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How to Successfully Influence Test Utilization & Improve Laboratory Efficiency Fred V. Plapp, Cynthia Essmyer, Anne Byrd & Marjorie Zucker Saint Luke’s.

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Presentation on theme: "How to Successfully Influence Test Utilization & Improve Laboratory Efficiency Fred V. Plapp, Cynthia Essmyer, Anne Byrd & Marjorie Zucker Saint Luke’s."— Presentation transcript:

1 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

2 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

3 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

4 Chance of One Test Being Abnormal

5 Strategies for Changing Physician Ordering Behavior Reviewed 49 articles between 1966 & 1998 JAMA 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

6 Strategies for Changing Physician Ordering Behavior Strategies that do work Administrative interventions Environmental interventions Combinations with other strategies

7 Lundberg’s Principles JAMA 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

8 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

9 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

10 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

11 Clinical Laboratory Letter Best Educational Tool

12 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

13 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

14 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

15 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

16 Vancomycin Monitoring Example 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

17 Vancomycin Orders Year#Tests Payer Cost Savings 19932127$95,524 1995905$40,644$54,880 19971113$50,085$45,439

18 Cardiac Marker Profile Example of Excess Testing Cardiac panel from 1998 to 2000 Total CK, MB & TnI 0, 6 & 12 hours

19 Cardiac Marker Profile Example 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?

20 WBC Differential Counts Example 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%

21 Manual WBC Diff Rate

22 WBC Differential Counts SLH 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

23 Rapid Bacterial Antigen Tests Example of an Obsolete Test Introduced in 1980s for Dx of bacterial meningitis H flu N meningitidis E coli S pneumo GBS

24 Rapid Bacterial Antigen Tests Example 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

25 Rapid Bacterial Antigen Tests SLH 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

26 Bleeding Time Example 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

27 Evaluating Bleeding Risk

28 Bleeding Time SLH 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

29 Band Neutrophil Count Example 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

30 Confidence Limits 100 Cell Manual Diff Count Bands %Confidence Limits % 51 – 12 104 – 18 158 – 24 2012 - 30

31 Labs That Are Band-less Stanford Cleveland Clinic MD Anderson Vanderbilt UCSF SLH 3500 counts/year 640 hours of labor

32 Blood Bank Serology Examples 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

33 Blood Bank Serology Examples 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

34 Blood Bank Serology Examples of Obsolete Tests Cord blood test policies ABO & Rh typing only if mom is Group O or Rh negative No elution if DAT+

35 Blood Bank Serology SLH 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

36 Clinical Pathways Example of Practice Guidelines Nurses & physicians wrote guidelines Pathologists reviewed lab tests Suggestions returned to authors Test utilization monitored before & after

37 70 Clinical Pathways Impact on Test Utilization YearCases/YrTests/CsTest/Yr 1992882350.3443,797 1996963044.3426,609 Diff807-6-17,188 % Diff+9%-12%-4%

38 Anti-nuclear Antibody Example 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

39 ANA Test Volumes Test May-June 1995 May-June 1996 ANA QL14551697 ANA QT448296 %Positive3117

40 Anti-nuclear Antibody Outcomes 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

41 Blood Culture Contamination Example 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

42 Blood Culture Contamination Procedure Change Chlorhexidine blood culture prep One step application Decreased drying time ED trial in August 2002 Hospital-wide in May 2003

43 Blood Culture Contamination SLH Quarterly Monitor

44 Blood Culture Contamination SLH Savings 9740 blood cultures per year Contaminants  from 238 to 135 $515,000 hospital cost savings per year

45 Specimen in Lab Policy Example 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

46 Specimen in Lab Policy SLH 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

47 CMV PCR Quantitation Example 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

48 CMV QT Reagent Wastage

49 CMV QT Turnaround Time

50 Urine Cultures Example 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

51 Urine Culture Results @ 48 vs. 24 Hours ResultsSep 95Jun 96Sep 98 Pos38%39%37% Neg12%45%47% Contam50%16%

52 Urine Culture SLH 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

53 Diarrhea Work-up Example 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

54 Diarrhea Work-up Lab 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

55 Diarrhea Algorithm

56 1995 HCV Algorithm Example of Optimizing Reflex Testing

57 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

58 1997 HCV Algorithm

59 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

60 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

61 2003 HCV Algorithm

62 Thyroid Testing Example 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

63 Thyroid Cascade

64 Thyroid Cascade Adaptation

65 Monoclonal Gammopathies Example 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

66 Lab Evaluation of Monoclonal Gammopathies

67 Monoclonal Gammopathies SLH IFE Utilization

68 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

69 Cystic Fibrosis Example 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

70 HCV Genotyping Example 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

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

72 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

73 Average Number of Units Transfused per OHS Case

74 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

75 POC Blood Glucose Testing Patient 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

76 Glucose Meter ID Errors

77 Inpatient Tests per Discharge

78 SLH Admitting Physician Satisfaction Survey

79 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

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