “The problem is really in overuse of initial testing as opposed to repeat testing… . It points us in a different direction for improving care in the lab and in the hospital at large.”

Nationwide, anatomic and clinical pathology lab tests cost between $60 billion and $70 billion, adding up to four percent of U.S. health spending. That dollar figure is on pace to double within the next four years, thanks in large part to spending on molecular and genetic testing.

No matter the source of unwarranted testing, the need to reduce overutilization may be even more vital at Broward than at many other health care organizations. During fiscal year 2013 alone, Broward—the country’s 10th largest public health care system and among the top five busiest emergency department and trauma services in Florida—provided $326 million in charity care and wrote off another $371 million in bad debts for unreimbursed care. Less than six percent of the system’s inpatient reimbursement is fee for service.

“We’re still in the black,” Serrano told the audience during a talk at the Lab Quality Confab in New Orleans last October. “We’re not going to roll over and die—yet.”

But given the system’s financial position, any money spent on tests that are outdated or superfluous seems especially wasteful. The leadership at Broward tapped into the system’s public mission to help motivate its physicians to take an active role in the effort to cut unwarranted lab testing.

“We’re a safety-net hospital, and we have a high percentage of indigent patients,” Dr. Giffler says. “And our medical staff is very well aware of that and wants to preserve assets to treat the largest number of patients that they can. Doctors read the newspaper every day. They’re aware of the situation. And they also want to order the right test and do the right thing.”

Here is how the laboratory leadership at this health system went from that big idea to their big savings.

The first step was to design the CPOE system to help reduce practice variation. That process began three years ago with a multidisciplinary committee charged with reviewing the best evidence on testing by disease group and proposing new order sets. A critical ingredient in the Broward process, however, was a second, all-physician committee with approval power over changes to the CPOE system.

This physician advisory committee “represented their colleagues,” Serrano says. “We’d frequently go back and meet with individual key players, particularly if they had reasons that they didn’t like what was recommended.”

Changes were made to the order sets in response to physician feedback, and the data and reasoning used to design the order sets were laid out for everyone to understand.

“The physician advisory committee is ultimately the group that blessed it,” Serrano notes.

Among other things, duplicative testing was targeted. The preset cardiac panel, for example, had included creatinine-kinase MB and troponin tests. Under the redesigned system, only troponin is included as part of the standard cardiac panel.