How to Successfully Influence Test Utilization Improve

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 n Increased number of false & weak positives n Follow-up increases cost, worry, discomfort, risk n Confirmatory tests n Specialist referrals n Invasive procedures n Unnecessary postponement of procedure n Attention diverted from primary problem

Chance of One Test Being Abnormal

Strategies for Changing Physician Ordering Behavior n Reviewed 49 articles between 1966 & 1998 JAMA 1998; 280: 2020 n Strategies that do not work by themselves n Physician consensus building n Test guideline dissemination n Traditional education n Utilization audits n Informing physicians of lab charges

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

Lundberg’s Principles JAMA 1998; 280: 2036 § Know the right thing to do n Confer w/ respected physician leaders n Implement changes administratively n Educate through writing & conferences n Weather the storm n Remain open to communication n Enjoy the success of more effective service

Examples of Environmental Interventions n n Test requisition redesign n Preferred tests & cascades emphasized n Outmoded tests less obvious or omitted n Large panels restricted Optimized testing & reporting n Rapid turnaround times n Minimal number of laboratory errors n Immediate & easy access to test results n Merged out & inpatient test results

Examples of Administrative Interventions n Administrative policy changes n n Pathologist approval for special tests Pathologist approval of send out tests Test intervals, frequencies & reflex policy Financial feedback n n Review of CPT codes denied payment Decision support systems

Examples of Educational Interventions n Clinical Laboratory Letter n n Clinical pathways n n n Test recommendations & algorithms Practice guidelines w/ standardized testing Timely pathology consults Physician feedback n Test utilization by service or peer group

Clinical Laboratory Letter Best Educational Tool

Analyzing the Problem n High test volume & diverse test menu n n 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 n n Pathologists & staff continuously monitor testing trends within their areas of expertise Targeted tests with following characteristics: n High volume n Expensive n Difficult to perform n Questionable medical benefit n Unusual number of abnormal results

Action Plan n Lab collaborated with: n n n Pathologists discussed proposals with: n n Hospital departments & patient care committees Nursing and medical staffs Key physicians Entire medical departments Hospital Performance Improvement committee Clinical Laboratory Letter n Published test utilization data & algorithms

Types of Projects Undertaken n n n Excessive Tests Obsolete Tests Clinical Pathways Reference Ranges Wastage Turnaround Time n n n Algorithms & Reflex Testing Send Out Tests In-sourcing Tests Transfusion Error Rate

Vancomycin Monitoring Example of Excess Testing n Clinical pharmacologists noted too many drug levels ordered in 1994 n n n Peak & trough levels ordered together Little scientific evidence supporting peak Lab & Pharmacy educated medical staff n n n Presented at medical staff meetings Published data in Clinical Laboratory Letter Deleted peak from computer order screens

Vancomycin Orders Year #Tests Payer Cost Savings 1993 2127 $95, 524 1995 905 $40, 644 $54, 880 1997 1113 $50, 085 $45, 439

Cardiac Marker Profile Example of Excess Testing n Cardiac panel from 1998 to 2000 Total CK, MB & Tn. I n 0, 6 & 12 hours n

Cardiac Marker Profile Example of Excess Testing n n n ACC & AHA guideline revision in 2000 Panel to MB & Tn. I at 0, 3, & 6 h Eliminated >23, 000 CK per year n n $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 Counts Example of Excess Testing n n n Manual diff rate was 40% in 1999 Installed Coulter Gen-S in 2000 Continually re-examined reflex criteria n n 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

WBC Differential Counts SLH Outcomes n n n Avoid 15, 000 manual diffs per year CAP average time = 11 minutes/slide Save 2750 hours of labor per year n n >1 FTE Expect rate to further in 2004 n n New analyzer Eliminate band counts

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

Rapid Bacterial Antigen Tests Example of an Obsolete Test n Clinical utility questioned today n n n Not sensitive enough to rule out bacterial origin Not specific enough to direct antibiotic therapy Improved empiric antibiotic Rx available

Rapid Bacterial Antigen Tests SLH Outcome n Pathologist reviewed 22 cases over 3 months n n Reviewed guidelines w/ ED physicians Published in Clinical Laboratory Letter Monitored utilization for 1 y after guidelines n n 50% ordered inappropriately Total number of orders decreased 75% Discontinued in Oct 2001

Bleeding Time Example of an Obsolete Test n n n Poor perioperative screening test Poor diagnostic test Poor clinical reproducibility n n Technical & patient factors Discontinuation not associated w/ adverse outcome n Clin Chem 2001; 47: 1204 -11

Evaluating Bleeding Risk

Bleeding Time SLH Outcomes n n n 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 Count Example of an Obsolete Test n n Previously considered mainstay in lab diagnosis of bacterial infection Recently clinical utility questioned n n Subjective band ID criteria Imprecision & sampling errors Accurate 5 part automated diff ANC = better predictor of infection

Confidence Limits 100 Cell Manual Diff Count Bands % Confidence Limits % 5 1 – 12 10 4 – 18 15 8 – 24 20 12 - 30

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

Blood Bank Serology Examples of Obsolete Tests n Recipient testing policies adopted n n Immediate spin crossmatch Routine use of anti-Ig. G Elutions on +DAT only if Tx w/in 3 mo Donor testing n n Anti-A, B to confirm group O units Rh type confirmed only on Rh units

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

Blood Bank Serology SLH Cost Savings n n n >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 n Only performed 11 in 2003

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

70 Clinical Pathways Impact 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%

Anti-nuclear Antibody Example of Reference Range Change n n Reported ANA >1: 40 as positive before 1995 Referrals & follow-up tests ordered n n <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 Test May-June 1995 May-June 1996 ANA QL 1455 1697 ANA QT 448 296 %Positive 31 17

Anti-nuclear Antibody Outcomes n n Positive ANA rate decreased 14% Follow-up testing eliminated n n n Payer charges $99, 925 per year Referrals & diagnostic procedures avoided Eliminated >500 manual tests per year

Blood Culture Contamination Example of Decreased Wastage n Contamination w/ skin flora causes n n n Unnecessary antibiotic administration Additional cultures & other lab tests Increased length of stay Increased hospital cost of ~$5000/case ASM goal is contamination rate <3% n ED usually have higher rates

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

Blood Culture Contamination SLH Quarterly Monitor

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

Specimen in Lab Policy Example of Decreased Wastage n n Worked with Blood Conservation Team to reduce iatrogenic blood loss SIL Policy implemented n n n Stored blood specimens for 2 weeks Publicized in Lab Letter & Nursing publications Avoided redrawing patients for add on tests

Specimen in Lab Policy SLH Outcomes n n 11, 244 requests for tests on SIL $51, 726 savings in labor & supplies Avoided 11, 244 venipunctures Conserved 71, 428 m. L of blood n Equivalent to 140 units of RBCs

CMV PCR Quantitation Example of Decreased Wastage n n Cobas Amplicor CMV QT - Oct 2001 Initially performed on M, W, F schedule n n Not enough specimens to use complete kit Unused reagents had to be discarded n n Wastage cost $5000 per month Flexible schedule introduced Jan 2003 n n Run whenever have 9 specimens Monitored wastage & TAT

CMV QT Reagent Wastage

CMV QT Turnaround Time

Urine Cultures Example of Improved TAT n n n 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%

Urine Culture SLH Benefits n n No change in true positive rate 6100 fewer contaminants per year n n Faster turnaround time n n Payer cost savings of $88, 740 per year Fewer contaminants worked up Fewer repeat cultures submitted Antibiotic Rx optimized more quickly Lab workload by 120 plates per day

Diarrhea Work-up Example of Optimizing Reflex Testing n n Questionable value for inpatients Reviewed >200 inpatient O&P & stool cultures n n No enteric pathogens detected Ordered for 3 consecutive days Payers billed $234, 375 w/o pathogen 20% exams on inpatients admitted >3 d

Diarrhea Work-up Lab Policy Change n n New nosocomial diarrhea policy >3 days after admission n n Substituted C. diff toxin for O&P <3 days after admission n n 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

1995 HCV Algorithm Example of Optimizing Reflex Testing

1995 HCV Algorithm Inefficiency Identified PCR if RIBA positive or indeterminate n n Most RIBA were Indeterminate 66% had RIBA & PCR performed Shared data with GI & ID physicians Changed algorithm in 1997

1997 HCV Algorithm

1997 HCV Algorithm n Financial Impact n n PCR had better sensitivity & specificity n Fewer RIBA performed Based on 1997 test volumes n Payer charges decreased $63, 000 n Laboratory costs decreased $39, 000

1997 HCV Algorithm Limitations n PCR QT had limited dynamic range n n n Not as sensitive as PCR QL 25% cases exceeded linearity Taq. Man RT PCR conversion n Much wider dynamic range n n Eliminated need for PCR QL Eliminated repeat testing n $23, 000 per year cost savings

2003 HCV Algorithm

Thyroid Testing Example of Optimized Reflex Testing n 3 Lab Letters recommended cascade n n Feb 96, Apr 98 & Feb 99 Screen w/ TSH Follow-up w/ f. T 4 85% of patients have normal TSH n No further testing required

Thyroid Cascade

Thyroid Cascade Adaptation

Monoclonal Gammopathies Example of Optimized Reflex Testing n n Physicians able order IFE w/o prior SPE Most patients did not have monoclonal IFE more expensive than SPE Established reflex testing n n Lab supply savings of $6000 per year Payer charges decreased $17, 800 per year

Lab Evaluation of Monoclonal Gammopathies

Monoclonal Gammopathies SLH IFE Utilization

Esoteric Send Out Requests n Esoteric test expenses increasing n n CLS & pathologists review requests n n n HHV-6, FISH, NK cells, CF, HCV genotypes Consult with ordering physician In source if feasible Annual cost savings of $200, 000/year

Cystic Fibrosis Example of In-sourcing a Test n ACOG & ACMG recommendation n n March 2001 Offer screening to pregnant couples Sent to reference lab initially Roche CF Gold in November 2002 n $40, 000 cost savings in 2003

HCV Genotyping Example of In-sourcing a Test n n 6 HCV genotypes recognized Genotype determines therapy n n n Type 1 requires 48 months Types 2 & 3 require 24 months Interferon Rx very expensive

HCV Genotyping SLH Savings n n n Sent to reference lab initially INNO-Li. Pa HCV II implemented in 2001 $55, 670 cost savings in 2002

Open Heart Surgery Example of Transfusion Review n n OHS transfused ~one third of components Pathologist analyzed blood usage each year n n n 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

Benefits of Decreased Transfusion n n 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 Testing Patient Identification Errors n Manual Patient ID entry n n 12, 000 tests per month 9. 7% average error rate ~450 unidentified results per month PI project in December 2002 n n Accu-Chek Inform & RALS Plus Barcoded armbands

Glucose Meter ID Errors

Inpatient Tests per Discharge

SLH Admitting Physician Satisfaction Survey

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