Strategies for Improving Laboratory Utilization
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The document outlines strategies for improving laboratory utilization management, focusing on issues of misutilization and the importance of appropriate test ordering. It emphasizes the need for clinicians to consider pre-test probabilities and highlights various tools for enhancing test utilization, such as education, banning unnecessary tests, and implementing clinical decision support systems. The ultimate goal is to provide high-quality, cost-effective patient care through better management of laboratory testing practices.
Strategies for Improving Laboratory Utilization
- 1. Ola H. Elgaddar MD, PhD, MBA, CPHQ, LSSGB Assistant Professor, Alexandria University, Egypt Chief Medical Officer - UAE, Al Borg Laboratories Strategies for Improving Laboratory Utilization Management
- 2. Learning objectives 1.Identify the problem of misutilization 2.Explain different causes for laboratory misutilization 3. Determine the minimum retesting intervals of common analytes 4.Choose appropriate tools for improving test utilization
- 3. Do you have a smart phone?? 1) Yes 2) No 3) I don’t know!
- 4. What is your OS? 1) iOS 2) Android 3) Windows 4) BlackBerry
- 5. Did you download AACC ME mobile app?? 1) Yes 2) No 3) I will !
- 6. Ice bucket challenge: ALS awareness
- 9. What is the common factor in the previous 3 slides? a.Water b.Waste c. People d.Fiction
- 14. There was once a time when it would be unthinkable and impractical for a hospital inpatient to get multiple laboratory tests per day, every day
- 15. Today, high frequency testing is almost the rule in resource-rich settings, rather than the exception. Most of the high frequency testing is for low cost tests ???
- 16. In your opinion, what is the cause of the high frequency ordering of Laboratory tests that are routine with low cost? a.Clinicians think it’s ok since they are ”cheap” b.Those are the tests “known” to all clinicians c. Lack of consensus on evidence based criteria for requesting them d.None of the above!
- 18. Laboratory Test utilization A strategy for performing appropriate laboratory and pathology testing with the goal of providing high-quality, cost-effective patient care.
- 20. Laboratory Test utilization Are you driven: a) financially b) medically c) Both
- 22. If the focus is solely on money, then that test utilization effort will have a short term success. However if good medical practice is the focus, then test utilization will have longevity and will likely be successful in our changing health care environment.
- 25. The Good, The Bad & The Ugly Do you know this movie? 1) Yes 2) No
- 26. The Good, The Bad & The Ugly • A ‘Good’ test: – Uses resources and provides information that is useful in patient management decisions • A ‘Bad’ test: – Uses resources but fails to provide information useful in patient management decisions • The ‘Ugly’ test: – Uses resources and provides information that is misleading or irrelevant
- 27. Considerations while addressing the utilization issue: ØYou can’t provide every test as fast as what everybody wants! ØOrdering test panels rather than ala carte’!! Ex: Liver functions, Kidney functions, Lipid profile,…..
- 28. Considerations while addressing the utilization issue: ØRedundant tests: Urea & Creatinine ALT & AST Troponin & CK-MB ØTests that are often ”said” together: PT & PTT Calcium, Phosphorus & Magnesium
- 29. Considerations while addressing the utilization issue: ØPre-analytical concerns that might cause test repetition: Timing, container, labeling, transportation ØAppropriateness of the ordered test: Diagnostic performance Affected by the patient’s condition Ex: Thyroid F. in an ICU patient HbA1c in hemolytic anemia
- 30. “If you ask a wrong question, you get a wrong answer”!!!
- 31. Pre – test probability An estimate of the probability of a disease before any test is ordered
- 32. How can it affect test ordering / utilization?? • Troponin ordered for a 15-year old boy complaining of chest pain! Most probably, this is a wrong test selection due to the very low pre- test probability that this boy is having a cardiac event So, Clinicians must be aware of the pre-test probability before ordering any test
- 38. Considerations while addressing the utilization issue: ØImpact of the result on management: ex: Mumps Abs ØHow fast do lab results change: Understanding how rapidly a given analyte may change is important to selecting how often it should be ordered
- 39. ØQ: What is the frequency of ordering HbA1c for the same patient? What is the rationale? ØDespite the inherent logic of this conclusion, there is still substantial variation amongst physicians in ordering HbA1c testing at rational intervals Lyon AW, Higgins T, Wesenberg JC, Tran DV, Cembrowski GS. Variation in the frequency of hemoglobin A1c (HbA1c) testing: Population studies used to assess compliance with clinical practice guidelines and use of hba1c to screen for diabetes. J Diabetes Sci Technol 2009;3:411-7
- 47. Test Utilization Management Tools
- 48. 1. Meet the clinicians ”Education” is the first tool, but if it was the only method being used then it will have a little lasting impact!
- 49. 2. Ban the test Obsolete tests; Legitimate tests used in inappropriate circumstances Ex: Bleeding time
- 50. 3. Stop paying for unnecessary testing ØVery strong but perceived to be unfair ØNeed objective pre-set criteria ØDepend on the insurance system
- 51. 4. Ban Repetitive Orders ØFor inpatients ØMeet the clinicians first! ØForce the limitation via CPOE
- 52. Ø The process of a medical professional entering physician instructions electronically instead of on paper charts. Ø Essential for EMR Ø A primary benefit of CPOE is that it can help reduce transcription errors. Ø Adjust ordering frequency or stop ordering a test Ø Needs cultural change supporting modification of ordering practices
- 54. 4. Laboratory guidelines and algorithms ØIT-driven: When clinical data is entered, appropriate lab tests will be suggested ØLab-driven: Clinicians order initial tests, and according to the result, laboratorians initiate a cascade of further tests
- 55. 5. Privilege ordering providers ØPathologists-driven: - For some low volume, high cost tests. - Ordered only by a pathologist or a genetic consultant, after the reviewing the results of all previously ordered tests
- 56. 6. The Test Menu as Formulary - When physicians in a health care organization prescribe a drug, they know that their pharmacy (or payment plan) only covers certain brands, generics, or formulations. They know that they cannot, and should not prescribe drugs carte-blanche.
- 57. -No off-formulary test can be available -Test menu is divided into 3 “tires”, each one is ordered on a certain clinician level. -The tires are ascendingly arranged keeping the most sophisticated and expensive tests (Genetic tests, outsourced,..) to the highest tire that requires the highest privilege approval
- 58. 7. Reflexive testing Ø Any test that has a cheaper screening option should be provided first. ØAdhere to algorithms ØIncrease pre-test probability ØEx: Limit ionized calcium ordering after total calcium screening
- 61. We have always been proud of providing high-quality, cost-effective care with a focus on providing service to the patient and clinician
- 62. Our new laboratory paradigm demands that the clinical laboratory also provide: Utilization Management, Clinical Effectiveness, and Data Integration as part of their expected performance
- 63. Thank you