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Laboratory Test Utilization Strategies

Use of Educational Efforts and the Test Ordering System

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Published: March 2013

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Dr. Pritt presents the third in our series “Laboratory Test Utilization Strategies.” The series addresses strategies for test utilization in the clinical laboratory. Dr. Pritt will discuss the use of educational efforts and the test ordering system.

Presenter: Bobbi S. Pritt, MD

  • Associate Professor of Laboratory Medicine and Pathology, College of Medicine
  • Director of the Initial Processing and Media Laboratory and the Parasitology Laboratory at Mayo Clinic in Rochester, Minnesota
  • Consultant in the Division of Clinical Microbiology

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Today I will be continuing on our theme of Laboratory test utilization strategies by specifically examining the role of education and test ordering in optimizing lab test use.

Before we start, I’d like to state that I have no disclosures.

So my goals for today’s hot topic presentation are to discuss 2 approaches to optimizing laboratory test utilization.  First, by providing education to ordering clinicians to close the knowledge gap between medical knowledge and appropriate test use and to utilize the test ordering system to control or guide test ordering.  Lastly, I will review tools and materials offered through Mayo Medical Laboratories on test utilization.

So let’s start with approach number 1, which is to close the knowledge gap. This can be accomplished in a number of ways, with some methods having a larger impact than others.

For example, closing the knowledge gap can be accomplished to some extent with 1-time educational efforts such as emails, memos, call for enhanced vigilance, educational pamphlets, and continuing medical education lectures.  These are important components for providing laboratory guidance on appropriate test ordering. 

However, we must understand the reality of only using simple educational efforts.  Specifically, one time education by itself will have little sustained impact when ordering patterns and habits. However, providing education helps to establish the laboratorian as a subject matter expert in the field, and to develop important relationships with the clinicians who will be using these tests. Furthermore, better results may be obtained by combining educational efforts with additional strategies.

For example, a larger impact is obtained by providing a continuous and reliable source of education, such as online test catalogs and ordering information. So, most of you are probably familiar with these devices; they are widely used by house staff now in many academic and private institutions.  Therefore, ways to provide information through these devices are likely to be well received if they are intuitive and simple to use. 

Having easily available information should facilitate understanding of test utility and appropriate ordering strategies.  This is especially useful for tests such as HIV, where multiple tests are available, the results are often difficult to interpret, and clinicians do not fully understand how to proceed after receiving an initial test results.

To overcome this, we offer comprehensive information on our website at MayoMedicalLaboratories.com where our entire test catalog is available.  For each test, such as the HIV 1 and 2 antibody test that is shown here, you can find an overview of the test, information on the type of specimen required, and the accompanying clinical and interpretative information. 

Easy accessibility to testing algorithms is also helpful.  At this same website, we offer over 70 different algorithms, including those for HIV testing such as the example shown here.

These educational efforts are often a good place to start when trying to optimize lab test utilization.  And they are relatively easy to do, given that laboratorians are best positioned to understand the strengths and limitations of the tests they offer in their laboratories.  Next, I’d like to discuss another approach which is how to use your ordering system to your advantage to both provide education and guide test ordering.

So, to start, let’s take a look at the way tests are named.  Something as simple as a test name can have an enormous impact on test selection by your physicians.  For example, we offer several different tests for detection of enteroviruses on CSF, including PCR and antibody tests.  Now let’s take the patient scenario of a 9-year- old boy with headache and stiff neck in the setting of an echovirus outbreak.  The savvy physician wants to order an echovirus test on this boy, but he doesn’t know that echovirus is a type of enterovirus.  Given that the boy has acute disease, the enterovirus PCR is the test of choice.  However, the physician may be tempted to order the echovirus antibody test because it has the word “echovirus” in the test name. But in this situation, the antibody test would NOT be appropriate, since it takes several weeks to form a detectable antibody response. So to avoid this potential misunderstanding, and better guide test ordering, we can make simple changes to the test name.  For example, we could specify that the enterovirus PCR includes testing for echoviruses as shown here. Furthermore, we can steer physicians away from using the echovirus antibody test by specifying that it is not appropriate for acute disease. This is a relatively easy change to make and yet it can have a big impact on test ordering patterns.

Another more aggressive, but potentially higher impact method, is to put actual stops into the ordering process, where additional information can be given or requested. For example, a system could require the ordering clinician to fill in check boxes for patient symptoms and exposure history before a test can even be ordered.  Based on the entered answers, only certain tests will be made available to that physician.

Shown here is what happens when a physician clicks on the thrombophilia panel in the in-patient setting.  In this case, the box to the right appears, which at higher magnification, we can see it has a section that recommends important supplemental testing if it has not been performed in the past 90 days. And it requires the physician to enter if the patient has been on any medications that may interfere with the tests on the panel.  The continue button will not work until one of the options is selected.

Other options for using the ordering system to guide testing are removing tests altogether, requiring specialist approval before the order can be placed, or restricting orders altogether to the specialists. No matter what methods are used in the ordering system to guide test utilization, it is still essential to keep the ordering system up-to-date.  Therefore, the lab should routinely review and modify requisitions and order screens frequently if Computer order “hot buttons” or panels are available, then they need to reflect best practice and recommended guidelines rather than just ease of ordering.

It is also important to obsolete tests that should be obsolete. For example, bleeding time, band count, and red cell folate tests which have largely been replaced by more objective and reliable methods. Finally, it is helpful to have an approval process for adding tests to your menu. And to do this, laboratorians and clinicians should work together to develop and implement this process.

Finally, I’d like to share with you a very effective example of how the ordering system can efficiently guide lab testing.  And that is through the use of laboratory-driven algorithms. 

For this example, I will refer to the celiac disease serology cascade.  This is an algorithm that was jointly developed by laboratorians and clinicians, and it is designed to guide testing so that only necessary tests are performed, rather than every single test that is available for celiac disease testing. 

When used, this algorithm allows for efficient test ordering and it provides significant cost savings to the patient. However, there are some drawbacks to the algorithmic approach because, following the algorithm requires the clinician to place the order, wait for the order, analyze the result, and then place additional orders as indicated by the algorithm. And unfortunately, this is not only time consuming for the physician, but it might also require multiple patient blood draws. So it might not be very patient friendly. Therefore, most physicians prefer to order all tests up-front instead of in a sequential approach. As a result, many more tests than necessary are usually ordered.

After creating this algorithm, we recognized that physicians may not prefer sequential ordering. Therefore we developed a system where the physician can order the algorithm itself, and the lab would take care of sequential testing. By placing a single order for the celiac disease algorithm, initial serum and whole blood samples are drawn and sent to the laboratory. The laboratory then performs a cascade of tests based on the algorithm, even sharing the samples amongst different laboratories if necessary.  The a la carte ordering is still available, but many clinicians choose to use the algorithm instead because it is efficient, uses only the tests that are needed, and is still patient friendly. By placing the order for the algorithm, the physician agrees to the number of tests that may be performed if the algorithm is followed.  

By using this approach, we have observed significant cost savings, while providing better quality care to the patient. Specifically, by performing some simple calculations, we have determined that the average cost of testing using this algorithmic approach is approximately one-seventh the cost of the whole panel of tests that could have been ordered for celiac disease.

I’d now like to finish by briefly discussing some test utilization resources that are offered by Mayo Medical Laboratories.

First, our web page not only includes the test catalog as shown earlier, but also includes specific resources for optimizing test utilization. By clicking on this tab, it will bring you to a page

Where there are resources for administrators as well as resources for clinicians. 

The resources for administrators include information on our test ordering analysis tool.  This tool is designed to provide you with information about your institution’s send-out test ordering patterns and offer suggestions for decreasing costs and even bringing some tests into your own laboratory.

Here is an example of a test ordering analysis tool printout for the fictional ABC Health System, and it includes utilization patterns, suggested cost savings initiatives, test sharing opportunities, and potential savings that could be appreciated by test utilization efforts. So, there is a lot of useful information that can be found in examining your lab’s current usage patterns and opportunities for cost savings.

Lastly, the resources for clinicians tab will provide you with links to all of our test algorithms, such as the ones that I showed you previously.

And to our educational offerings such as other Hot Topics.  You may be especially interested in our recent series on Common Test Ordering Errors.

So, in summary, I’ve reviewed a few different strategies for tackling problems with test utilization. First, I’ve discussed how education is important for establishing the laboratorian as a subject matter expert and providing information for new and changed tests. But that education alone rarely impacts long-term behavior. Also, I discussed that education in combination with other enhancements such as changes to test ordering system can be more successful in facilitating change than education alone. I’ve also discussed how the test ordering system can be a powerful tool to guide test usage. So, I hope that you’ve found some good ideas in this presentation and wish you the best with your test utilization efforts!

 


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