Transcript No Slide Title

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 & 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
Strategies for Changing
Physician Ordering Behavior

Strategies that do work



Administrative interventions
Environmental interventions
Combinations with other strategies
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
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


Clinical pathways



Test recommendations & algorithms
Practice guidelines w/ standardized
testing
Timely pathology consults
Physician feedback

Test utilization by service or peer group
Clinical Laboratory Letter
Best 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:



Pathologists discussed proposals with:




Hospital departments & patient care committees
Nursing and medical staffs
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 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
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

Cardiac panel from 1998 to 2000
Total CK, MB & TnI
 0, 6 & 12 hours

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?
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%
Manual WBC Diff Rate
45.0
40.0
35.0
Percent
30.0
25.0
20.0
15.0
10.0
5.0
0.0
1999
2000
2001
2002
2003
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
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
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
Rapid Bacterial Antigen Tests
SLH Outcome

Pathologist reviewed 22 cases over 3 months




Reviewed guidelines w/ ED physicians
Published in Clinical Laboratory Letter
Monitored utilization for 1y after guidelines


50% ordered inappropriately
Total number of orders decreased 75%
Discontinued in Oct 2001
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
Evaluating Bleeding Risk
Personal &/or Family
History of Bleeding
No
Yes
No Further
Testing Required
PT, APTT,
Platelet Count
vWD Panel
Normal
Abnormal
PFA 100
or
Platelet Aggregation
Hematology Consult
Hematology Consult
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
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
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






Stanford
Cleveland Clinic
MD Anderson
Vanderbilt
UCSF
SLH
 3500 counts/year
 640 hours of labor
Blood Bank Serology
Examples of Obsolete Tests

Recipient testing policies adopted



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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 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
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+
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
Clinical Pathways
Example of Practice Guidelines




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


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
Test
May-June
1995
May-June
1996
ANA QL
1455
1697
ANA QT
448
296
%Positive
31
17
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
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
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
Blood Culture Contamination
SLH Quarterly Monitor
7.00%
ED% Contam
Non-ED% Contam
6.00%
Pilot chlorihexidine in ED 8/02
5.00%
4.00%
3.00%
2.00%
1.00%
0.00%
4Q03
3Q03
2Q03
1Q03
4Q02
3Q02
2Q02
1Q02
4Q01
3Q01
2Q01
1Q01
4Q00
3Q00
2Q00
1Q00
4Q99
3Q99
2Q99
1Q99
4Q98
3Q98
2Q98
1Q98
Blood Culture Contamination
SLH Savings



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


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 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
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
2003 Dec
2003 Nov
2003 Oct
2003 Sep
2003 Aug
2003 July
2003 Jun
2003 May
2003 Apr
2003 Mar
2003 Feb
2003 Jan
2002 Dec
2002 Nov
2002 Oct
2002 Sep
2002 Aug
2002 Jul
2002 Jun
2002 May
2002 Apr
2002 Mar
2002 Feb
2002 Jan
CMV QT Reagent Wastage
$7,000
$6,000
$5,000
$4,000
$3,000
$2,000
$1,000
$0
CMV QT Turnaround Time
60
2002
2003
50
% of Samples
40
30
20
10
0
0
1
2
3
Days
4
5
6
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
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 Culture
SLH Benefits


No change in true positive rate
6100 fewer contaminants per year




Faster turnaround time


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


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-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
Diarrhea Algorithm
Diarrhea in Adult Patients
Hospitalized
<3 Days
Giardia Screen
Bacterial Culture
Hold x 7 days
Travel
Immunocompromised
Persistent symptoms
Microscopic O & P
Hospitalized
>3 Days
C. difficile toxin A & B
Hold x 7 days
1995 HCV Algorithm
Example of Optimizing Reflex Testing
HCV EIA
Negative
Positive
RIBA
Negative
Indeterminate
Positive
PCR QL
PCR QL
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
HCV EIA
Negative
Positive
HCV PCR QL
Negative
Negative
Positive
RIBA
PCR QT
Genotype
Indeterminate
Positive
Repeat HCV
Previous Infection
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
HCV EIA
Negative
Positive
S/CO >3.8
S/CO <3.8
If candidate for Rx
TaqMan PCR QT
HCV Genotype
TaqMan
PCR QT
Negative
Positive
RIBA
Genotype
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
Thyroid Cascade
TSH
Decreased
Normal
Increased
free T4
Euthyroid
Stop
free T4
Increased
Normal
Decreased
Decreased
Normal
Increased
Hyper
T3 toxicosis
Subclin hyper
Steroids
NTI
Drug effect
Hypo
Normal
Subclin hypo
Pituitary Tumor
Thyroid Cascade Adaptation
90
80
70
% Total Tests
60
50
40
30
20
10
0
1995
1999
2003
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
Lab Evaluation of Monoclonal
Gammopathies
Clinical suspicion
Increased Total Protein
SPE
M-Protein
Absent
Low Index
of Suspicion
High Index
of Suspicion
or
Hypogamma
Stop
24 H UPE
M-Protein
Present
Serum
IFE
M-Protein
Present
M-protein
Absent
Classify
Investigate
SPE artifact
Monoclonal Gammopathies
SLH IFE Utilization
20
18
16
Percent of SPE
14
12
10
8
6
4
2
0
1998
1999
2000
2001
Esoteric Send Out Requests

Esoteric test expenses increasing


CLS & pathologists review requests



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

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 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
HCV Genotyping
SLH 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
4.5
Average # Units per Patient
4
3.5
RBC
FFP
Platelets
3
2.5
2
1.5
1
0.5
0
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
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 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
nFe 02
bM 02
ar
-0
A 2
pr
M 02
ay
-0
Ju 2
n0
Ju 2
lA 02
ug
S 02
ep
-0
O 2
ct
N 02
ov
D 02
ec
-0
Ja 2
nFe 03
bM 03
ar
-0
A 3
pr
M 03
ay
-0
Ju 3
n0
Ju 3
lA 03
ug
S 03
ep
-0
O 3
ct
N 03
ov
D 03
ec
-0
3
Ja
Error Rate %
Glucose Meter ID Errors
12.0
10.0
8.0
6.0
4.0
2.0
0.0
Inpatient Tests per Discharge
60
50
40
30
20
10
0
75th per centi l e
25th per centi l e
1Q94 1Q95 1Q96 1Q97 1Q98 1Q99 2Q00 1Q01 1Q02 1Q03 1Q04
SLH Admitting Physician
Satisfaction Survey
100
CP
All
90
80
70
% Satisfied
60
50
40
30
20
10
0
2001
2002
2003
2004
Summary of the SLH Approach



Target problems that are solvable
Collect & analyze data from your own lab
Present the data to influential physicians


Communicate changes to medical staff


These experts are the lab’s best advocates
Lab newsletter is a very effective educational tool
Monitor impact of changes