How to Successfully Influence Test Utilization

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How to Successfully Influence Test Utilization
Improve Laboratory Efficiency
Fred V. Plapp, Cynthia Essmyer, Anne Byrd
Marjorie Zucker Saint Lukes Health System Kansas
City

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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

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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

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Chance of One Test Being Abnormal
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Strategies for Changing Physician Ordering
Behavior

• Reviewed 49 articles between 1966 1998
• JAMA 19982802020
• Strategies that do not work by themselves
• Physician consensus building
• Test guideline dissemination
• Traditional education
• Utilization audits
• Informing physicians of lab charges

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Strategies for Changing Physician Ordering
Behavior

• Strategies that do work
• Administrative interventions
• Environmental interventions
• Combinations with other strategies

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Lundbergs PrinciplesJAMA 19982802036

• 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

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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

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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

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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

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Clinical Laboratory LetterBest Educational Tool
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Analyzing the Problem

• High test volume diverse test menu
• 2 million tests performed per year
• gt300 different tests offered
• No single project would be effective
• Multi-pronged long term strategy was required

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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

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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

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Types of Projects Undertaken

• Algorithms Reflex Testing
• Send Out Tests
• In-sourcing Tests
• Transfusion
• Error Rate

• Excessive Tests
• Obsolete Tests
• Clinical Pathways
• Reference Ranges
• Wastage
• Turnaround Time

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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

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Vancomycin Orders
Year Tests Payer Cost Savings
1993 2127 95,524
1995 905 40,644 54,880
1997 1113 50,085 45,439
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Cardiac Marker ProfileExample of Excess Testing

• Cardiac panel from 1998 to 2000
• Total CK, MB TnI
• 0, 6 12 hours

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Cardiac Marker ProfileExample of Excess Testing

• ACC AHA guideline revision in 2000
• Panel ? to MB TnI at 0, 3, 6 h
• Eliminated gt23,000 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?

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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 lt0.8
• No flags on high RBC, Hb, Hct, MCV, RDW
• Set neutrophil flag to 12.0 90

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Manual WBC Diff Rate
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WBC Differential CountsSLH Outcomes

• Avoid 15,000 manual diffs per year
• CAP average time 11 minutes/slide
• Save 2750 hours of labor per year
• gt1 FTE
• Expect rate to ?? further in 2004
• New analyzer
• Eliminate band counts

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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

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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

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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

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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 2001471204-11

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Evaluating Bleeding Risk
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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

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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

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Confidence Limits100 Cell Manual Diff Count
Bands Confidence Limits
5 1 12
10 4 18
15 8 24
20 12 - 30
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Labs That Are Band-less

• Stanford
• Cleveland Clinic
• MD Anderson
• Vanderbilt
• UCSF
• SLH
• 3500 counts/year
• 640 hours of labor

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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

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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

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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

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Blood Bank SerologySLH Cost Savings

• gt1900 hours of labor per year
• gt23,100 tubes per year
• 90 vials of anti-D per year
• 48 vials of anti-A and B
• Numerous elutions
• Only performed 11 in 2003

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Clinical PathwaysExample of Practice Guidelines

• Nurses physicians wrote guidelines
• Pathologists reviewed lab tests
• Suggestions returned to authors
• Test utilization monitored before after

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70 Clinical PathwaysImpact on Test Utilization
Year Cases/Yr Tests/Cs Test/Yr
1992 8823 50.3 443,797
1996 9630 44.3 426,609
Diff 807 -6 -17,188
Diff 9 -12 -4
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Anti-nuclear AntibodyExample of Reference Range
Change

• Reported ANA gt140 as positive
• before 1995
• Referrals follow-up tests ordered
• lt5 positive if ANA lt1160
• Discussed with rheumatologists
• Changed cutoff to 1160 in June 95
• Started testing at 1160 dilution

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ANA Test Volumes
Test May-June 1995 May-June 1996
ANA QL 1455 1697
ANA QT 448 296
Positive 31 17
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Anti-nuclear AntibodyOutcomes

• Positive ANA rate decreased 14
• Follow-up testing eliminated
• Payer charges ? 99,925 per year
• Referrals diagnostic procedures avoided
• Eliminated gt500 manual tests per year

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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 lt3
• ED usually have higher rates

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Blood Culture ContaminationProcedure Change

• Chlorhexidine blood culture prep
• One step application
• Decreased drying time
• ED trial in August 2002
• Hospital-wide in May 2003

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Blood Culture Contamination SLH Quarterly Monitor
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Blood Culture ContaminationSLH Savings

• 9740 blood cultures per year
• Contaminants ? from 238 to 135
• 515,000 hospital cost savings per year

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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

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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

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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

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CMV QT Reagent Wastage
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CMV QT Turnaround Time
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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

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Urine Culture Results _at_ 48 vs. 24 Hours
Results Sep 95 Jun 96 Sep 98
Pos 38 39 37
Neg 12 45 47
Contam 50 16 16
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Urine CultureSLH 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

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Diarrhea Work-upExample of Optimizing Reflex
Testing

• Questionable value for inpatients
• Reviewed gt200 inpatient OP stool cultures
• No enteric pathogens detected
• Ordered for 3 consecutive days
• Payers billed 234,375 w/o pathogen
• 20 exams on inpatients admitted gt3d

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Diarrhea Work-upLab Policy Change

• New nosocomial diarrhea policy
• gt3 days after admission
• Substituted C. diff toxin for OP
• lt3 days after admission
• Substituted Giardia screen for OP
• Payer cost savings gt400,000/year
• Reagent labor savings of 11,592 per year
• Specimen held for 7 days

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Diarrhea Algorithm
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1995 HCV AlgorithmExample of Optimizing Reflex
Testing
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1995 HCV Algorithm Inefficiency 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

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1997 HCV Algorithm
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1997 HCV Algorithm

• 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

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1997 HCV Algorithm Limitations

• 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

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2003 HCV Algorithm
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Thyroid TestingExample 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

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Thyroid Cascade
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Thyroid Cascade Adaptation
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Monoclonal GammopathiesExample 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

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Lab Evaluation of Monoclonal Gammopathies
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Monoclonal GammopathiesSLH IFE Utilization
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Esoteric Send Out Requests

• 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

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Cystic FibrosisExample of 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

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HCV GenotypingExample 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

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HCV GenotypingSLH Savings

• Sent to reference lab initially
• INNO-LiPa HCV II implemented in 2001
• 55,670 cost savings in 2002

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Open Heart Surgery Example 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

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Average Number of Units Transfused per OHS Case
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Benefits of Decreased Transfusion

• 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

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POC Blood Glucose TestingPatient 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

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Glucose Meter ID Errors
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Inpatient Tests per Discharge
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SLH Admitting Physician Satisfaction Survey
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Summary of the SLH Approach

• Target problems that are solvable
• Collect analyze data from your own lab
• Present the data to influential physicians
• These experts are the labs best advocates
• Communicate changes to medical staff
• Lab newsletter is a very effective educational
  tool
• Monitor impact of changes