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Smart test ordering—new program provides the tools

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Amy Carpenter Aquino

February 2018—A new CAP program with a novel approach makes it easier to take on an old problem: misapplied laboratory tests.

The CAP Test Ordering Program, available now and complimentary to all members, is different from other laboratory test utilization initiatives, says Richard W. Brown, MD, medical director for system laboratory services at Memorial Hermann Health System in Houston. He is a member of the CAP Quality Practices Committee, whose members conceived of and developed the program. “Rather than directly addressing ordering physicians, we are writing this for pathologists to help them optimize testing in their particular practice setting. It’s the first program that provides this much detail in terms of an actual model for pathologist intervention.”

Educating pathologists in how to initiate systemwide test use management is important, says QPC member Gary W. Procop, MD, MS, medical director of medical operations and clinical microbiology at Cleveland Clinic. “It’s getting pathologists involved in optimal care delivery. We’re not just doing the test. We’re helping the test be done right at our medical centers.”

The CAP Test Ordering Program is modular and focuses on individual tests or conditions and diseases. The à-la-carte design makes it easy for members to select the modules best suited to their practice.

The October 2017 program launch consists of four modules: cardiac marker testing practices, appropriate testing for HCV infection, red blood cell folate testing, and B-type natriuretic peptide (BNP) or N-terminal-proBNP (NT-proBNP). Members can download the modules at www.cap.org.

The modules follow a standard format that begins with a synopsis and objectives and then provides background on the test (or tests), its appropriate use, and how to apply this information to evaluate and improve testing. Each module lists multiple interventions from which to choose.

For example, from the HCV infection module: Create a best practice alert, such as a pop-up or soft stop, whenever a second HCV serologic study is unnecessarily ordered on a known seropositive patient. And: “Create a laboratory-based algorithm that assures that an HCV viral load of sufficient quantity is present before proceeding to HCV genotyping.” From the BNP and NT-proBNP module: “Use different names for the same test to guide appropriate utilization. For example, inpatient orders might be limited to BNP (admission) and BNP (discharge).” And from the not-yet-released thyroid disorders module: “Discourage the use of resin T3 uptake, reverse T3 in thyroid function, and FT4 index testing. Attempt to obtain consensus to eliminate these tests from the laboratory menu.”

The impact analysis is a key section of each module. It demonstrates how to assess the efficacy of the intervention, either with a financial model or with a model that addresses another measure, such as length of stay or appropriateness of antibiotic therapy, Dr. Brown says.

“We’re providing the pathologist with a tool for measuring outcomes, not clinical outcomes necessarily, but outcomes in terms of ‘How successful was the intervention?’ We envision a conversation the pathologist could have with their administrator to say, ‘This is what we did, here’s how we did it, and we’ve actually saved this much in length of stay or in cost,’” Dr. Brown says. “It gets back to the idea that pathologists add value beyond diagnosing disease from a glass slide.”

Dr. Brown

Dr. Brown

Modules have a reference list and a question-and-answer section to assess learning. Some modules include a testing algorithm example. And for each module, CAP members can download a one- to two-page handout to share with clinicians. The handout is one way for the pathologist to say, “‘Here’s the evidence-based science behind what I’m telling you,’” Dr. Brown says. He adds, “The handouts are a great resource because they provide the background needed to have an informed conversation with the clinician.”

The American Board of Pathology recognizes the importance of pathologist leadership in improving medical practice in a system-based manner, says Dr. Procop. The ABP has therefore approved the modules for Maintenance of Certification part IV, so pathologists can self-claim the modules for MOC part IV credit.

The multidisciplinary group of pathologists who compose the Quality Practices Committee select the module topics based on test use issues of importance. Some of the future modules will be disease oriented, says former QPC vice chair Ron B. Schifman, MD, professor of pathology at the University of Arizona College of Medicine and chief of pathology and laboratory medicine at the Tucson VA Medical Center. One such module in development—screening for and monitoring carcinoid syndrome—addresses multiple tests. Others will focus on diagnosing celiac disease and tick-borne infections. Also to come are modules on repetitive constitutional genetic testing and free PSA. New modules will be added each year.

Two of the modules now available—red cell folate testing and cardiac marker testing practices—address tests that are likely unnecessary, Dr. Schifman says.

“Red cell folate—I think it’s pretty well established that test is rarely, if ever, needed,” Dr. Schifman says. “It’s just as good to measure serum folate, and for some populations it would be questionable if serum folate should be routinely done at all.”

Clinical studies show that improvements in troponin testing have made troponin sufficient, and CK-MB unnecessary, in most cases of acute cardiac injury evaluation.

One part of the HCV infection test module addresses “more of an omission issue where the patient has an antibody to hepatitis C detected but that’s not sufficient to make the diagnosis,” Dr. Schifman says. “You have to confirm the diagnosis of chronic hepatitis by following up with measuring hepatitis C viral RNA as well.”

The module for HCV infection cites two national guidelines related to confirming positive hepatitis C antibody tests to prevent the misdiagnosis of a patient who has become immune or may have a false diagnosis of chronic infection because the follow-up RNA test was not completed.

“It also addresses other types of gaps in practice,” Dr. Schifman says. “For example, a patient with chronic hepatitis C no longer has to have antibody testing. It doesn’t serve any useful purpose. There are suggestions on different kinds of problems that could be encountered with these specific tests—what to look for and how to evaluate them in your practice.”

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