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Practical Utilization
James Hernandez, MD Pathologist, May Clinic
Phoenix, AZ
Verlin Janzen, MD, FAAFP Family Physician & Laboratory Director
Hutchinson Clinic, Hutchinson, KS
John Daly, MD COLA Chief Medical Officer
DESCRIPTION:
This session provides an overview of tools that can be used to effectively order laboratory tests and discussion of those tools you should be requesting be made available to optimize laboratory test ordering. OBJECTIVES: At the end of the session, participants will be able to:
Understand the need to determine where tests are most efficiently performed i.e. POS vs. Reference Laboratory
Provide practitioners with knowledge of those tools which are available to assist them in ordering the >4000 analytes available
Emphasize the necessity of a robust IT laboratory system to incorporate the laboratory utilization tools
Provide information on effect of improper laboratory test utilization
Friday April 7, 2017
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James S Hernandez, MD Pathologist - Mayo Clinic
Phoenix, AZ
Verlin K Janzen, MD, FAAFP Family Physician & Laboratory Director
Hutchinson, KS
John Daly, MD COLA Chief Medical Officer
“..ensuring adequate utilization of needed tests in some patients and discouraging superfluous tests in other patients” (1)
Superfluous Too frequent
Routine anything
Wrong test – wrong reason
Any test that won’t change action
Underutilization(2) – less frequently studied, could be > overutilization
(1) Geoffrey Baird - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4083574/ (2) Zhi M - http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0078962#s5
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A major component of US healthcare expenditure is an estimated $65 billion spent each year to perform more than 4.3 billion laboratory tests (1)
Estimated that $6.8 billion of medical care in the US involves unnecessary testing and procedures that do not improve patient care and may even harm the patient (2)
(1) Alexander B. Reducing healthcare costs through appropriate test utilization. Critical Values 2012; 5: 6-8 (2) Holladay EB. Test right. Critical Values 2012; 5: 3.
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Transition to ‘Value-based” reimbursement
Value = Outcome / Cost
Diagnostics including lab become ‘cost’ center, not revenue generator
Down-stream costs of ‘false positives’
More not always better, can be harmful
Waste – duplicative testing
Evidence is building in some areas
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“Where are the morning labs, Jim??”
“You want to change when we can order CBC’s??”
Because medical students and residents have very little authority or control, ordering lab tests are some of the only actions that have not been highly scrutinized in the past
Ordering lab tests is considered one of the “fun” activities of being a student or resident
Attending physicians often order many tests
Physicians who order few tests may be regarded as not as comprehensive/compulsive (not as smart)
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OK in the past when there were 40 tests, now there are 4,000!
All doctors want to emulate “House” – a case of “vitamin deficiency”
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Lab is still most often a revenue generator Lack of administration support
Why change – we’ve always done it this way
Tolerance of uncertainty – some have less
Takes time to do it right – change habits, think about if test is needed
Evidence still lacking for many tests
Malpractice concerns ‘if I’m not thorough’
Patients like thorough doctors – more is better If I don’t do it – their employer (or someone else) will –
I’ll look bad
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Lack of knowledge
Lack of systems – reminders
Doctor’s favorites – need to review & update regularly
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Lack of knowledge – laboratorian trained physicians tend to order less FPs – uncertain about what test (14.7% encounters) or
interpretation (8.3% encounters) (1)
Mid-level providers tend to order more
Lack of knowledge to explain ‘why not’
OCD – more Junior, less schooled Historical patterns from training/previous practice
Swimming against the tide is hard
Lack of time Easier to order what the patient wants rather than to
explain why not
Faster to do the test before I see the patient “just in case”
Duplicate testing – no system to detect
(1) J Am Board Fam Med 2014;27:268–274.)
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Lack of evidence – what is right frequency, when should we stop
If I don’t … malpractice, patient satisfaction, someone else will
Shotgun testing – ordering all tests you think of rather than focusing initial testing
Not understanding/agreeing with risk of harm of false positive result Patient anxiety, lack of trust
Lab testing only 3-5% of healthcare spending, BUT downstream activities are $$$ (Rx, XR, surgery, hospital stays, etc)
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Mainly problem with low volume – esoteric testing
Vitamin D
Celiac testing
Coag workups
Genetic testing – right test/panel
SHOULD I TEST
Genetic testing
Will the result change what I do?
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72 involve lab testing Don’t obtain routine blood work (e.g., CBC, liver function
tests) other than a CEA level during surveillance for colorectal cancer
Don’t perform urinalysis, urine culture, blood culture or C. difficile testing unless patients have signs or symptoms of infection. Tests can be falsely positive leading to over diagnosis and overtreatment.
Don’t obtain a C. difficile toxin test to confirm “cure” if symptoms have resolved.
Don’t order multiple tests in the initial evaluation of a patient with suspected thyroid disease. Order thyroid-stimulating hormone (TSH), and if abnormal, follow up with additional evaluation or treatment depending on the findings.
http://www.choosingwisely.org/clinician-lists/
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Don’t test for myoglobin or CK-MB in the diagnosis of acute myocardial infarction (AMI). Instead, use troponin I or T.
Don’t order an erythrocyte sedimentation rate (ESR) to look for inflammation in patients with undiagnosed conditions. Order a C-reactive protein (CRP) to detect acute phase inflammation.
Don’t obtain baseline laboratory studies in patients without significant systemic disease (ASA I or II) undergoing low-risk surgery – specifically complete blood count, basic or comprehensive metabolic panel, coagulation studies when blood loss (or fluid shifts) is/are expected to be minimal.
Don’t routinely screen for prostate cancer using a prostate-specific antigen (PSA) test or digital rectal exam.
http://www.choosingwisely.org/clinician-lists/
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It’s change – we’ve always done it this way
Lab is still source of $$
Patients still want it – more is better
Low tolerance for uncertainty – pt & Dr
No evidence – no benchmarks/norm
Moves toward population health, value, and bundling of reimbursement is huge opportunity to start discussions with providers & patients OP hospital Medicare patients in many parts of the
country are bundled – move to bundling everywhere
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Physician Champion – multi-specialty task force Outpatient – Office-based: VJ
Hospital – System-based: JH
Start small w/small group – expand as able
Evidence-based when available
Need for transparency
Tools http://www.mayomedicallaboratories.com/articles/reso
urces/algorithms.html
https://arupconsult.com/algorithms
Reduction in reimbursement – PAMA effect
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How can my IT system help:
Order sets
Cost
Highlight given test which brings up more info on a test or orderable algorithm
Information @ provider’s fingertips
Ability to type in disease and get blurb on it
Algorithms for testing
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Education
Data
Test order pattern comparison in group
Audit w/feedback
Cost-awareness
Financial incentives / risk sharing
Change test ordering procedures
Mandated protocols for test ordering
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NT-proBNP
Total protein/albumin
CBC
Basic metabolic panel
Magnesium
Ionized calcium
Urinalysis
Complete metabolic panel
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Fecal occult blood testing – use Hemoquant, Fecal Immunochemical Testing (FIT), or Cologuard (not quick, but accurate)
Tzanck smear – Polymerase chain reaction (PCR)
for Herpes
Sed rate – use CRP
AST - use ALT only
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Tests ordered (no.)
Bleeding time Single-standard DNA Total T4 and T3 uptake
PCR tests for microbiology Psychiatric genomic tests for monitoring depression
Myoglobin CK-MB
Overuse or misuse
Evidence-based use
Time to adopt newer tests
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Many sed rates
Most uses of CKMB in the USA
Most requests for O&P (ova and parasites)
Any low volume tests, especially if you are running more quality control samples than patient specimens
Large chemistry panels except for Medicare approved panels
Routine ordering of electrolytes in outpatients
Routine use of CBC with differential instead of CBC
Routine use of rapid strep test/throat culture if physician intends to treat the patient regardless of the result (and times when other tests
add no value)
Routine use of PT and PTT before surgery without supporting history
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Post guidelines on test requisition
Computerized reminders regarding guidelines
Utilization report cards
Changes to manual requisition or CPOE
Utilization report cards with peer review
Higher level approval or consultation required
Utilization report cards with leadership review and incentives or penalties to encourage behavior
Forbidding tests
Gentle Guidance
Strong Guidance
Adapted with permission from Dr. Michael Astion, Seattle
Children’s Hospital
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Guaiac testing is associated with high false-positive rates due to dietary and pharmaceutical interferences, and multiple stool collections are needed to achieve even moderate sensitivity.
Guaiac testing on specimens obtained from digital rectal exam by a provider are potentially misleading due to the risk of traumatic collection.
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Rationale: EBM-Based on clinical evidence of superiority over guaiac tests, on patient convenience, and on multiple societal guidelines, we recommend switching to fecal immunochemical testing (FIT) or to Cologuard for those choosing to use stool testing for CRC screening.
Use instead: FIT and Cologuard have been shown to be more specific and sensitive than guaiac tests for CRC detection. FIT detects human hemoglobin and is less affected by interferences, eliminating the need for dietary and medication restrictions. Cologuard detects both human hemoglobin and cellular DNA from shed intestinal cells. Both FIT and Cologuard demonstrate superior clinical specificity over guaiac for CRC screening.
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To evaluate occult GI bleeding in patients with anemia or iron deficiency, the “Stool HemoQuant MML” test (test code HQ) should be used.
Warning! Guaiac testing cannot reliably detect upper GI bleeding because globin and heme are degraded during intestinal transit. In contrast, HemoQuant detects occult bleeding equally well from all sources within the GI tract.
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Occult Blood Test
Detection of GI bleeding Indication
Charge
FIT or Cologuard
Lower GI only Colorectal cancer
screening
$118 (FIT), up to $650 (Cologuard,
sent to Exact Sciences in WI)
HemoQuant Upper and lower GI Anemia, iron
deficiency, other
$129
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Lab tests utilization is more mainstream now
Can help each other change – using evidence
More guidance available
Not easy
Value-based reimbursement will drive the discussion
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