Optimizing Laboratory Test Utilization
in Microbiology and Beyond
Bobbi Pritt, MD
Laboratory Director, Clinical Parasitology
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DISCLOSURES
• Relevant Financial Relationship(s)
• None
• Off Label Usage
• None
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Today’s Goals
• Discuss the role of laboratory test utilization
in providing high quality patient care
• Describe the drivers behind inappropriate lab
test utilization
• Review tools and strategies that are
available to the laboratory for evaluating and
controlling test utilization in Microbiology and
beyond
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©2011
Mayo Clinic
Locations
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Our Health Care picture today
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National Health Spending, 1960 - 2010
$3,000
$2,472 $2,570
(in billions)
$2,500
$2,240
$1,983
$2,000
$1,363
$1,500
$1,000
$714
$500
$28
$75
1960
1970
$253
$0
1980
1990
2000
2005
2007
2009
2010
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Healthcare and Laboratory Costs
• Annual US healthcare expenditures:
• $2,570 billion dollars
• Laboratory tests including anatomic pathology:
• 4% of healthcare costs
• $55 - $60 billion
• 20-25% increase annually
• Molecular/Genetics is 15% of laboratory costs;
anticipated to reach 25% soon
• Largest growth: proprietary tests, genetic tests,
and test bundling
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Today’s Big Picture:
“Healthcare Reform”
• Our current system isn’t sustainable
• Introduction of new payment models
› Accountable Care Organization (ACO) models
› “Fee for service”
▪ Moving towards “Fee for diagnosis” or “Reward for
outcome”
▪ Similar to a DRG model for hospital in-patients with
better reimbursement for better outcomes
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What can the laboratory do in this setting of
decreasing reimbursement?
• Laboratory leadership needs to champion
programs that allow for appropriate laboratory and
pathology testing
• If we do not act, we risk having someone else
make cuts for us.
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The Role of the Laboratory
and Pathologist in an ACO
• Experts in medical test selection:
• Reduce laboratory overutilization
• Aid in getting the right tests ordered
• Avoid unnecessary treatments that could adversely
affect patient outcomes and increase downstream
costs
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Improving Test Utilization is about:
• Performing:
The Right test
For the Right patient
At the Right Time
Every time
• Goal is to provide high quality, cost-effective patient care
• If the focus is solely on money, then efforts will fail
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In order to optimize lab test utilization, we
need to understand why we have issues
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Reason #1: The “Knowledge Gap”
• The number and complexity of lab tests has
increased
• Knowledge gap between clinicians and laboratory
• Knowledge gap between science and therapies
• Laboratories do not always provide guidance for the
appropriate use of assays in various diseases
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Reason # 2: Non-Optimized Laboratory
Systems and Processes
• Ordering process
• Requisition forms provide no help
• Check boxes and alphabetical lists, with no information
• In-lab review process
• Limited processes to review test requests
• Limited processes to sequentially add or delete tests after initial
results are determined
• Understand that clinical knowledge is often incomplete at the time
the test is ordered. The clinician is compelled to order everything
as it may be the only chance get that information.
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Reason #3: The ordering system
makes it easy to over-order
• Test Panels and order sets may contain unnecessary
tests
• Example: extensive panels for tick-borne organisms haven’t
been proven to be human pathogens
• “Standing orders” allow the same test to be
performed repeatedly, regardless of the result
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Reason #4: Wrongly-Aligned Incentives
• Incentives
• Hospitals depend on laboratories for $$$
• A “successful” laboratory is often defined as one
that has a high profit margin
• If you decrease volumes, you decrease $$$
• No incentives for clinicians to order less
• No incentives for pathologists to campaign for
decreased tests – less professional fees
• This will change with implementation of ACOs
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Reason #5: Societal and Patient Demands
• Patients demand more
• Patient dissatisfaction with healthcare
• Patient desire for wellness
• Google is the source of all medical knowledge
• Marketing pressures
• Litigation fears
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What are some other approaches that the
laboratory can undertake to improve test
utilization?
• Close the knowledge gap
• Use the ordering system to your advantage
• Empower the laboratory, pathologist, or genetic
counselor to guide test utilization through lab-driven
cascades
• Use your laboratory data to drive your utilization
efforts and receive support/recognition for your
efforts
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APPROACH 1 – CLOSE THE
KNOWLEDGE GAP
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CLOSE THE KNOWLEDGE GAP
Low Impact: 1-time educational efforts
• Emails and memos
• Call for enhanced vigilance
• Educational pamphlets
• CME lectures/talks
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Reality check
• 1-time educational efforts have a limited impact on
changing ordering patterns
• However, they help to establish the laboratorian as
the subject matter expert and facilitate interactions
with clinicians
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Ongoing Education has a greater impact
• Readily available test information
• Test catalog
• Online information
• Providing algorithms
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CLOSE THE KNOWLEDGE GAP
Easy availability of test information
• Example: HIV testing
• Multiple tests available
• Results are often difficult to interpret
• Clinicians do not understand how to proceed
following an initial test
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Mayomedicallaboratories.com
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Algorithms
• Goal: provide step-by-step procedures to the
provider for:
• Ordering the correct sequence of tests
and/or
• Interpreting test results
• Useful when ordering options or interpretation
of results is complex
• They should be based on widely accepted
guidelines; data driven
• Formulated with provider input
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APPROACH 2 - USE THE ORDERING
SYSTEM TO YOUR ADVANTAGE
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Use of the Ordering System
• Provides an opportunity to influence the
provider at the point of order, usually before a
specimen is obtained from the patient
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Ordering System – Simple interventions
• Remove tests
• Rename tests to be more intuitive
• Require specialist (ID physician) approval to order or
restricting orders to specialists only
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Renaming tests
• hCG: useful to diagnose/monitor pregnancy and useful
as a tumor marker
• hCG pregnancy assay:
• hCG tumor marker assay:
31
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Renaming tests, continued
• Testing for Enteroviruses, CSF
Test A: Enterovirus PCR
Test B: Coxsackievirus antibodies
Test C: Echovirus antibodies
Test D: Poliovirus antibodies
Patient scenario –
• 9 year old boy with headache and stiff neck;
echovirus outbreak is occurring
Echovirus antibodies (Use Enterovirus PCR for
acute disease testing)
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USE THE ORDERING SYSTEM TO YOUR
ADVANTAGE - Other options
• Requiring ordering clinician to fill in check boxes for
patient symptoms and exposure history.
• Based on entered answers, only certain tests will be
available
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USE THE ORDERING SYSTEM TO YOUR
ADVANTAGE - Other options, continued
• Set up IT rules to control utilization
• Rule type #1: only allow a certain number of
tests within a certain time period
• Example: Clostridium difficile toxin PCR
testing – once in a 7 day period
• Rule type #2: only allow a repeat order within a
certain time frame if the previous result was
abnormal
• Example: Ionized calcium
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USE THE ORDERING SYSTEM TO YOUR
ADVANTAGE - Keep the Ordering System
Up-to-Date
• Review and modify requisitions and order screens
frequently
• Computer order “hot buttons” need to reflect guidelines and not
just ease of ordering
• Be quick to obsolete tests that are obsolete
• Bleeding time, band count, red cell folate, etc.

Have an approval process for adding tests to your menu
(consider having a utilization review group)

Simple changes can impact utilization
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APPROACH #3:
Empowering the laboratory to drive
the algorithms through use of
Cascade testing
Taking the algorithm 1 step further
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Clinician places 1 order.
Serum is drawn and
sent to the lab
Most specimens only require 2 tests!
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USE THE ORDERING SYSTEM TO YOUR
ADVANTAGE
Laboratory-Driven Algorithms
• INSTEAD of ordering a number of celiac tests upfront,
the algorithm itself can be ordered
• Initial serum and whole blood samples are drawn and
sent to the laboratory (“send and hold”)
• The laboratory performs a cascade of tests based on
the algorithm
• Most samples only require 2 tests
• A la carte ordering is still available, but most clinicians
choose to use the algorithm
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Laboratory-Driven Algorithms
Comparison of Testing Options
Celiac Disease Serology Cascade:
Weighted Average Price
$ 67.60
Total package – if ordered a la carte
$ 515.00
© 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved.
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Cascades (laboratory-driven algorithms)
• Why they work:
• The clinician only places 1 order
• The patient only undergoes a single blood draw
• Initial limited laboratory testing drives additional
testing
• The Laboratory has control over the algorithm
rather than the Clinician
• A cascade requires the laboratory to coordinate
the transit of the specimen and tests that are
performed.
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To make this work
• Need physician buy-in
• Should be data driven or adhere to widely
accepted guidelines
• Ordering clinicians must know which tests are in
the cascade and must understand that one or
all of these tests may be performed based on
the algorithm
• A la carte ordering may still available
• But in our experience, most clinicians prefer
to use the cascade for initial testing
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Unique Challenges for optimizing
test utilization for microbiology
• Initial AND sequential testing often depends on
clinical factors
• Exposure history
• Travel
• Pets, other animals
• Food ingestion
• Immune status (HIV, steroid use, age, pregnancy)
• Vaccination history
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Can we get the information we
need?
Ova and Parasite (O&P) exam
examination as an example
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Parasitic Investigation of Stool Specimens Algorithm
Watery diarrhea in patients who:
•Have AIDS
•Have contact with farm animals
•Are involved in outbreak
Municipal water supply
Day care centers
Watery diarrhea in patients who:
•Are ≤5 years old (or contact)
•Are campers or backpackers
•Are involved in outbreak
Resort community
Day care centers
Patient is:
•A resident or visitor to a developing country
•A resident or visitor to an area of North
America where helminth (worm)
infections have been reported with
some frequency
If roundworms or tapeworms
are seen or suspected, do
visual inspection of gross stool
#80335 Cryptosporidium antigen,
feces
Positive
No additional
testing
required
unless clinical
picture
indicates
Negative
#80231 Giardia antigen, feces
Positive
No additional
testing
required
unless clinical
picture
indicates
Negative
#50016 O&P examination
Positive
Organism
indentified
Negative
If diarrhea persists
If diarrhea persists
Specific exam for microsporidia (#81507 Microsporidia dectection stain) and/or Cyclospora (#81506 Cyclospora species detection stain)
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Trying to get information from the
ordering clinician or referring lab
Stool specimen for Giardia antigen testing
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Trying to get information from the patient…
“Have been in car for 1 hr 40 min”
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USE THE ORDERING SYSTEM TO YOUR
ADVANTAGE - Parasitic Examination of Stool
• Reality – patients and clinicians rarely provide the
necessary information to guide testing
• Strict measures to obtain this information would be
cumbersome and met with resistance
• Therefore, the algorithm cannot be ‘ordered’
• Solution – Change the Ordering Requisition to better
guide appropriate testing and encourage use of the
algorithm
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Stool (Micro)
Next
Cancel
Guide
Comments
Common Procedures
C. difficile Toxin PCR 83124
Select Either Enteric Pathogens Culture OR PCR (not both)
Bacterial Enteric Pathogens Culture, Stool 8098
***Includes Shiga Toxin PCR
Bacterial Enteric Pathogens PCR 60235
***Rapid test for Salmonella, Shigella, Yersinia, Campylobacter, Shiga Toxin
***Reflexive culture performed if positive
Microbiology
Stool Testing
Outpatient
Ordering system
Fecal Leukocytes 8046
Fecal Parasite Screen (See Guide for Algorithm)
Giardia Ag 80231
Cryptosporidium Ag 80335
Tiered testing
shows preferred order
Rotavirus Ag 8886
Additional procedures
Helicobacter pylori Ag 81806
Vibrio Culture 89658
VRE PCR 84406
Acid Fast Smear for Mycobacterium 8213
M. tuberculosis Complex PCR 88807
Mycobacterial Culture 8205
Fungal Smear 84390
Fungal Culture, Routine 84389
Adenovirus PCR 89074
Viral Culture, Non-Respiratory 87266
We’ve seen a 30%
decrease in O&P
orders over expected
volumes since this
change was made
Cyclospora Stain 81506
Microsporidia Stain 81507
***Microsporidia found primarily in immunocompromised patients
Parasitic Examination (O&P) 9216
***Order only if appropriate history (see Guide for Algorithm)
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APPROACH #4 – CONTROL SEND-OUT
TESTING USING A TIERED APPROACH
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“STOP LIGHT” Approach
• Black: Test in not an option. Testing could cause patient
harm; i.e. false positives/negatives. These tests are not
open for exceptions. Alternate testing may be available in
DLMP. Please contact a DLMP Lab Director to discuss
patient presentation.
• Red: Testing has no documented clinical utility. Alternate
testing may be available in DLMP. Please contact a
DLMP Lab Director to discuss patient presentation.
• Yellow: Testing has limited clinical utility/application.
Approval to order must be coordinated through Section
Head of Specialty Area.
• Green: Testing has proven clinical utility and its use is
well-defined in clinical practice. Testing should be made
available in Orders97 in select Order Aggregates.
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Steps in this process
1. Microbiologists reviewed a list of all send out tests in
the 5 years and assign them a color
2. Infectious diseases groups then reviewed the color
ranking
• Only 4 test colors were changed
3. All green tests are built into the ordering system to
allow for ease of ordering
4. Yellow and red tests will require approval; only the
most expensive tests will be included
• Clinical Microbiology fellows and pathology
residents will perform the review/approval
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Approach #5 – Train Laboratory
Staff to provide 1-on-1 education
and interventions at the time of
ordering
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Laboratory Staff – Best for expensive, low
volume tests
• Example: Genetic Counselors (GC) and genetic
technologists at Mayo
• Review test requests that “don’t make sense” and Make
phone calls to clinicians
• 30% of all requests get changed after GC intervention – add
or delete test(s)
• ~$500,000 savings per year
• Can we use technologists or residents to perform
interventions?
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APPROACH #6:
USE DATA TO YOUR ADVANTAGE
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Using Data to your advantage
• Share data with lab and institutional leadership – and
attach dollar amounts
• This is an excellent approach for getting the support
you need to start and/or continue utilization efforts
• Gather pre- and post-intervention data
• You may find out that your intervention isn’t working!
(time to try something new)
• Share ordering data with your clinicians
• This can be very powerful for identifying ‘outliers’ –
clinicians who order far more tests than the others –
and getting them to change their practices
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Summary
• There are many different approaches for tackling test utilization
issues – some with more impact than others.
• Education is important for establishing the laboratorian as a
subject matter expert and providing information for
new/changed tests
• However, education alone - especially 1-time interventions rarely impacts long term behavior
• Education with other enhancements (e.g. changes to test
ordering system, peer report cards) have greater impact.
• The test ordering system can be a powerful tool to guide test
usage.
• Using laboratory professionals to review and guide testing can
be highly beneficial when used selectively
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Thank you!
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