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Powering down on excessive test use

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William Check, PhD

February 2014—Utility companies can generate electricity in many ways—fossil fuel, nuclear reaction, solar panel, wind turbine. Which power source is preferable depends on the circumstances and the work that needs to be done. Generating optimal laboratory utilization is much the same. Providing an efficient and effective combination of tests for diagnosing hematologic neoplasms requires a different approach from achieving appropriate repeat ordering of chemistry tests in ICU patients. Delivering only the necessary blood components to cardiovascular surgery patients may take different tactics from curbing orders of expensive molecular genetic send-out tests.

Dr. Lewandrowski

Dr. Lewandrowski

Pathologists today face all of these challenges and more. Fortunately, they have a variety of methods to power their utilization objectives. Over the past 10 years pathologists at Massachusetts General Hospital have developed a broad repertoire of tools in their utilization program, says Kent B. Lewandrowski, MD, associate chief of pathology and director of pathology laboratories and molecular medicine, one of the leaders of this program since its inception. Among their tools, says Dr. Lewandrowski, professor of pathology at Harvard Medical School, are clinical education, practice standards, laboratory review (gatekeeper functions), physician profiling, ordering frequency limits, order-entry pop-ups, a test menu formulary, and, occasionally, a ban on a test.

At Mayo Clinic the laboratory and pathology practice committee works from much the same toolbox. In particular, Curtis A. Hanson, MD, professor of laboratory medicine and pathology, who leads the Mayo utilization effort, puts emphasis on a variety of steps that can be invoked to establish a utilization review process: develop medical criteria for sending out high-cost tests, avoid repeating tests unnecessarily, and set up a laboratory review process using algorithms and guidelines for selected tests.

To some extent, profligate testing practices can be laid at the door of the laboratories, Dr. Hanson says. “We have encouraged the notion that a clinician will get any test they want, anytime, instead of helping them to sequence tests, to do the most likely test first,” he says. “Labs don’t provide guidance on how to order the appropriate assays in various diseases. And if laboratories don’t have an appropriate review and ordering process in place, clinicians have no choice but to order excess testing.”

Dr. Hanson

Dr. Hanson

The job of laboratories, he says, is to move clinicians from asking “Do you do this test?” to “Can you help me solve this clinical problem?”

Making this transition requires that there be trust and confidence between clinicians and laboratorians, says hematopathologist Annette S. Kim, MD, PhD, assistant professor of pathology at Vanderbilt University Medical Center, who represents a team of clinicians and pathologists (led by Mary Zutter, MD, assistant vice chancellor for integrative diagnostics, and Adam Seegmiller, MD, PhD, director of hematopathology) that carried out a successful intervention to improve ordering of hematopathology tests.

Pathologists can’t simply demand that internists and surgeons change their ordering patterns, any more than utilities can get consumers to use electricity and gas in a more environmentally aware way by simply showing them the data and telling them to change. To get users to employ pathology services more judiciously, pathologists must change clinicians’ attitudes. And that requires a formal, committed, long-term interdisciplinary effort.

Dr. Kim

Dr. Kim

At Vanderbilt the hematopathology campaign took the form of a joint committee, termed diagnostic management team, to devise evidence-based standard ordering protocols. At the University of Washington, where a similar effort is underway, it will be a bit different, Daniel Sabath, MD, PhD, told CAP TODAY. “We are being asked more to come up with testing algorithms and clinicians will give their blessing,” says Dr. Sabath, head of the hematology division in the Department of Laboratory Medicine. “They will not be as involved in the initial stages of the process. The tricky part,” Dr. Sabath says, “is this: If the lab is going to be ordering tests, we need to make sure we don’t give the appearance of self-referral, which could raise compliance issues.”

In the effort to change ordering practices, experts agree clinician education is a relatively weak intervention. Truly changing behavior requires forcing functions, such as clinician profiling, or report cards, which create peer pressure. “One of the most decisive things in changing clinician behavior is peer review and approval and peer data,” Dr. Hanson says. “As physicians we didn’t get where we are by being willing to be at the bottom.” For example, peer pressure has been highly effective in Mayo’s campaign to get cardiovascular surgeons to improve their use of blood products.

Dr. Sabath

Dr. Sabath

At MGH, report cards and peer review were used to curb orders of expensive pediatric genetic send-outs, says Anand Dighe, MD, PhD, associate pathologist and director of the core laboratory. “Forcing functions work,” agrees Dr. Dighe, associate professor of pathology at Harvard Medical School.

Informatics also works. In the MGH program, informatics provides online decision support and computer dashboards for test ordering and reporting. Dr. Dighe calls provider order entry “a key leverage point” for improving ordering practices and preventing ordering errors. At the other end of the process, informatics can provide enhanced interpretive results reporting.

Dr. Dighe’s team used an advanced informatics program, Supervised Machine Learning, to achieve highly accurate identification of spurious glucose values. Techniques such as these can be adapted for routine results reporting, he says, and can provide more information to the clinician by putting the test results in the context of other related results.

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