Laboratory Test Utilization and Stewardship 2020.pdfmarket forces & competition Government & payer...
Transcript of Laboratory Test Utilization and Stewardship 2020.pdfmarket forces & competition Government & payer...
© 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved.
Department of Laboratory Medicine and Pathology
Laboratory Test Utilization and
Stewardship
Curtis A. Hanson, M.D. Mayo Clinic – Division of Hematopathology
Professor of Laboratory Medicine & Pathology
Chief Medical Officer, Mayo Medical Laboratories
© 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved.
Department of Laboratory Medicine and Pathology
Outline for Today
What is test utilization?
How does utilization fit into our current healthcare
environment?
Do we have utilization issues in medicine – including
pathology and the clinical laboratories?
Why do we have laboratory utilization issues?
How can we get a utilization program started?
What could a practical utilization program look like?
© 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved.
Department of Laboratory Medicine and Pathology
U.S. Demographics
Health care market forces &
competition
Government & payer initiatives
Rapid changes in technology
Consumer factors
Perfect Storm for Disruption: The U.S. Health Care Market
© 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved.
Department of Laboratory Medicine and Pathology
“It’s the only treatment option he has under
his current health plan.”
New Yorker Magazine
© 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved.
Department of Laboratory Medicine and Pathology
Laboratory Test Utilization – Definition
A strategy for performing appropriate
laboratory and pathology testing with
the goal of providing
high-quality, cost-effective patient care
© 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved.
Department of Laboratory Medicine and Pathology
MOLECULAR GENETICS IS
15–25% OF TOTAL; FASTEST
GROWTH AREA
LABORATORY COSTS ACCOUNT FOR
~4% OF HEALTH CARE COSTS; BUT ARE INCREASING AT
A RAPID ANNUAL RATE
CONVENTIONAL WISDOM IS THAT
20–40% OF LABORATORY
TESTING IS UNNECESSARY
Laboratory Spend is Gaining Attention from Payers and Patients
• Niche Laboratories
• Explosion of New Tests
• Clunky Pre-authorization
• Claims Denials
• Medical Policy
• Undocumented Clinical
Utility
• High Deductibles &
Copays
• General Confusion
© 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved.
Department of Laboratory Medicine and Pathology
How does utilization fit into our
current healthcare
environment?
© 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved.
© 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved.
Department of Laboratory Medicine and Pathology
Healthcare Delivery is Changing
More and more primary care is being performed by non-
physicians in non-traditional settings – which can offer superior
IT, access and location.
Employer / Insurer Market Transformation – examples • High Deductible Plans paired w/ HSA
• Public Exchanges
• Direct Contracting between employers and providers
• Private Exchanges
7,600+
locations
4,700+ locations 8,600+ locations
© 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved.
Department of Laboratory Medicine and Pathology
Transition From Volume to Value
Gap
Management
VOLUME-BASED
LEGACIES
FEE-FOR-SERVICE REIMBURSEMENT
HIGH QUALITY NOT REWARDED
NO SHARED FINANCIAL RISK
ACUTE INPATIENT HOSPITAL FOCUS
LIMITED IT INVESTMENT INCENTIVES
STAND ALONE CARE SYSTEMS CAN THRIVE
REGULATORY ACTIONS IMPEDE COLLABORATION
VALUE-BASED MUST
HAVE CAPABILITIES
REWARDS FOR QUALITY & EFFICIENCY
QUALITY IMPACTS REIMBURSEMENT
SHARED RISK
INCREASED PATIENT SEVERITY
IT CAPABILITIES ARE ESSENTIAL
SCALE INCREASE IN IMPORTANCE
REALIGN INCENTIVES, COORDINATION ENCOURAGED
© 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved.
Department of Laboratory Medicine and Pathology
Do we have utilization issues in
medicine – including pathology
and the clinical laboratories?
© 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved.
Department of Laboratory Medicine and Pathology Dartmouth Atlas of Healthcare
Geographic Variation in Patient Care
© 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved.
Department of Laboratory Medicine and Pathology
Utilization: Heme-Associated Assays Assay Utilization Guideline MCR Data
JAK2V617F Blood and bone marrow give equivalent results 15% over-ordered
JAK2 exon 12 Only if a possible PV and JAK2V617F is negative 42% over-ordered
10% under-ordered
MPL exon 10 Only if a possible MPN with equivocal morphology 38% over-ordered
5% under-ordered
Chromes - lymphoma staging Only useful if unexplained cytopenias 31% over-ordered
MDS FISH Only if <20 metaphases or cytogeneticist needs 68% over-ordered
KIT816V – blood Negative in SM; use only if heme-associated SM 95% over-ordered
B- and T-cell lymphoma FISH –
blood and marrow Only to follow morph and flow studies 73% over-ordered
T-GR – blood and marrow Only in context of T-cell phenotyping studies 43% over-ordered
B-GR – blood and marrow Almost never useful 98% over-ordered
PML-RARA FISH Not useful in follow-up APL 27% over-ordered
CLL FISH Only useful in CLL 15% over-ordered
Plasma cell FISH Not useful if no monotypic plasma cells 13% over-ordered
©2013 MFMER | slide-12
© 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved.
Department of Laboratory Medicine and Pathology
Everybody Has Examples
HIV – both qualitative and
quantitative on same order
Serum bacterial antigens
Heliobacter pylori, IgM
Stool ova and parasites
Mumps, measles, and varicella
serologies
Lyme serologies
Plasma thiamin
Red blood cell folate
Zinc protoporphyrin (ZPP)
Coag DNA assays before
functional assays
Factor V Leiden vs. APC
resistance (functional)
VWF multimers before you have
a diagnosis of VWF
Free thyroxine index (FTI) and T3
uptake
Uroporphyrinogen III synthase
“Known” mutations vs. screening
assay for mutations
Anti-reticulin antibodies
© 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved.
Department of Laboratory Medicine and Pathology
The Philosophical Challenge with Clinical Laboratory Utilization
How can we help our clinicians deal with the reality of
“uncertainty” with laboratory and pathology testing?
• Medicine is all about being comfortable with degrees
of uncertainty.
› You can never get to “zero” uncertainty.
› There is always “one more test” you can do – “one
more disease” to rule out.
We must use our clinical and laboratory knowledge to
help lower the anxiety of uncertainty.
Remember: Data and information are our friends and
evidence is our trump card.
© 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved.
Department of Laboratory Medicine and Pathology
The Practical Challenge with Laboratory Utilization
It is critical for pathologists and laboratorians to
understand the clinical problem. Pathologists have to be
clinicians!
Deep knowledge of diseases and awareness of clinical
issues in addition to analytical/laboratory management
expertise is a “must have” in today’s laboratory world.
We must change the question that comes from our
clinicians:
• Do you do test XYZ? No!
• Can you help me solve this clinical problem? Yes!
© 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved.
Department of Laboratory Medicine and Pathology
“Medicine is a science of uncertainty and an art of probability.”
Dr. William Osler (1849 – 1919)
“Information is the resolution of uncertainty.”
Claude Shannon (1916 – 2001)
• Realities of practice • Knowledge gap • Marketing • Litigation fear • $$$ incentives
• Fee for service • $$$ incentives • EMR / IT • Coding systems
• Lab systems and processes
• Ordering systems • Test names • Test bundles • $$$ incentives • Patents
•“More” is better • Google • Dissatisfaction
with healthcare • Marketing • Societal demands
Utilization
Why Do We Have Utilization Issues?
Providers
Clinical Labs
Patients
Health Systems
©2013 MFMER | slide-17
© 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved.
Department of Laboratory Medicine and Pathology
Laboratory Systems and Processes
Reporting process
• Laboratory information systems don’t make it
easy for the clinicians to efficiently get
information
• Laboratory reports do not always transmit the
intended information and are often just lists of
results instead of a correlation and diagnosis
based on all the results for that episode of care
© 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved.
Department of Laboratory Medicine and Pathology
Test Names Contribute to Utilization Mistakes
BCR/ABL, Translocation 9;22, FISH (D-FISH)
BCR/ABL, p190, mRNA Detection, Reverse Transcription-
PCR (RT-PCR), Quantitative, Monitoring Assay
BCR/ABL, mRNA Detection, Reverse Transcription-PCR
(RT-PCR), Qualitative, Diagnostic Assay
BCR/ABL, p210, mRNA Detection, Reverse Transcription-
PCR (RT-PCR), Quantitative, Monitoring Chronic
Myelogenous Leukemia (CML)
BCR/ABL, Tyrosine Kinase Inhibitor Resistance, Kinase
Domain Mutation Screen
© 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved.
Department of Laboratory Medicine and Pathology
How can we get a utilization program started?
© 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved.
Department of Laboratory Medicine and Pathology
How Do We Get Started?
Identify your target tests
• Understand clinical needs
• Know your finances
Identify your strengths and weaknesses
Know your people resources
• Pathologists, technologists, genetic counselors, etc.
Identify your champions
• Laboratory, clinical, and leadership
Know what your IT system(s) can and cannot do for you
Don’t be afraid to use manual solutions for high cost tests
Don’t aim for “perfection” – any progress is good progress!
21
© 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved.
Department of Laboratory Medicine and Pathology
Utilization Management Tools
Provide clinician education – albeit little lasting impact
• Necessary first step
Obsolete certain tests
• Examples: Bleeding time, band counts, most
erythrocyte sedimentation rates, etc.
Establish gatekeeper functions
• Identify tests that require laboratory review
Restrict the frequency of specific tests
• Focus on hospitalized patient
Review admission and treatment templates
• Look for redundancies and test frequency
© 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved.
Department of Laboratory Medicine and Pathology
Utilization Management Tools Use order entry pop-ups and online decision support
tools to provide immediate guidance for ordering
• For example, same day/repeat ordering of non-
emergent tests
Use physician profiling or report cards as feedback
• Use Transfusion Medicine practices on blood
product utilization as a guide
Establish a utilization review process for send-out tests
• Restrict ordering of expensive send-out tests to
certain specialists
• Establish medical criteria for sending out high-cost
tests
• Insert a laboratory review process for certain tests
© 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved.
Department of Laboratory Medicine and Pathology
Use Your Laboratory Staff
Example: Genetic Counselors (GC) and genetic
technologists at Mayo
• Review test requests that “don’t make sense”
• Make phone calls to clinicians
• 10 to 20% of all requests get changed after GC
intervention – add or delete test(s)
• At Mayo:
› ~$500,000 savings per year
› Genetic techs make 200 calls per week to
add or delete testing
© 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved.
Department of Laboratory Medicine and Pathology
Test Formulary
Method used to review/control testing; features similar
to a Pharmacy Formulary
• Primary focus is typically on test send outs, but can
be used for expensive in-house testing
• Laboratory and clinician driven
• Decisions based on established medical and
laboratory criteria; understand medical need and
how test(s) will be used clinically
• Send only to CLIA-approved lab; understand if
insurance pays or whether advanced beneficiary
notices are needed; understand alternative testing
© 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved.
Department of Laboratory Medicine and Pathology
Develop list of acceptable laboratories
Tier test request by specialty:
• Available to all users vs. only to subspecialists vs.
only after review from laboratory committee – need
to understand medical view
Should also be used to review utilization of selected in-
house performed tests
Select tests have to be run through algorithm or
guideline – based on user utilization issues
Identify alternative in-house or less expensive tests
Need to develop genetic knowledge!
Test Formulary Test Formulary
© 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved.
Department of Laboratory Medicine and Pathology
Understand your tools that you
can use
© 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved.
Department of Laboratory Medicine and Pathology
Order is processed
Lab performs
test
Lab sends results
MD analyzes
result
MD acts on the results
MD requests
tests
The Patient
Clinicians & IT
Labs & Techs
GC’s & Pathologists
© 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved.
Department of Laboratory Medicine and Pathology
Laboratory Test Algorithms and Guidelines
Four types of algorithms:
IT-driven: Clinical input and information drive what
testing gets ordered or not
Laboratory-driven: Laboratory results drive
subsequent test selection. Testing is performed by
laboratories using available specimens; specimens are
shared between labs
Pathologist-driven: Review of pathology findings
determine next steps in testing algorithms; cancel or add
appropriate next steps
Genetic Counselor-driven: Review of genetic test
requests require genetic experts with laboratory
knowledge; make phone calls to add or cancel testing
© 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved.
Department of Laboratory Medicine and Pathology
Clinical Decision Support (CDS) Tools
EMR’s, such as EPIC and Cerner, have CDS capabilities
High-cost imaging studies in radiology are required to go
through a CDS for maximum CMS reimbursement
(PAMA)
Middleware:
• Sept. 19, 2017: “Mayo Medical Laboratories and
National Decision Support Company Unveil
CareSelect™ Lab to Provide Real-Time Medical
Guidance When Ordering Laboratory Tests”
© 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved.
Department of Laboratory Medicine and Pathology
How a CDS Tool for Laboratory Tests Works
Trigger: Lab
test
ordered
Rules
Engine
Rule
Output Physician
Advisory
Educational
Soft Stop
Hard Stop Data from EMR
• Labs ordered
• Lab results
• ICD10
• CPTs
• Drug order
• Problem list
• Etc.
Knowledge
• Mayo Clinic
• DLMP • Algorithms
• Choosing
Wisely
• Societies
• Etc.
• Data analytics
• Reports
Proceed
with Order
© 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved.
Department of Laboratory Medicine and Pathology
Order is
processed
Lab
performs
test
Lab
sends
results
MD
analyzes
result
MD acts
on the
results
MD
requests
tests
The Patient
Labs & Techs
GC’s &
Pathologists
CDS & EMR
tools
© 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved.
Department of Laboratory Medicine and Pathology
Real Life Examples
© 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved.
Department of Laboratory Medicine and Pathology
©2013 MFMER | slide-34
5/1/2010 - 12/31/2013
n=71,379
97.5%
99.2%
© 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved.
Department of Laboratory Medicine and Pathology
Case Study: Celiac Disease Diagnosis Perception: Testing panels that include
multiple tests are the most cost-effective
approach
Analysis of Mayo Clinic patient data identified
the following about celiac panel testing:
4 Tests included the most commonly ordered panel
97% Cases in which
only 2 tests were necessary2
3x Cost of 4 test panel compared to 2-test
approach with reflex
© 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved.
Department of Laboratory Medicine and Pathology
Sometimes more testing is less cost.
$200 Cost of Test
19 Average number of plasma exchanges per misdiagnosed
patient
$38,000 Total cost of
plasma exchanges per patient
(19 plasma exchanges x $2,000 per exchange)
Case Study: ADAMTS13
The exclusion of TTP by this test leads to a potential reduction of costly plasma exchanges.
© 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved.
Department of Laboratory Medicine and Pathology
Utilization: Heme-Associated Assays
Assay Utilization Guideline Mayo Data
JAK2V617F Blood and bone marrow give equivalent results
15% over-ordered
JAK2 exon 12 Only if a possible PV and JAK2V617F is negative
42% over-ordered 10% under-ordered
MPL exon 10 Only if a possible MPN with equivocal morphology
38% over-ordered 5% under-ordered
Chromes - lymphoma staging Only useful if unexplained cytopenias 31% over-ordered
MDS FISH Only if <20 metaphases or cytogeneticist needs 68% over-ordered
KIT816V – blood Negative in SM; use only if heme-associated SM
95% over-ordered
B- and T-cell lymphoma FISH – blood and marrow
Only to follow morph and flow studies 73% over-ordered
T-GR – blood and marrow Only in context of T-cell phenotyping studies 43% over-ordered
B-GR – blood and marrow Almost never useful 98% over-ordered
PML-RARA FISH Not useful in follow-up APL 27% over-ordered
CLL FISH Only useful in CLL 15% over-ordered
Plasma cell FISH Not useful if no monotypic plasma cells 13% over-ordered
© 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved.
Department of Laboratory Medicine and Pathology
http://www.mayomedicallaboratories.
com/media/articles/algorithms/mpn-
bonemarrow.pdf
© 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved.
Department of Laboratory Medicine and Pathology
Test Utilization: Bone Marrow Case Study Below are the results of a study conducted by Optum
Labs with Mayo Clinic data.
Disease or Diagnostic Group Patients who underwent bone marrow biopsy/aspiration
Test Pathway Flow and chromosome testing
Impact of Guideline Reduction in cost of testing per case
Cost Savings Per Case $1,214 (USD)
Incidence of Disease 700,000 bone marrow biopsies in U.S. per year, incidence in U.S. therefore at 0.22%
$ Impact Per 100,000 Lives $267,162 (USD)
© 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved.
Department of Laboratory Medicine and Pathology
Optum Labs (Mayo + Optum): The Impact of Concurrent ESR and CRP
ESR is an antiquated test that has many causes of false positive and
negative results. ESR, when ordered in addition to CRP, rarely yields
additional diagnostic information except in some specific
rheumatologic disorders. CRP is a more reliable and reproducible
laboratory assay as a marker of an underlying inflammatory
condition.
Data pulled from Optum Labs (Dr. Darci Block)
From 2009 – 2013:
Only ESR 4,465,492 (54.2%)
Only CRP 1,173,131 (14.2%)
CRP and ESR within 7 days 2,606,775 (31.6%)
Also looked at test orders as they relate to diagnosis codes.
© 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved.
Department of Laboratory Medicine and Pathology
Do we need to do RBC Folate Testing?
0
100
200
300
400
500
600
700
1 3 5 7 9 11 13 15 17
Serum Folate (ng/mL)
Fre
qu
en
cy
Mayo patient data
24,177 serum folates (2008-2010)
35 < 2.0 ng/mL (0.14%)
125 < 3.0 ng/mL (0.52%)
Unpublished Mayo data
Serum Folates
© 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved.
Department of Laboratory Medicine and Pathology
RBC Folate Testing is Unwarranted: Equivalence of Serum and RBC Folate
Simultaneous serum and RBC folate assays (1999 to 2009; n=1082)
• Prevalence of deficiency =0.09% (n = 1, both low)
3 difficult to interpret – results weren’t reproducible; 1 was non-fasting patient
No clinical value – old dogma about RBC folate is just not true in today’s world
A manual test – high labor costs
Negative reimbursement relative to costs
Serum Folate (ng/mL)
Deficient (< 3.0) Sufficient (> 3.0)
RBC Folate
(ng/mL)
Deficient (<140) 1 (0.09%) 4 (0.4%)*
Sufficient (>140) 8 (0.7%) 1069 (98.8%)
© 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved.
Department of Laboratory Medicine and Pathology
1,25 Dihydroxyvitamin D Intervention Problem:
• 1,25-Dihydroxyvitamin D is common send-out
• 68% of the 1,25-Vitamin D were ordered in error; 25-Vitamin D was
intended test
Intervention
• Email template describing the use of the two Vitamin D tests
• Asked provider if want to cancel and change order to 25-Vitamin 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.
0
5
10
15
20
25
30
35
Nu
mb
er
of
Ord
ers
Cancelled
Approved
Intervention Privileging added
After intervention:
• 58% (n=134) of the 1,25-
Vitamin D orders were
canceled and changed to
25-Vitamin D.
© 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved.
Department of Laboratory Medicine and Pathology
Reduce Laboratory Testing in the Hospital Patient
Testing patterns from your practice
Reduce repeat testing. Examples:
• Serum magnesium and phosphorus – reduce frequency of repeat
Mg/Phos checks in patients with normal levels
• CBC with differential – Change to CBC without diff in patients with
normal diff within 3 days
• Ionized calcium – Reduce frequency of iCAL when previous value
normal
• NT pro BNP – Reduce frequency of measurement during
hospitalization
• ANA (and others) no more than once per week
• Hereditary tests no more than once ever
• Other tests based on per day, per week, or per hospitalization
44
© 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved.
Department of Laboratory Medicine and Pathology
Order Entry Decision Rule: Results
iCAL, Mg, NT pro BNP rules implemented
Test volumes 30 day before and after rule
Test Volume
pre (30 days)
Volume
post (30 days) % change
iCAL 1465 582 - 60%
MG 4828 2297 - 52%
NT Pro BNP 140 125 - 11%
Controls
ELPN 3858 3810 - 1%
PHOS 2138 1711 - 20%
Bilirubin 796 810 + 2%
AST 936 932 - <1%
© 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved.
Department of Laboratory Medicine and Pathology
Renaming tests
hCG: useful to diagnose/monitor pregnancy
and useful as a tumor marker
hCG pregnancy assay:
hCG tumor marker assay:
46
© 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved.
Department of Laboratory Medicine and Pathology
Ordering System – ‘Moderate complexity’ interventions
Rearrange how tests appear on ordering cards or
screens
Consider:
• How are your tests currently listed?
• Have you seen your ordering screens?
• Are the tests simply listed alphabetically or in a
way designed to guide use?
© 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved.
Department of Laboratory Medicine and Pathology
Next
Cancel
Guide
Comments
Stool (Micro)
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
Fecal Leukocytes 8046 Fecal Parasite Screen (See Guide for Algorithm) Giardia Ag 80231 Cryptosporidium Ag 80335
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
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)
Tiered testing
shows
preferred order
Microbiology
Stool Testing
Outpatient
Ordering system
We saw a 30%
decrease in O&P
orders over expected
volumes (based on
the previous year)
since we changed the
ordering system
© 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved.
Department of Laboratory Medicine and Pathology
Getting information from our
physicians or patients…
© 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved.
Department of Laboratory Medicine and Pathology
Trying to get information from the
ordering clinician or referring lab
Stool specimen for Giardia antigen testing
© 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved.
Department of Laboratory Medicine and Pathology
Trying to get information from the
patient…
“Have been in car for 1 hr 40 min”
© 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved.
Department of Laboratory Medicine and Pathology
Working with our clinical
colleagues…
© 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved.
Department of Laboratory Medicine and Pathology
This all sounds great, but how am I going to deal with Dr. “Pain-in-the-A**”
Repeat after me… •Data is your friend and processes are key. •I’m an MD, too – Appeal to patient care! •Patience and persistence! •90% of the noise comes from 10% of the people •Perfection is the enemy of the good! •Aim for the “80-20” •Differentiate between the routine and the “special”
© 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved.
Department of Laboratory Medicine and Pathology
Outline for Today
What is test utilization?
How does utilization fit into our current healthcare
environment?
Do we have utilization issues in medicine – including
pathology and the clinical laboratories?
Why do we have laboratory utilization issues?
How can we get a utilization program started?
What does a successful utilization program look like?
© 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved.
Department of Laboratory Medicine and Pathology
Move from philosophy of laboratory passively performing tests – any test, any time, any way you want it
to Laboratory and pathologists collaborating with clinicians to solve diagnostic and laboratory problems
© 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved.
Department of Laboratory Medicine and Pathology
Thank You!