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Test utilization: a united front against waste

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Anne Paxton

July 2013—When it comes to laboratory test orders, the connection between bloodletting and financially draining an institution is more than metaphorical. But a wide range of techniques can help stem test overutilization, clinical laboratory experts have found; you don’t have to drive a stake through a vampire’s heart to stanch the flow.

It took only a simple intervention to slash daily phlebotomy charges at one tertiary care hospital. In their 2011 article, “Surgical vampires and rising health care expenditure” (Arch Surg. 2011:146[5]:524–527), Elizabeth A. Stuebing, MD, and Thomas Miner, MD, report on how they reduced the cost of daily phlebotomy by announcing each week to surgical house staff and attending physicians the dollar amount charged to nonintensive care unit patients for laboratory services.

After 11 weeks, the charges for daily phlebotomy had dropped from $147.73 to $108.11 per patient per day.

It was a classic study, not only demonstrating that knowledge is power, but also that process improvement begins by the mere act of monitoring the process. In business, the maxim is known as the Hawthorne effect, says A. Neil Crowson, MD, chief of staff at St. John Medical Center and president of Pathology Laboratory Associates, Tulsa, Okla.

Dr. Crowson

At his institution, the for-profit core laboratory has taken these principles and applied them for a basic purpose: avoiding the misclassification of patients with normal test results as abnormal. St. John’s Regional Medical Laboratory is one of a few labs in the U.S. with an enterprise knowledge warehouse, Dr. Crowson says.

“This is a vast granular database, created since 1998, with more than 2 million unique patients and over 350 million lab tests that can be correlated on these patients with ICD-9 codes.”

In the old days, Dr. Crowson explains, people would take only 100 presumably normal people and use them as the reference range for a test such as liver function. “But with the enterprise knowledge warehouse data, when we do normal reference ranges, we have up to 100,000 patients by decade for each of the analytes we study.”

The laboratory develops these more precise reference ranges for every analyte it runs. “When we look, we find, for example, that roughly a third of transaminases reported as abnormal in men age 20 to 50 are, in fact, normal.”

“The benefit is, if you run your reference ranges properly, you don’t misidentify normal people as abnormal and then embark on an investigation that might lead, for example, to an unnecessary liver biopsy and potentially to an adverse patient outcome.”

Using the large database allows the laboratory to add refinements in setting reference ranges. “Each ethnic group has minor variances in lab results and we can create separate data universes. African-Americans, for example, have lower white cell counts and that’s normal. But you need to have a database that can identify huge numbers of people for these things to become significant.”

The laboratory also uses data to tailor the pop-up blockers that appear during computerized physician order entry, Dr. Crowson says. “In flagging test orders that might be duplicates, the time period varies depending on the type of test. If it’s a trauma patient, you might order a CBC every three hours, but if it’s a patient coming for a breast biopsy, for example, you might only need to know you’ve ordered one in the last week.”

With the relational database, current lab data for each patient can be related to the lab tests that person has had for the last 12 years. “For molecular testing, that’s significant data, because you rarely want to do that test a second time in the setting of solid organ malignancies. Leukemias and lymphomas, in contrast, can show an altered genotype over time.”

The other category under scrutiny is tests that should not be ordered in the hospital, Dr. Crowson says. “For example, if a patient comes in with a stroke, many of their coagulation parameters are abnormal because of the clot, so what you want to do is manage the neurological injury, get them anticoagulated according to national stroke guidelines [St. John is a nationally recognized stroke center], and then do an investigation of coagulation abnormalities two to four weeks later on an outpatient basis.”

At that point, the tests will have meaning because they won’t be conducted after an acute thrombotic event. “If the patient has a hereditary abnormality such as factor V Leiden, there’s no reason to do that test when they’re in the hospital because it may not influence short-term patient management. We can do the test after they’re out.”

It’s all part of operating in a DRG environment, because when the hospital gets paid a set charge by disease, event, and type, “the more tests you order, the more you erode the hospital’s profitability.” St. John itself is a Catholic, not-for-profit institution, Dr. Crowson points out. “In 2010, we did $60 million worth of indigent care. But it doesn’t matter whether you’re a for-profit or not-for-profit facility; you have to be efficient. If we lose $20 million, we have to close our doors. ‘No margin, no mission,’ as the saying goes.”

A more comprehensive strategy for controlling utilization would help many clinical laboratories, says Michael Hallworth, MA, MSc, a clinical chemist and laboratory director at Royal Shrewsbury Hospital in Shropshire, England. “We’re all tack-ling overutilization in a few selected areas, but very few of us are controlling it consistently across laboratory medicine. In the UK, we’re sitting on a lot of data on overutilization which we aren’t making the best use of. So it’s about putting together a package of measures that everybody should use.”

The new molecular tests are particularly relevant to reducing utilization, he notes. “People don’t tend to understand what they’re for and they do tend to be very expensive tests you have to send out. Some of the low-hanging fruit for cost savings are things like endocrine testing and tumor markers. But it’s important to remember there are other savings to be had. Hundreds of thousands, or millions, of very cheap tests still cost a lot of money, right across the spectrum of tests.”

Dr. Hallworth

While he has found retrospective approaches powerful educational tools, the most effective way to save money has been talking to clinicians prospectively about the ways tests are used. “Clearing up any misapprehensions they may have about what tests can and can’t do, getting the right tests done at the right intervals, and following any local agreements or national guidelines—those are the things that stick best.”

The Pathology Harmony Group in the UK is an initiative the government funds to minimize the variation among hospitals in a range of areas—very simple things, like ‘Do we all use the same reference range for potassium?’ If the lab community cannot agree on what’s normal and what’s not normal, how is the physician supposed to work with that?” Professional bodies such as the UK Association for Clinical Biochemistry and Laboratory Medicine have recommended national minimum retesting intervals (www.acb.org.uk/CPS/CPSNews.asp).

Dr. Hallworth finds especially promising what a few labs in the U.S. are doing. “Instead of asking physicians to guess which coagulation tests they actually want, the approach is to say, ‘Tell me what your problem is, then the laboratory will address it through the right test. All you do is indicate the clinical problem on a request form.’”

“There aren’t many places where it’s happening, but we do use that approach for thyroid function testing. We have a box on the form that essentially says ‘tell me what’s wrong,’ and we will decide based on the clinical presentation what tests to provide.”

This would be a new role for the pathologist and it’s one that is in an evolutionary stage at this point, Dr. Hallworth says. But he notes that in the U.S. physicians “order” tests, while in the UK they “request” them.

Dr. Levy

“There is a cultural difference in there that’s quite important. Treating the laboratory as a black box is not a particularly good model, and as lab testing becomes more complex and sophisticated, it’s becoming an unsustainable model. No physician can understand all the complexities of lab testing, and there’s a real role for workers in the lab, who do understand, to say which tests should be requested.”

One doesn’t find similar problems in radiology, he notes. “A physician would have no qualms at all in calling a radiologist and saying ‘what do I need to do, how do I interpret this, and what does this mean?’ But they seem to think that we in the lab community can’t help them so much.”

One of the problems Dr. Hallworth encounters in the UK occurs when physicians screen for rare causes of abnormal metabolic function. “Wilson’s disease is one condition; it’s an inborn error of metabolism, if you have a teenager and they have an abnormal liver function test, that needs to be in the forefront of your mind. But if someone is 85, then Wilson’s disease is vanishingly unlikely. For someone in their 50s we would offer testing, but not include it in our first-line panel.”

Another common mistake relates to confusion over test names—in the U.S. there are at least 18 different names for vitamin D-related tests, for example, 25-hydroxy and 1,25. “That’s not rocket science. If we can at least call the same things the same names, we can reduce physician confusion.”

He hopes that the focus on laboratory utilization will grow stronger and clearer. “Rather belatedly, it’s become a hot topic in the U.S. and Europe as we try to practice medicine in a much more cost-controlled environment. But people are also realizing that controlling utilization is about preventing overdiagnosis and overmedicalization as well.”

At the University of Rochester (NY) Medical Center, where Paul C. Levy, MD, chairs the Department of Medicine, the initial efforts to improve test utilization got underway in 2009 and were centered on reference laboratory tests.

“There were concerns in the area of reference lab testing that medical necessity was not being met,” Dr. Levy says. “This was an especially important problem because with some of the more expensive tests that were being ordered, we may not be fully reimbursed, and ultimately our institution was having to cover these costs.”
URMC chose to develop a formulary for laboratory tests, a tiered system similar to the pharmacy formulary model. “Our efforts were not driven only by cost but by matching a provider’s training and understanding of a clinical area with certain diagnostic tests.”

For each subspecialty area—allergy, dermatology, GI, and so on—a group of five or six experts on a committee would assign each test on the menu to three tiers. This three-tiered, layered approach has had a big impact on the hospital’s physician ordering profile, he says.

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