Best Practices for a Data-driven Approach to Test Utilization
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The document outlines best practices for improving laboratory test utilization, emphasizing the need for a data-driven approach to reduce costs and overutilization in healthcare. It highlights the role of a utilization management committee at Seattle Children's Hospital, which focuses on tracking and managing test requests, particularly genetic tests, to improve patient outcomes and reduce unnecessary expenditures. Key interventions discussed include automated reminders, educational outreach to providers, and the importance of genetic counselors in the test ordering process.
Best Practices for a Data-driven Approach to Test Utilization
- 1. Best Practices for a Data-driven Approach to Test Utilization MICHAEL ASTION, MD, PHD AUG. 30, 2016
- 2. Michael Astion, MD, PhD • Medical Director, Department of Laboratories, Seattle Children’s Hospital • Clinical Professor, University of Washington, Department of Laboratory Medicine Financial disclosure statement: • Univ. Washington Intellectual Property licensed to – EviCore Inc., (Guide to Lab Utilization) – Medical Training Solutions • Dr. Astion is employed by Seattle Children’s Hospital and is here representing Seattle Children’s.
- 3. Agenda • Utilization Management (UM) – Background • Value in lab testing. Why is genetics different? • Why improve utilization? • Trends in healthcare affecting UM – Data from insurance claims – Interventions to improve test ordering • Seattle Children’s UM plan/Pediatric Laboratory Utilization Guidance Service (PLUGS) • Conclusions
- 4. Why improve lab utilization? • ¯ patient costs • ¯ direct lab costs • ¯ societal costs • ¯ false + results especially with ¯ pretest probability • ¯ worry • ¯ false Dx, associated harms • ¯ unnecessary work Value = Quality/Cost Warren JS. Lab test utilization program… Am J Clin Path. 2013;139:289-297.; Lewandrowski K. Managing utilization of new diagnostic tests. Clin Leadersh Manag Rev. 2003 Nov-Dec;17(6):318-24.; Kim JY et al. Utilization management in a large urban academic medical center. AJCP. 2011;;135:108-118.
- 5. Root causes of lab overutilization Care providers Patients Labs testing Health system google …$$ incentive… fee for service malpractice fear.. gene patents... $ incentive… dissatisfaction… more is better... mktg pressure… coding system... patient pressure… wellness movement…
- 6. Univ Washington- EviCore collaboration to study lab utilization in commercially-insured populations in the USA (2008 – present) • Study of national, regional lab insurance claims databases • Characteristics of largest insurance dbase we have studied: – 1 year of data (2009) – 3.5 million covered individuals (members) – 8.2 million doctor’s visits in 48 states – Total spent on lab was $668 million. – Lots of overutilization. • Example: 2.3% of members had ANA test (about $ 1 million spent). Prevalence of Lupus in population is 0.2 – 1.5 per 1000 Eckert LO, Tait JF, Astion ML, et al 2010. Use of Molecular Diagnostics for Lower Genital Tract Complaints: Comparison of Practice Patterns with Published Guidelines. Am College of Obstetrics and Gynecology Annual Meeting.;; Eckert LO, Astion ML, Tait JF, et al. 2011.Use of molecular diagnostics in women without genital symptoms presenting for Pap smear: How common? How costly? Infectious Disease Society for Obstetrics and Gynecology (winner of outstanding poster award).;; Bradley SM, Tait J, O’Brien KD et al. 2011. Use of novel cardiovascular risk biomarkers in clinical practice. Annual Meeting for Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke.
- 7. Major domains of overutilization Bundling and nonstandard tests are drivers in all domains • Wellness • CVD risk • Pain • Women’s health (cervicitis, vaginitis) • Nutrition and metals • Flow cytometry • Allergy • Autoantibodies (e.g., celiac test bundles) • Inpatients: daily labs • Genetic testing, especially by non-geneticists Adults Peds Eckert LO, Tait JF, Astion ML, et al 2010. Am College of Obstetrics and Gynecology Annual Meeting.;; Eckert LO, Astion ML, Tait JF et al. 2011. Infectious Disease Society for Obstetrics and Gynecology;; Bradley SM, Tait J, O’Brien KD, et al. 2011. Annual Mtg, Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke.
- 8. Overuse/ Misuse of Allergen-specific tests Novel biomarkers are overused (4.4% waste of $) Allergen specific test # visits (Dates of Service) $ spent (% of total) IgE allergy test 18553 $2,315,447 (95.7%) IgG-IgG4 allergy test 28 $71,420 (3.0%) ALC antibody 48 $33,267 (1.4%) • Astion M, Tait J, et al. CareCore collaboration, unpublished data • Used our largest annual database of 3.5 million covered individuals • >500 clinical labs represented in the >18,000 dates of service
- 9. For allergen-specific IgE testing, 28 tests per doctor’s visit is the norm! 26 % 19 % 24 % 23 % 7 % 0 1000 2000 3000 4000 5000 6000 1 - 10 u 11 - 20 u 21 -30 u 31 - 40 u > 40 u DOS Range of IgE units • N = 18,553 doctor’s visits • Ave units of allergen specific IgE : 28 (SD:13, Range: 12 – 71) • 54% of workups are associated with testing > 21 allergens
- 10. INTERVENTIONS to improve utilization require backbone, energy, and data “I’m revitalized and ready to decrease Vitamin D testing!”
- 11. Seattle Children’s Hospital approach to utilization management (UM) is typical and illustrative • Utilization management committee, meets weekly – 3 genetic counselors – 4 - 6 doctoral level staff including pathologists, medical geneticists, and clinical chemists – 2 lab managers – Subcommittees for special topics (e.g. exome testing) • 1 GC, 1 doctor on call for UM each week. • All UM cases recorded in database. Dbase allows case tracking, consistency in case resolution, and enables research and QI • Emphasis is on sendout tests, but all aspects of UM are covered. Dickerson JA, Cole B, Conta JH, et al.. Improving the value of costly genetic reference laboratory testing with active utilization management. Arch Path Lab Med. 2014 Jan;;138(1):110-3.
- 12. Seattle Children’s Hospital: What test requests are placed under active management with review? – Tests > $700 – Tests ordered for multiple genes – Requests to use alternate labs – Requests for banned tests or labs – Request for test labeled in lab system as “Under Management” (e.g., reverse T3) Dickerson J, et al. Ten Ways to Improve the Quality of Send-out Testing. Clin Lab News. 2012;;38(4): 12-13. www.aacc.org/publications/cln/2012/april/Pages/SendOutTesting.aspx#;; Dickerson JA, Cole B, Conta JH, et al.. Improving the value of costly genetic reference laboratory testing with active utilization management. Arch Path Lab Med. 2014 Jan;;138(1):110-3.
- 13. Where should health systems focus interventions? It is most realistic to focus on care providers. Perverse Financial Incentives MD, RN, PA, other Patient Pressure Marketing Pressure Lab Test result Test order Astion M. Quackery interventions: The hopelessness and the hope. Laboratory Errors and Patient Safety.2007. 4(1): 1 – 6.
- 14. Common weaker interventions to improve lab utilization • Memos • Call for enhanced vigilance • Training – Distribution of materials – Formal continuing education MEMO 10/07/10 To: All Providers in Clinic X From: Dr. BigEgo, Clinic Chief Re: Lab test utilization Stop ordering the wrong tests, and start ordering the right tests. Please, don’t order too many tests. Be more careful. You all don’t know what you are doing.
- 15. • Posting of guidelines on the requisition • Computerized reminders regarding utilization guidelines Utilization Management – Overview of Interventions Ÿ Utilization report cards with peer review Ÿ Changes to manual requisition Ÿ CPOE templates Ÿ LIS flagging of duplicate orders Ÿ EMR hard and soft stops. Ÿ Privileging Ÿ Sendouts formulary Ÿ Forbidding tests Ÿ Requirement for higher level collaboration or approval (e.g. Pathologist or genetic counselor consultation) Gentle Strong Strength of Guidance Solomon DH et al. Techniques to improve…use of diagnostic tests. JAMA. 1998; 280:2020-2027.; Warren JS. Laboratory test utilization program: structure and impact in a large academic medical center. Am J Clin Pathol. 2013;139:289-297. Medium
- 16. Influencing physician behavior IT intervention Physician happiness Hard stops Soft stop Change to CPOE templates, Test Definitions and Names Report Cards -plain Report Cards with +++ reinforcement One useful tactic under this approach is nudging, i.e. steering physicians in the direction that we know is usually right, while still giving them freedom to deviate where appropriate. This requires engineering the information environment in which they act, such that usually correct actions become the default, and deviation requires a conscious choice. —Dr. Brian Jackson, ARUP/Univ Utah Jackson BR. Nudging our way to more efficient care. Clinical Laboratory News. April 1, 2016. www.aacc.org/publications/cln/articles/2016/april/nudging-our-way-to-more- efficient-care-how-to-win-friends-among-doctors-while-influencing-them
- 17. Computerized Reminders: Less is More “I wouldn’t have ordered that! Do you know what you are doing? Y / N” “Would you like to discontinue standing order for electrolytes? Y / N” “Recommended screening test for thyroid disease is TSH.” Niazkhani et al. J Am Med Inform Assoc. 2009 16(4):539-49. Epub 2009 Apr 23.
- 18. Changes to CPOE, manual requisitions, and test definitions… • …should send obsolete tests into the sunset after sending a phase out notice. • …for manual requisitions, need to be supported by a policy and procedure to destroy old requisitions • Make unwanted behavior difficult to achieve;; make desired behavior easy Portion of a requisition for genetics tests
- 19. Effect of removing ionized Ca+2 from requisition and replacing it with reflexive Ca+2 panel, which is a total Ca+2, and ionized Ca+2 if total Ca+2 < 8.0 mg/dL 0 1000 2000 3000 4000 5000 6000 Month Monthly tally: iCa+2 Hospital 1 Hospital 2 Baird et al. Clin Chem. 2009 Mar;;55:533-40.
- 20. EMA Monthly Volumes Intervention 1: email with phase out notice;; other communication Intervention 2: Remove from orders 0 orders after Jan 2015 Monitor Impact of an intervention to eliminate Endomysial Antibody (EMA testing) in celiac disease
- 21. Example of a typical intervention: 1,25 Dihydroxyvitamin D Problem: • 1,25 Dihydroxyvit D is common send-out with > 300 tests/yr • Retrospective chart review found 68% of 1,25 Vit D were ordered in error and 25 Vit D was intended. Intervention: • Email describing use of the two Vit D tests, and asking if provider wants to change to 25 Vit D. • Email managed by front-line sendouts staff. Dickerson J, Cole B, Jack R, Astion M. Another laboratory test utilization program: our approach to reducing unnecessary 1,25 Vitamin D orders with a simple intervention. Am J Clin Pathol. 2013. 140(3):446-7.
- 22. 1,25 Vitamin D Intervention The lab received a request for 1,25 dihydroxy vitamin D on your patient. In our lab, we found that this is ordered accidentally 68% of the time. Utility of 25- Vit D vs. 1,25 Vit D Two options: 1. Cancel and add-on 25-OH Vit D 2. Proceed with original order Dickerson J, Cole B, Jack R, Astion M. Another laboratory test utilization program: our approach to reducing unnecessary 1,25 Vitamin D orders with a simple intervention. Am J Clin Pathol. 2013. 140(3):446-7.
- 23. 0 5 10 15 20 25 30 35 Number of Orders Cancelled Approved Intervention Privileging added Effect of an email to doctors on Vitamin 1,25 D orders (2012-2013, 7 months) After intervention: • 58% (n=134) of the 1,25 Vit D orders were changed to 25 Vit D. • 1,25 Vit D now <10 /mo Dickerson J, Cole B, Jack R, Astion M. Another laboratory test utilization program: our approach to reducing unnecessary 1,25 Vitamin D orders with a simple intervention. Am J Clin Pathol. 2013. 140(3):446-7.
- 24. Doctors Love the 1,25 Vitamin D Intervention I am not making these up. “Thanks so much for your help (and education). You are exactly right—please cancel the order of 1,25 and I’ll add on for 25 hydroxy. ” “Thank you so much for the email. You are correct I wanted 25-hydroxy. I will cancel and reorder.”
- 25. Privileging “Dear Send-out Team, I’ve created a list of our privileged providers who do not need to be contacted regarding ______ orders. Simply, send these tests out. ”
- 26. SBAR: Too many CBC-DIFFs Situation: High proportion of CBCs are ordered with a differential. Background: CBC-Diffs create more manual work, and can slow down the laboratory TAT during peak times. Assessment: CBCs (without differential) are sufficient in many patient populations. Recommendation: Analyze the data, identify target populations/divisions to pilot interventions.
- 27. Phase 1: Provider Feedback
- 28. Phase 2: Removed CBC-Diff from CICU Ordersets 85% of CBCs include a differential Cardiac ICU utilization decreased by 50% CBC CBC-DIFF Thanks to Patrick Mathias, MD PhD CICU NICU PICU Months (Jan 2015 – June 2016) 100 90 80 70 60 50 40 30 20 10 Proportion CBC-DIFF to CBC + CBC-DIFF
- 29. Genetic Counselors as a form of enhanced supervision In this study: 1 / 3 of genetic test orders were in error and correcting the order improved patient care and saved $ for patients and hospitals. Miller C. Clin Lab News. 2012: 38(1). www.aacc.org/publications/cln/2012/january
- 30. Email template to physicians who are not Medical Geneticists but who are ordering expensive genetic tests Lab received expensive, unusual request on your patient: You have 3 options: 1. Involve genetics or lab GC 2. Hold for pre-authorization 3. Proceed after telling $cost to patient Info on completing insurance pre-auth
- 31. A day in the UM life at SCH… 32% of genetic test requests are canceled or decreased Request received by SO team E-mail to Lab GC/ SO Consultant Case review & Adjudication Approved Additional information needed Discussion with ordering provider Modified Cancelled Outcome 68% 10%22% Dickerson JA, Cole B, Conta JH, et al.. Improving the value of costly genetic reference laboratory testing with active utilization management. Arch Path Lab Med. 2014 Jan;;138(1):110- 3.
- 32. $6,033,371* Total genetic requests $980,953 savings $5,052,418 Actual 32% order modification ~$340 saved per request *Data collected Sept 2011 – Feb 2016 N=2908 genetic cases Seattle Children’s Hospital Financial Implications of UM
- 33. SCH UM Dashboard Turn-around Time Requests Over Time Cost – Cost Savings Request Details
- 34. PLUGS: nationalizing our experience Mission/Vision • Needs expenses while increasing the value of testing to patients. • Be the #1 provider of services that promote pediatric test utilization management (UM) programs in hospitals and health systems. Goal • Help hospitals implement / strengthen their own UM programs Outcomes • Decrease ordering errors • Decrease send-out bill for genetic tests by 20-40% • Decrease send-out bill for non-genetic tests by 10% • Decrease patient complaints by reducing out of pocket expenses and unnecessary testing. Pediatric Laboratory Utilization Guidance Services
- 35. THANK YOU TO OUR SPONSORS & PARTNERS: 56 INSTITUTIONS, AND COUNTING… Health Partners: Regions Hospital & Park Nicolette Hospitals Intermountain/Primary Children’s Hospital Johns Hopkins Hospital Lancaster General Hospital Le Bonheur Children’s Hospital Lurie Children’s Hospital Chicago Mercy Children’s Hospital – St. Louis Meriter- Unity Point Health Medical Neurogenetics (MNG) Laboratories MultiCare Tacoma General Nationwide Children's Hospital Nemours/Alfred I. duPont Hospital for Children Nationwide Children’s Hospital Norton Healthcare Oregon Health Sciences University Phoenix Children’s Hospital PWN Health Quest Diagnostics Salem Health Stanford Health Care St. Louis Children’s Hospital Tricore Reference Lab University of Florida- Shands University of Michigan University of Washington Wake Forest Baptist Health York Hospital (WellSpan Health System) Akron Children's Hospital Arkansas Children’s Hospital Baylor Genetics Bronson Methodist Hospital Blood Center of Wisconsin Boston Children’s Hospital Cardinal Glennon, SSMH CentraCare Health Children’s of Alabama Children’s Healthcare of Atlanta Children's Hospital & Clinics of MN Children's Hospital of Colorado Children’s Hospital of Los Angeles Children’s Hospital of Philadelphia Children’s Hospital of Pittsburgh of UPMC Children’s Hospital of Wisconsin Children’s Mercy Hospital Children’s National Medical Center Cincinnati Children’s Hospital Cleveland Clinic Connecticut Children’s Hospital Dayton Children’s Hospital Dell Children’s Fairview Health Services GeneDx
- 36. PLUGS provides… UM Tools • Needs assessment and 1 year plan • Policies, procedures & communication templates that help providers reduce unnecessary testing & correct test orders • Database for collecting, tracking & analyzing UM cases • Tools to assess risk of errors in send-outs • Provider satisfaction survey Communication • Office hours/call center • Weekly newsletter • Member teleconferences with presentations by SCH team & members • Website: www.seattlechildrens.org • Discussion forum Education • Tips & tricks from PLUGS experts • UM learning modules • UM webinars • Case of the Week • Extensive materials on how to get a UM program started in a lab or hospital • PLUGS Summit
- 37. PLUGS Summit (June 2017) • 10 hours, CME/CEU • Sharing best practices • Debates / Roundtables • Posters • Networking (nice party) • Largest lab utilization management gathering – >175 participants – Labs – IT companies – Insurance companies
- 38. Conclusions and Thanks! • Lab test utilization management improves value to patients. • It is here to stay. • Over the next 10 years, most testing will be actively managed by insurers and hospital systems. • Stronger UM interventions are structural • From our lab UM experience, we helped create a UM product for insurance companies and Seattle Children’s launched PLUGS, a nonprofit outreach to hospitals with components of service, research, and teaching Value = Quality/Cost
- 39. Acknowledgements • Seattle Children’s / Univ Washington – Jane Dickerson – Jessie Conta – Bonnie Cole – Darci Sternen – Shannon Stasi – John Tait – Patrick Mathias – Nitasha Kumar – Rhona Jack – Monica Wellner / Lisa Wick and the Sendouts and CPA Teams – Joe Rutledge – Mark Del Beccaro – Geoff Baird – Linda Eckert – Kevin O’Brien • Seattle Children’s Charitable Foundation • EviCore: • Lon Castle • Melissa Bennet • Denise Needham • Michael Graf • Individual members of PLUGS • Viewics • Heidi Wilbanks • Tim Kuruvilla
- 40. Thank you Click to watch on-demand webinar (https://goo.gl/O1f5HG)
Editor's Notes
- #16: 15
- #25: Privileging
- #30: A recent study at ARUP, a major reference laboratory did a study where they had all genetics tests vetted by a genetic counselor. They concluded that 1/3 of genetic tests were ordered incorrectly which had major cost implications. By correcting the orders they simultaneously improved patient care and saved hospitals and ultimately patients half a million dollars per year.
- #32: Discuss process (tests flagged as “UM” or manual review of MISC orders), e-mail template, review of clinic notes & insurance preauth, follow-up information gathered by phone or e-mail, case is approved, modified (give example), or provider decides to cancel. Review/adjudication same day or next business day. All info is capture in database to facilitate steps of the UM process (e.g. sequential testing), monitor metrics (e.g. cost savings) and facilitate weekly case review discussion (e.g. ensure similar case adjudication each time).
- #33: In addition to correct orders and improving the quality of testing. The savings from this program allow us to bolster other lab operations (e.g. phlebotomists, etc) , our intervention has a significant financial impact for the institution and families directly – we know that we are improving satisfaction and preventing surprise bills in the mail.
- #34: Overview of dashboard, where it’s posted at SCH, hospital goals/strategic plan
- #36: Subscription bases service –
- #40: I moved this slide to the end because it seemed to make more sense here. If you need to move it back to the beginning, that’s fine.