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

Why Be Concerned About Excessive Testing?

1. Increased laboratory costs Once operational efficiencies are maximized,

reducing unnecessary testing is the only way to significantly reduce costs

2. Payer pressure Continued squeeze on reimbursement Required documentation of utilization

Why Be Concerned About Test Utilization?

3. 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

Chance of One Test Being Abnormal

#Tests Ordered

Probability of Abnormal

1 5%

5 23%

10 40%

15 54%

20 64%

Strategies for Changing Physician Ordering Behavior

Reviewed 49 articles between 1966 & 1998JAMA 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

Strategies for Changing Physician Ordering Behavior

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

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

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

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

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

Clinical Laboratory LetterBest Educational Tool

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

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

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

Types of Projects Undertaken

Excessive Tests Obsolete Tests Clinical Pathways Reference Ranges Wastage Turnaround Time

Algorithms & Reflex Testing

Send Out Tests In-sourcing Tests Transfusion Error Rate

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

Vancomycin Orders

Year #TestsPayerCost

Savings

1993 2127 $95,524

1995 905 $40,644 $54,880

1997 1113 $50,085 $45,439

Cardiac Marker ProfileExample of Excess Testing

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

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?

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%

Manual WBC Diff Rate

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

1999 2000 2001 2002 2003

Per

cen

t

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

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

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

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

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

Evaluating Bleeding Risk

No FurtherTesting Required

No

Hem atology Consult

PFA 100or

Platelet Aggregation

Norm al

Hem atology Consult

Abnorm al

PT, APTT,P latelet Count

vW D Panel

Yes

Personal &/or Fam ilyHistory of Bleeding

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

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

Confidence Limits100 Cell Manual Diff Count

Bands %Confidence Limits

%

5 1 – 12

10 4 – 18

15 8 – 24

20 12 - 30

Labs That Are Band-less Stanford Cleveland Clinic MD Anderson Vanderbilt UCSF SLH

3500 counts/year 640 hours of labor

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

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

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+

Blood Bank SerologySLH Cost 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

Clinical PathwaysExample of Practice Guidelines

Nurses & physicians wrote guidelines

Pathologists reviewed lab tests Suggestions returned to authors Test utilization monitored before &

after

70 Clinical PathwaysImpact on Test Utilization

YearCases/

YrTests/Cs Test/Yr

1992 8823 50.3 443,797

1996 9630 44.3 426,609

Diff 807 -6 -17,188

% Diff +9% -12% -4%

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

ANA Test Volumes

TestMay-June

1995May-June

1996

ANA QL 1455 1697

ANA QT 448 296

%Positive 31 17

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

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

Blood Culture ContaminationProcedure Change

Chlorhexidine blood culture prep One step application Decreased drying time

ED trial in August 2002 Hospital-wide in May 2003

Blood Culture Contamination SLH Quarterly Monitor

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

1Q98

2Q98

3Q98

4Q98

1Q99

2Q99

3Q99

4Q99

1Q00

2Q00

3Q00

4Q00

1Q01

2Q01

3Q01

4Q01

1Q02

2Q02

3Q02

4Q02

1Q03

2Q03

3Q03

4Q03

ED% Contam Non-ED% Contam

Pilot chlorihexidine in ED 8/02

Blood Culture ContaminationSLH Savings

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

year

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

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

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

CMV QT Reagent Wastage

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

2002 J

an

2002 F

eb

2002 M

ar

2002 A

pr

2002 M

ay

2002 J

un

2002 J

ul

2002 A

ug

2002 S

ep

2002 O

ct

2002 N

ov

2002 D

ec

2003 J

an

2003 F

eb

2003 M

ar

2003 A

pr

2003 M

ay

2003 J

un

2003 J

uly

2003 A

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ct

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2003 D

ec

CMV QT Turnaround Time

0

10

20

30

40

50

60

0 1 2 3 4 5 6

Days

% o

f Sam

ples

2002

2003

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

Urine Culture Results @ 48 vs. 24 Hours

Results Sep 95 Jun 96 Sep 98

Pos 38% 39% 37%

Neg 12% 45% 47%

Contam 50% 16% 16%

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

Diarrhea Work-upExample of Optimizing Reflex Testing

Questionable value for inpatients Reviewed >200 inpatient O&P & stool

cultures No enteric pathogens detected Ordered for 3 consecutive days Payers billed $234,375 w/o pathogen 20% exams on inpatients admitted >3d

Diarrhea Work-upLab Policy Change

New nosocomial diarrhea policy >3 days after admission

Substituted C. diff toxin for O&P <3 days after admission

Substituted Giardia screen for O&P Payer cost savings >$400,000/year Reagent & labor savings of $11,592 per

year Specimen held for 7 days

Diarrhea Algorithm

G iardia ScreenBacterial Culture

Hold x 7 days

M icroscopic O & P

TravelIm m unocom prom isedPersistent symptoms

Hospitalized<3 Days

C. diffic ile toxin A & BHold x 7 days

Hospitalized>3 Days

D iarrh ea in Ad u lt P a tien ts

1995 HCV AlgorithmExample of Optimizing Reflex Testing

N egative

N egative

PC R Q L

Indeterm inate

PC R Q L

Positive

R IB A

Positive

H C V E IA

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

1997 HCV Algorithm

Negative

Negative

Repeat HCV

Indeterm inate

Previous Infection

Positive

RIB A

Negative

PCR Q TG enotype

Positive

HCV PCR Q L

Positive

HCV EIA

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

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

2003 HCV Algorithm

Negative

If candidate for RxTaqM an PCR QTHCV G enotype

S/CO >3.8

RIB A

Negative

G enotype

Positive

TaqM anPCR Q T

S/CO <3.8

Positive

HCV EIA

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

Thyroid Cascade

H yp e r

In c rea sed

T 3 to x ico s isS u b c lin h yp er

S te ro ids

N o rm a l

N T ID ru g e ffe ct

D e c rea sed

fre e T4

D e c rea sed

E u thyro idS top

N o rm a l

H yp o

D e c rea sed

N o rm a lS u bc lin h ypo

N o rm a l

P itu ita ry T u m or

In c rea sed

fre e T4

In c rea sed

T S H

Thyroid Cascade Adaptation

0

10

20

30

40

50

60

70

80

90

1995 1999 2003

% T

ota

l Tes

ts

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

Lab Evaluation of Monoclonal Gammopathies

S top

L o w Ind exo f S u sp ic ion

2 4 H U P E

H igh Ind exo f S u sp ic ion

o rH yp o ga m m a

M -P ro te inA b se n t

C la ss ify

M -P ro te inP re se n t

In ves tig a teS P E artifa ct

M -p ro te inA b se n t

S e rumIF E

M -P ro te inP re se n t

S P E

C lin ica l su sp ic ionIn c rea se d T o ta l P ro te in

Monoclonal GammopathiesSLH IFE Utilization

0

2

4

6

8

10

12

14

16

18

20

1998 1999 2000 2001

Per

cen

t o

f S

PE

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

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

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

HCV GenotypingSLH Savings

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

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

Average Number of Units Transfused per OHS Case

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Ave

rag

e #

Un

its p

er P

atie

nt

RBC FFP Platelets

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

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

Glucose Meter ID Errors

0.0

2.0

4.0

6.0

8.0

10.0

12.0

Err

or

Ra

te %

Inpatient Tests per Discharge

010

2030

4050

60

1Q94 1Q95 1Q96 1Q97 1Q98 1Q99 2Q00 1Q01 1Q02 1Q03 1Q04

75th percentile

25th percentile

SLH Admitting Physician Satisfaction Survey

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10

20

30

40

50

60

70

80

90

100

2001 2002 2003 2004

% S

atis

fied

CP

All

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 lab’s best advocates Communicate changes to medical staff

Lab newsletter is a very effective educational tool Monitor impact of changes