A presentation in AACC ME 2019 talking about the problem of lab utilization and several efforts to improve it

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