A Cost-Effective Interdisciplinary Approach to Microbiologic Send-Out Test Use

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1 A Cost-Effective Interdisciplinary Approach to Microbiologic Send-Out Test Use Scott W. Aesif, MD, PhD; David M. Parenti, MD; Linda Lesky, MD; John F. Keiser, MD, PhD Context. Use of reference laboratories for selected laboratory testing (send-out tests) represents a significant source of laboratory costs. As the use of more complex molecular analyses becomes common in the United States, strategies to reduce costs in the clinical laboratory must evolve in order to provide high-value, cost-effective medicine. Objective. To report a strategy that employs clinical pathology house staff and key hospital clinicians in the effective use of microbiologic send-out testing. Design. The George Washington University Hospital is a 370-bed academic hospital in Washington, DC. In 2012 all requisitions for microbiologic send-out tests were screened by the clinical pathology house staff prior to final dispensation. Tests with questionable utility were brought to the attention of ordering clinicians through the use of interdisciplinary rounds and direct face-to-face consultation. Results. Screening resulted in a cancellation rate of 38% of send-out tests, with proportional cost savings. Nucleic acid tests represented most of the tests screened and the largest percentage of cost saved through screening. Following consultation, requested send-out tests were most often canceled because of a lack of clinical indication. Conclusions. Direct face-to-face consultation with ordering physicians is an effective, interdisciplinary approach to managing the use of send-out testing in the microbiology laboratory. (Arch Pathol Lab Med. 2015;139: ; doi: / arpa oa) Understanding the economic strain of health care costs to 30% of ordered tests are redundant or inadvertently in the United States is complicated by estimates that repeated. 4,5 These tests have little or no impact on the as much as 30% of the delivered health care in the United hospital course of the patient, save the cost of the test. States is duplicative or unnecessary. 1 To encourage the However, unnecessary laboratory investigations can trigger profession to improve its stewardship of health care expensive and/or invasive diagnostic work-ups or therapies. resources, health care leaders have proposed adding a In the inpatient setting, reference testing represents a seventh general competency, cost-consciousness and direct upfront cost to the laboratory. When billed as part of a stewardship of resources, to the current six competencies diagnosis-related group, it is difficult to recover a significant defined by the Accreditation Council for Graduate Medical portion of these costs. A common cost-containment strategy Education and the American Board of Medical Subspecialties. However, a recent survey of practicing physicians review of reference laboratory tests. 6 This approach is at some academic institutions is the pathologist-conducted found that only a third of those surveyed thought that traditionally thought of as time-consuming and most physicians bear the responsibility for controlling health care applicable to teaching hospitals, where the task of vetting costs. 3 send-out tests is delegated to the clinical pathology resident. There are scant data with regard to what types of tests are Diagnostic testing often occurs early in the care and most often being screened by pathology house staff and the management of hospitalized patients, and much of its clinical rationale behind order modifications. We therefore financial impact is determined by how the test result affects employed an interdisciplinary approach to screening microbiologic send-out tests in order to assess cost impact and the hospital course of the patient. Estimates suggest that up clinical rationale. Accepted for publication March 19, Published as an Early Online Release April 23, MATERIALS AND METHODS From the Department of Pathology (Drs Aesif and Keiser), and the The George Washington University Hospital is a 370-bed tertiary Divisions of Infectious Diseases (Dr Parenti) and Hospital Medicine care hospital located in downtown Washington, DC. For the last 15 (Dr Lesky), Department of Medicine, The George Washington years, we have routinely employed a resident or house staff based University, Washington, DC. approach to screening reference laboratory testing. Using this The authors have no relevant financial interest in the products or companies described in this article. approach, the client services division of the core laboratory requires Presented in poster format at the 2012 annual meeting of the that all microbiologic send-out tests be reviewed by the clinical American Society for Clinical Pathology; November 2, 2013; Boston, pathology house staff prior to being sent to the reference Massachusetts. laboratory, regardless of test type or cost. In the last year we Reprints:JohnF.Keiser,MD,PhD,DepartmentofPathology,The adopted a more interdisciplinary approach to screening send-out George Washington University, 2100W Pennsylvania Ave NW, Ste 5027, Washington, DC ( jkeiser@mfa.gwu.edu). test requests. Key clinicians were identified who could facilitate communication with ordering physicians. These individuals were 194 Arch Pathol Lab Med Vol 139, February 2015 Microbiologic Send-Out Tests Aesif et al

2 Table 1. A Summary of All Send-Out Test Requisitions Screened by Pathology House Staff and Faculty in 2012, Categorized by Test Type and With Associated Cancellation Percentages and Cost Savings Test Type Orders Percent Cost Saved Percent of Cost Saved Nucleic acid tests $48, Serology and culture $5, $53, identified using service-based test-ordering totals and the likelihood that they would be caring for any one patient for whom microbiologic send-out tests were ordered. Using those criteria we approached the Department of Medicine s Divisions of Hospital Medicine and Infectious Diseases. In discussing the laboratory s role in the usage management of send-out tests, we asked that these individuals facilitate communication with ordering clinical services. This was accomplished in a number of ways, including but not limited to: introduction of pathology faculty and house staff to clinical teams, provision of clinical round times and locations, and facilitation of pathology faculty and house staff participation in patient rounds. As client services staff receive orders for send-out microbiologic tests, they are held in the laboratory and delivered to the clinical pathology house staff once or twice daily, with a range of 0 to 12 requisitions daily. The test requisitions are then used to review patients electronic medical records for pertinent history and laboratory data. Finally, rather than attempt to call or page the ordering physician, test requisitions are taken directly to the wards and emergency department for discussion. 7,8 In addition, for those test requisitions not addressed by the method described above, clinical house staff members are engaged as part of microbiology-specific rounds that are held 5 times a week in the microbiology laboratory. These rounds are attended by medicine and infectious diseases house staff and occasionally attending physicians, and are led by the clinical pathology house staff and attending microbiologist. As a result of these face-to-face discussions and laboratory rounds, tests are approved, modified, or canceled. All send-out test requisitions for calendar year 2012 were archived, and data regarding order date, ordering service, the indication for order modification, and the ultimate dispensation of the test were recorded. Cost analyses were performed using the price per test as negotiated by The George Washington University Hospital with an extramural reference laboratory. These prices represent direct billing charges to The George Washington University Hospital by the extramural reference laboratory. All of the data presented herein represent orders placed for inpatient services only. No tests were canceled without prior discussion with a treating physician. All study methods were approved by the Institutional Review Board at The George Washington University. Data and statistical analyses were performed using Microsoft Excel software (Microsoft Corporation, Redmond, Washington). A detailed analysis of nucleic acid test requisitions demonstrated that most nucleic acid tests were ordered for the detection of viral pathogens (93%, or 740 tests). The remaining nucleic acid tests were ordered for the detection of bacterial pathogens (7%, or 57 tests). Hepatitis C virus (225 tests) and herpes simplex virus (138 tests) represented the largest proportion of total nucleic acid tests ordered and reviewed (Table 2). The hepatitis C virus test requisitions were further analyzed to reveal that 30% of all of the hepatitis C virus nucleic acid tests were ordered with either a negative antibody screening test or concomitantly with an antibody screening test that was ultimately negative. Of all the hepatitis C virus nucleic acid tests ordered, 31% did not require modification prior to final dispensation. The herpes simplex virus test requisitions were further analyzed to Table 2. Detailed List of Screened Nucleic Acid Tests a Test Name Orders Percent Borrelia spp, DNA, qualitative Cytomegalovirus virus, DNA, qualitative Epstein-Barr virus, DNA, qualitative Epstein-Barr virus, DNA, quantitative Enterovirus, RNA, qualitative HIV-1, genotype HIV-1, DNA, qualitative HIV-1, RNA, quantitative Hepatitis B virus, DNA, qualitative Hepatitis B virus, DNA, quantitative Hepatitis C virus, genotype Hepatitis C virus, RNA, qualitative Hepatitis C virus, RNA, quantitative RESULTS Summary of Reviewed Send-Out Tests and Cost Savings Analysis Varicella zoster virus, DNA, HSV 1 and 2, DNA, qualitative JC virus, DNA, qualitative qualitative During the course of 1 year, the clinical pathology house West Nile virus, RNA, staff reviewed a total of 1207 microbiologic send-out test qualitative requisitions (Table 1). tests represented a total savings of $53, in direct cost to the laboratory. All of Other (,5 total annual orders) the data in Table 1 exclude the cost of in-house labor and supplies. The average unit cost per canceled reference test was $117 per test. A survey of all clinical pathology house Abbreviations: HIV, human immunodeficiency virus; HSV, herpes simplex virus. a A detailed summary of all nucleic acid send-out test requisitions staff found the average amount of time needed to review screened by pathology house staff and faculty in 2012 is given; the tests are listed by name with associated cancellation percentages. The send-out test requisitions and meet with clinical staff to be other category of nucleic acid send-out tests included: BK virus, 71 (629) minutes per day (n ¼ 15 residents), including dengue fever virus, parvovirus, and Pneumocystis jirovecii amplification rounds held in the microbiology laboratory. assays. Arch Pathol Lab Med Vol 139, February 2015 Microbiologic Send-Out Tests Aesif et al 195

3 Table 3. Test Name Detailed List of Screened Serologic Tests and Cultures a Orders Percent Adenosine deaminase Aspergillus spp, antigen Bacterial meningitis, antigen panel Bartonella spp, Ig Cytomegalovirus, Ig Coxsackie virus, Ig Dengue fever virus, Ig Epstein-Barr virus, Ig Hepatitis B virus, e antigen Histoplasma spp, antigen Herpes simplex virus, culture Borrelia spp, Ig and WB Mycoplasma pneumoniae, Ig Parvovirus B19, Ig Toxoplasma gondii, Ig West Nile virus, Ig Other (,5 total annual orders) Abbreviations: Ig, immunoglobulin, including IgG, IgM, and/or total; WB, Western blot analysis. a A detailed summary of all serologic and culture send-out test requisitions screened by pathology house staff and faculty in 2012 is given; the tests are listed by name with associated cancellation percentages. The other category of serologic and culture send-out tests included: adenovirus, Bordetella spp, Coccidioides spp, Coxiella spp, Cryptococcus spp, DNase B, Echinococcus spp, Entamoeba histolytica, Ehrlichia spp, hepatitis A virus, human T-lymphocyte virus, Rickettsia spp, rubella virus, Trichinella spp, and Western equine encephalomyelitis virus Ig assays. Antigen assays included: beta-dglucan, Cryptococcus spp, Giardia spp, Legionella spp, norovirus, and Streptococcus pneumoniae. reveal that 76% of all of the herpes simplex virus nucleic acid tests were ordered on cerebrospinal fluid specimens. Of those cerebrospinal fluid specimens, 72% had normal white blood cell counts, and 46% had normal white blood cell counts, glucose concentration, and total protein concentration, as defined by our laboratory s reference intervals. A detailed analysis of serology and culture test requisitions demonstrated that most tests were ordered for the detection of viral pathogens (51%, or 210 tests) and bacterial pathogens (27%, or 112 tests). The remaining tests were ordered for the detection of fungal (12%, or 49 tests), protozoal (7%, or 29 tests), and parasitic pathogens (3%, or 10 tests). Epstein-Barr virus immunoglobulins (51 tests) and a bacterial meningitis antigen agglutination panel (47 tests) represented the largest proportion of total serology and culture tests ordered and reviewed (Table 3). Stratification of Ordered and Tests by Ordering Department and Consultation Status An analysis of the total number of send-out microbiologic tests ordered by individual departments demonstrated that most time spent in consultation by the pathology house staff was focused on a handful of clinical departments (Figure, A and B). Further analysis revealed that if the Division of Infectious Diseases had been consulted on patients for whom a test request was being reviewed, the dispensation was more likely to be canceled (P,.001, v 2 test; Figure, C and D). Rationale for Test Cancellation All canceled requisitions were determined to have been canceled for preanalytic reasons. 9 The requisitions were further categorized based on the fundamental rationale behind canceling the order. Three categories were used: clinical indication, order entry error, and follow-up. The clinical indication category represented 65% of canceled tests and included such reasons as: a confirmation test ordered in the absence of a screening test order, a confirmation test ordered with a negative screening test result, and a change in clinical status and/or clinical history. The order entry error category represented 35% of canceled tests and included such reasons as: mistaken orders, duplicate orders, incorrectly inputted test orders, and insufficient specimen quantity. The follow-up category represented rare insistences, 0.2% of canceled tests, when patients were discharged prior to a test being screened by the pathology house staff and the ordering physician determined that the test be followed up in the outpatient setting. COMMENT Previous studies have estimated the average cost of reference tests to be $26 to $46; however, our data suggest an average cost per microbiologic reference test to be $ ,11 The rapid emergence of molecular diagnostic reference testing portends an even greater relative contribution to overall health care cost. There are limited published data from which to assert that our cancellation rate or service ordering trends for microbiologic send-out tests are consistent with those of other United States or international institutions. 10,12 However, in a recent workgroup publication the American College of Physicians highlighted microbiologic screening tests in a list of clinical situations in which testing does not reflect high-value care. 7 It has been demonstrated that the formation of formal oversight committees can effectively reduce laboratory send-out test expenditures when there is active involvement by medical staff. 13,14 We demonstrate that simple face-toface interdisciplinary communication between pathology and either infectious diseases or hospitalist medical staff is a cost-effective method in itself for ensuring high-value sendout test use, and that pathologists can engage with clinicians regularly enough to actively influence diagnostic testing and patient management decisions. Furthermore, the benefits of such an approach to clinical pathology house staff and medical staff were tangible. There was no resistance to test review on the part of the ordering clinicians, given that this has been standard practice in the microbiology department for the greater part of two decades. In addition to the educational benefits reaped by pathology house staff with regard to testing methods and interpretation, medical staff were equally engaged in active learning. Similarly, we believe such an approach helps to prepare clinical house staff to constructively deal with future questions they may face as attending physicians regarding their send-out test requisitions. Furthermore, data shown in Figure 1 suggest that when pathology house staff could use key clinical services, such as infectious diseases and hospitalists, as a portal to the clinical staff treating the patient, the likelihood 196 Arch Pathol Lab Med Vol 139, February 2015 Microbiologic Send-Out Tests Aesif et al

4 All send-out test requisitions screened by pathology house staff and faculty in 2012, presented as either total tests ordered (A and C) or canceled tests (B and D). The tests are broken down by ordering department (A and B) and whether the Division of Infectious Diseases had consulted on the patient for whom a send-out test had been ordered (C and D; *P,.001). The other department category included: cardiology, interventional radiology, neurologic surgery, orthopedic surgery, general surgery, obstetrics and gynecology, and nephrology. Abbreviations: ED, emergency department; ID, Division of Infectious Diseases. was higher that a send-out test order would ultimately be modified or reconsidered. Our estimated time commitment per test screened (approximately 15 minutes) is longer than was estimated in a recent, more administrative-based intervention. 12 The advantage with our approach is that the review of send-out tests happens essentially in real time. This avoids the perception on the part of the clinical staff that such a review is delaying patient care, and allows the pathology house staff to get the most up-to-date patient information. Similarly, face-to-face interaction makes for fruitful and collegial discussion. Our data demonstrate that although order entry errors make up a significant fraction of canceled send-out tests, most send-out tests were canceled following interdisciplinary discussion of the patient s clinical findings. This type of discussion is challenging to have by impersonal electronic or telephone communication. The general applicability of the current study is somewhat limited to the inpatient setting. The fee-for-service reimbursements sought in the outpatient setting are not relevant to the per diem reimbursements sought for the inpatient services examined herein. Therefore, the cost savings estimated by this study are thought to represent direct savings through avoidable and unnecessary charges to the hospital from extramural reference laboratories. Similarly, the practice of screening reference laboratory tests need not apply only to the academic hospital with resident house staff. This type of consultation represents a leadership role for pathologists to take in the era of more sophisticated and costly molecular testing. Because most clinicians do not currently have the time to provide such a service, it is unlikely that in the future they will find the necessary time or knowledge base to do so on their own. Furthermore, in anticipation of bundled payments for care, prevention of avoidable or unnecessary testing represents a modality wherein the pathologist can effectively demonstrate his or her value to patient care. Pathologists can proactively reach beyond the laboratory to help manage the appropriate use of testing and drive appropriate postanalytic interpretation of test results and clinical decision making, but they must do so in conjunction and collaboration with clinicians in order to ensure the most appropriate cost-effective patient care. References 1. Smith M, Saunders R, Stuckhardt L, McGinnis JM, eds.; National Research Council. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Washington, DC: National Academies Press; Weinberger SE. Providing high-value, cost-conscious care: a critical seventh general competency for physicians. Ann Intern Med. 2011;155(6): Tilburt JC, Wynia MK, Sheeler RD, et al. Views of US physicians about controlling health care costs. JAMA. 2013;310(4): van Walraven C, Raymond M. Population-based study of repeat laboratory testing. Clin Chem. 2003;49(12): Bates DW, Boyle DL, Rittenberg E, et al. What proportion of common diagnostic tests appear redundant? Am J Med. 1998;104(4): Carter E, Bennett BD. Reference test review by pathology house staff: a cost-containment strategy for the clinical laboratory. Clin Leadersh Manag Rev. 2002;16(1): Qaseem A, Alguire P, Dallas P, et al. Appropriate use of screening and diagnostic tests to foster high-value, cost-conscious care. Ann Intern Med. 2012; 156(2): Arch Pathol Lab Med Vol 139, February 2015 Microbiologic Send-Out Tests Aesif et al 197

5 8. Laine C. High-value testing begins with a few simple questions. Ann Intern Med. 2012;156(2): Hawkins R. Managing the pre- and post-analytical phases of the total testing process. Ann Lab Med. 2012;32(1): MacMillan D, Lewandrowski E, Lewandrowski K. An analysis of reference laboratory (send out) testing: an 8-year experience in a large academic medical center. Clin Leadersh Manag Rev. 2004;18(4): Valenstein PN, Praestgaard AH, Lepoff RB. Six-year trends in productivity and utilization of 73 clinical laboratories: a College of American Pathologists laboratory management index program study. Arch Pathol Lab Med. 2001;125(9): Liu Z, Abdullah A, Baskin L, Lewis G, Kelter G, Naugler C. An intervention to reduce laboratory utilization of referred-out tests. Lab Med. 2012;43(5): Zhao JJ, Liberman A. Pathologists roles in clinical utilization management: a financing model for managed care. Am J Clin Pathol. 2000;113(3): Warren JS. Laboratory test utilization program: structure and impact in a large academic medical center. Am J Clin Pathol. 2013;139(3): Arch Pathol Lab Med Vol 139, February 2015 Microbiologic Send-Out Tests Aesif et al

DEPARTMENT OF MICROBIOLOGY IMPORTANT NOTICE TO USERS Turnaround Times (TATs) for Microbiology Investigations

Dear User, ISSUE: M008 DEPARTMENT OF MICROBIOLOGY IMPORTANT NOTICE TO USERS Turnaround Times (TATs) for Microbiology Investigations In order to comply with national quality guidance and as part of our