Virtual Lectures Planning Committee Disclosure Summary

Mayo Medical Laboratories Virtual Lectures 2014 MFMER MFMER Virtual Lectures Planning Committee Disclosure Summary As a provider accredited by ACCME, College of Medicine, Mayo Clinic (Mayo School of CPD) must ensure balance, independence, objectivity and scientific rigor in its educational activities. Course Director(s), Planning Committee Members, Faculty, and all others who are in a position to control the content of this educational activity are required to disclose all relevant financial relationships with any commercial interest related to the subject matter of the educational activity. Safeguards against commercial bias have been put in place. Faculty also will disclose any off label and/or investigational use of pharmaceuticals or instruments discussed in their presentation. Disclosure of these relevant financial relationships will be published in activity materials so those participants in the activity may formulate their own judgments regarding the presentation. Listed below are individuals with control of the content of this program who have disclosed Relevant financial relationship(s) with industry: None No relevant financial relationship(s) with industry: Joaquin Garcia, MD program presenter Curtis Hanson, MD program planning committee Sharon Preuss program planning committee Bobbi Pritt, MD, MSc, DTMH program presenter, program planning committee Cara Schmidt program planning committee References to off-label and/or investigational usage(s) of pharmaceuticals or instruments in their presentation: None MFMER 1

Test Utilization in the Clinical Microbiology Lab What Works and What Doesn t Bobbi Pritt, M.D. Medical Director, Clinical Parasitology Laboratory Mayo Clinic, Rochester, Minnesota, U.S.A. 2016 MFMER 3281918-3 DISCLOSURES Relevant Financial Relationship(s) None Off-Label Usage None 2016 MFMER 3281918-4 2

Optimizing Test Utilization in Clinical Microbiology Similar challenges as other areas of the clinical laboratory Some unique considerations: Testing is dependent on numerous clinical factors Exposure history: Geographic location/travel Contact with infected individuals or animals Immune status (HIV/AIDS, HTLV-1, chemotherapy) Current outbreaks Presence of instrumentation (e.g. catheters, prosthetic joints) 2016 MFMER 3281918-5 Fecal Parasite testing as an example Complex testing options Traditional method for identification of parasites in feces is the Ova and Parasite examination (O&P) Appropriate for identifying many of the exotic parasites Less sensitive method for detecting the more common intestinal parasites in the United States (Giardia and Cryptosporidium) Requires up to 7 stool specimens for optimal detection of Giardia 2016 MFMER 3281918-6 3

Additional Detection Methods Antigen detection (Immunoassays) for Giardia and Cryptosporidium Multiplex PCR for bacterial, viral and parasitic pathogens Special staining methods: Modified acid fast stain for the coccidia Modified trichrome stain for microsporidia Individual PCR, culture and serologic tests 2016 MFMER 3281918-7 Too many options! Common approaches: Order all of the tests! Order the routine O&P that s what I learned in medical school I don t know what my patient has so I want the most inclusive test Preferred approach: Order of selective tests based on the clinical presentation and risk factors. Solution: An algorithm was developed based on published guidelines and clinician input 2016 MFMER 3281918-8 4

http://mayomedicallaboratories.com 2016 MFMER 3281918-9 A real-life experience The situation: the lab supervisor felt that the O&P was over-ordered and that physicians did not use our algorithm My approach: Step 1 examine the data 2016 MFMER 3281918-10 5

Stool Parasite Exam Test volumes 2005 2008 5000 4500 4000 3500 3000 2500 2000 1500 1000 500 0 Only <5% of our specimens were positive O&P Giardia EIA Cryptosporidium EIA Jan-05 Mar-05 May-05 Jul-05 Sep-05 Nov-05 Jan-06 Mar-06 May-06 Jul-06 Sep-06 Nov-06 Jan-07 Mar-07 May-07 Jul-07 Sep-07 Nov-07 Jan-08 Mar-08 May-08 Jul-08 Sept-08 Nov-08 Jan-09 Mar-09 May-09 2016 MFMER 3281918-11 A real-life experience continued Step 2 perform chart review Most O&P orders were incorrectly placed Patients were actually more likely to have Giardia or Cryptosporidium for which EIAs were recommended. Step 3 Talk to providers Most did not know that an algorithm was available for guiding orders Assessment The algorithm was not being used to guide O&P testing Plan Provide education 2016 MFMER 3281918-12 6

30 min Educational Video 60 min Educational Program Ongoing education To in-house physicians And residents O&P Educational Bulletin Giardia EIA Cryptosporidium EIA Mar 07 May-07 Jul-07 Sep-07 Nov-07 Jan-08 Mar-08 May-08 Jul-08 Sept-08 Nov-08 Jan-09 Mar-09 May-09 Jul-09 Sep-09 Nov-09 Jan-10 Mar-10 May-10 Jul-10 Sept-10 Nov-10 Jan-11 Mar-11 May-11 Jul-11 Sept-11 Nov-11 Jan-12 Mar-12 2016 MFMER 3281918-13 Conclusion Educational efforts are not enough to change ordering practices Why? Messages don t reach the right people Habit/patterns are hard to break Regular influx of new trainees and physicians 2016 MFMER 3281918-14 7

Can we turn this algorithm into a cascade? Cascade definition: a sequence of tests that are performed by the lab based on results of preceding tests. The cascade should be based on accepted guidelines and the components need to be transparent to providers. 2016 MFMER 3281918-15 2016 MFMER 3281918-16 8

Use of the Cascade Allows for efficient test ordering and significant cost savings Provider places an order for the algorithm Serum is drawn and sent to the laboratory ( send and hold ) The laboratory performs a cascade of tests based on the algorithm A la carte ordering is still available, but most clinicians choose to use the algorithm 2016 MFMER 3281918-17 Cost Comparison Comparison of Testing Options Celiac Disease Serology Cascade: Weighted Average Price $ 67.60 Total package if ordered a la carte $ 515.00 2010 Mayo Foundation for Medical Education and Research. All Rights Reserved. 2016 MFMER 3281918-18 9

Laboratory-Driven Algorithms Why this works: Only serum is required Initial limited laboratory testing drives additional testing Hence, the Laboratory has control over the algorithm rather than the Clinician 2016 MFMER 3281918-19 Can we turn this algorithm into a cascade? The most important question: can we get the information we need from our clinicians to guide testing? 2016 MFMER 3281918-20 10

Necessary information to determine if testing for intestinal parasites is even warranted 2016 MFMER 3281918-21 From a doctor s office: Stool specimen for Giardia antigen testing 2016 MFMER 3281918-22 11

Form for patients to complete: Have been in car for 1 hr 40 min 2016 MFMER 3281918-23 Challenges in implementing laboratorydriven cascades for intestinal parasites Initial AND sequential testing depends on clinical factors The laboratory has a difficult time getting this information Therefore, laboratory professionals have little control over testing Need to rely on the ordering clinician to use the algorithm 2016 MFMER 3281918-24 12

How do we get the ordering clinician to use the algorithm? 2016 MFMER 3281918-25 FINAL SOLUTION: Use the Ordering System 2016 MFMER 3281918-26 13

Use of the Test Ordering System Provides an opportunity to influence the provider at the point of order, usually before a specimen is obtained from the patient This is the best place to intervene! You can use the ordering system to: Provide education Collect information Make it easy to do the right thing and hard to do the wrong thing 2016 MFMER 3281918-27 Experience from our practice: We have noticed that tests at the top of the ordering screen get ordered more often than those at the bottom. Therefore, listing tests alphabetically may guide users to the first test they see (which might not be the correct one). A recommended approach: Put Common tests at the top of your order requisition or ordering screen. This is what we now do for all microbiology tests. 2016 MFMER 3281918-28 14

Stool (Micro) Next Cancel Guide Comments 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 Giardia Ag 80231 Cryptosporidium Ag 80335 Rotavirus Ag 8886 Additional procedures Helicobacter pylori Ag 81806 Nocardia Stain 87294 Vibrio Culture 89658 VRE PCR 84406 ***For infection control purposes 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 9216 ***Includes Fecal Leukocytes ***Recommend three collections, place new order for each 1 day 2 day 3 day Previous Order Screen Nothing to call these Out; no reference to algorithm Box around parasitic exam highlights this test Stool (Micro) Next Cancel Guide Comments 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 Testing for diarrhea (See Guide for Algorithm) Giardia Ag 80231 Cryptosporidium Ag 80335 Rotavirus Ag 8886 Additional procedures Helicobacter pylori Ag 81806 Nocardia Stain 87294 Vibrio Culture 89658 VRE PCR 84406 ***For infection control purposes 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 9216 (order only if appropriate exposure history) ***See Guide for Algorithm ***Recommend three collections, place new order for each 1 day 2 day 3 day New Order Screen We ve seen a sustained 20% decrease in orders compared to previous years since implementing these changes 15

Conclusions Changing the order that tests appear is relatively simple method to achieve a modest change in ordering patterns. Consider: Have you seen your ordering screens? Do you know how your tests appear to your providers? How are your tests currently listed? Are the tests simply listed alphabetically or in a way designed to guide use? Can anyone order any test? 2016 MFMER 3281918-31 Options for Ordering System Interventions Low Complexity Removing tests Changing test names Moderate Complexity Changing the lay-out of the order screens/forms Adding helper text High Complexity Set up IT rules (Dr. Donato s inpatient test rules) Require information to be entered at the time of ordering 2016 MFMER 3281918-32 16

EXAMPLE: Ordering urine bacterial culture on patients with indwelling Foley catheter A reason must be checked for this order to be placed or the physician can t place the order. 2016 MFMER 3281918-33 A twist to the Ova and Parasite story Implementation of multiplex PCR tests for bacteria, viruses and parasites 2016 MFMER 3281918-34 17

GI Pathogens Panel Simultaneously tests for 22 pathogens Multiplex PCR Testing is performed in 1 hour Includes testing for: Giardia duodenalis Cryptosporidium spp. Cyclospora cayetanensis Entamoeba histolytica Expensive! 2016 MFMER 3281918-35 Special considerations Not all patients with diarrhea need testing How to guide provider ordering? Need to avoid duplicate testing for the same pathogens E.g. culture, EIA, individual PCR 2016 MFMER 3281918-36 18

How we accomplished this Created an algorithm with our ID partners Embedded the algorithm into the ordering system, along with helper text Embedded the algorithm into AskMayoExpert, a widely-used clinician support tool Created IT rules to prevent duplicate testing Also use manual cancellation in the lab for duplicates Education there s still a role! 2016 MFMER 3281918-37 Laboratory Testing for Infectious Causes of Diarrhea Community-acquired diarrhea, <7 days duration WITHOUT warning signs or risk factors for severe disease 1,2 Community-acquired diarrhea 7 days duration OR Travel-related diarrhea OR Diarrhea with warning signs/risk factors for severe disease 1 Health care-associated diarrhea (onset after the 3 rd inpatient day) or patients with recent antibiotic use Testing not generally indicated If diarrhea persists: GIP / Gastrointestinal Pathogen Panel, PCR, Feces 3 Consider OAP / Parasitic Examination if traveler with >2 weeks of symptoms 4 NEGATIVE POSITIVE CDFRP / Clostridium difficile Toxin Molecular Detection, PCR, Feces NEGATIVE If diarrhea persists: No additional testing required unless clinical picture indicates If diarrhea persists: Consider: STL / Enteric Pathogens Culture, Stool GIAR / Giardia Antigen, Feces LCMSP / Microsporidia species, Molecular Detection, PCR (immunocompromised patients) OAP / Parasitic Examination 4 Use clinical judgment to guide the need for additional testing. 1 Warning signs and risk factors for severe disease include fever, bloody diarrhea, dysentery, severe abdominal pain, dehydration, hospitalization, and immunocompromised state. 2 During the summer, consider ordering STFRP / Shiga toxin, Molecular detection, PCR, Feces on children with diarrhea even if they don t have frankly bloody diarrhea, are not toxic-appearing, and diarrhea has been present <7 days. 3 GI Pathogen Panel tests for common bacterial, viral and parasitic cases of diarrhea 4 Submit 3 stool collected on separate days for maximum sensitivity Note: in outbreak scenarios with a known organism, consider ordering a specific test for that organism (CYCL / Cyclospora Stain, CRYPS / Cryptosporidium Antigen, Feces, GIAR / Giardia Antigen, Feces, bacterial stool culture) Mayo Foundation for Medical Education and Research (MFMER), All rights reserved. MAYO, Mayo Medical Laboratories and the triple-shield Mayo logo are trademarks and/or service marks of MFMER. 2016 MFMER 3281918-38 06/2015 19

Laboratory Testing for Infectious Causes of Diarrhea Community-acquired diarrhea, <7 days duration WITHOUT warning signs or risk factors for severe diseases 1,2 Community-acquired diarrhea, <7 days duration WITHOUT warning signs or risk factors for severe disease 1,2 Testing not generally indicated 1 Warning signs and risk factors for severe disease include fever, bloody diarrhea, dysentery, severe abdominal pain, dehydration, hospitalization, and immunocompromised state. 2 During the summer, consider ordering STFRP / Shiga toxin, Molecular detection, PCR, Feces on children with diarrhea even if they don t have frankly bloody diarrhea, are not toxic-appearing, and diarrhea has been present <7 days. 2016 MFMER 3281918-39 Laboratory Testing for Infectious Causes of Diarrhea Community-acquired diarrhea, <7 days duration WITHOUT warning signs or risk factors for severe diseases 1,2 Community-acquired GIP diarrhea, / Gastrointestinal <7 days duration WITHOUT Pathogen warning Panel, signs or PCR, Feces 3 risk factors for severe Consider diseases OAP 1,2 / Parasitic If diarrhea persists: Examination if traveler with >2 weeks of symptoms 4 Testing not generally indicated 3 1 Warning GI Pathogen signs Panel and risk tests factors for common for severe bacterial, disease viral include and parasitic fever, bloody cases diarrhea, of dysentery, severe abdominal pain, 4 dehydration, Submit 3 stool hospitalization, collected on separate and immunocompromised days for maximum state. sensitivity 2 During the summer, consider ordering STFRP / Shiga toxin, Molecular detection, PCR, Feces on children with diarrhea even if they don t have frankly bloody diarrhea, are not toxic-appearing, and diarrhea has been present <7 days. 2016 MFMER 3281918-40 20

Laboratory Testing for Infectious Causes of Diarrhea Community-acquired diarrhea, <7 days duration WITHOUT warning signs or risk factors for severe diseases 1,2 Community-acquired diarrhea 7 days duration OR Travel-related diarrhea OR Diarrhea with warning signs/risk factors for severe disease 1 Health care-associated diarrhea (onset after the 3 rd inpatient day) or patients with recent antibiotic use Testing not generally indicated If diarrhea persists: GIP / Gastrointestinal Pathogen Panel, PCR, Feces 3 Consider OAP / Parasitic Examination if traveler with >2 weeks of symptoms 4 NEGATIVE POSITIVE CDFRP / Clostridium difficile Toxin Molecular Detection, PCR, Feces NEGATIVE If diarrhea persists: No additional testing required unless clinical picture indicates If diarrhea persists: Consider: STL / Enteric Pathogens Culture, Stool GIAR / Giardia Antigen, Feces LCMSP / Microsporidia species, Molecular Detection, PCR (immunocompromised patients) OAP / Parasitic Examination 4 Use clinical judgment to guide the need for additional testing. 1 Warning signs and risk factors for severe disease include fever, bloody diarrhea, dysentery, severe abdominal pain, dehydration, hospitalization, and immunocompromised state. 2 During the summer, consider ordering STFRP / Shiga toxin, Molecular detection, PCR, Feces on children with diarrhea even if they don t have frankly bloody diarrhea, are not toxic-appearing, and diarrhea has been present <7 days. 3 GI Pathogen Panel tests for common bacterial, viral and parasitic cases of diarrhea 4 Submit 3 stool collected on separate days for maximum sensitivity Note: in outbreak scenarios with a known organism, consider ordering a specific test for that organism (CYCL / Cyclospora Stain, CRYPS / Cryptosporidium Antigen, Feces, GIAR / Giardia Antigen, Feces, bacterial stool culture) Mayo Foundation for Medical Education and Research (MFMER), All rights reserved. MAYO, Mayo Medical Laboratories and the triple-shield Mayo logo are trademarks and/or service marks of MFMER. 2016 MFMER 3281918-41 06/2015 Laboratory Testing for Infectious Causes of Diarrhea Community-acquired diarrhea 7 days duration OR Travel-related diarrhea OR Diarrhea with warning signs/risk factors for severe disease 1 Community-acquired diarrhea 7 days duration OR Travel-related diarrhea OR Diarrhea with warning signs/risk factors for severe disease 1 GIP / Gastrointestinal Pathogen Panel, PCR, Feces 3 Consider OAP / Parasitic Examination if traveler with >2 weeks of symptoms 4 1 Warning signs and risk factors for severe disease include fever, bloody diarrhea, dysentery, severe abdominal pain, dehydration, hospitalization, and immunocompromised state. 3 GI Pathogen Panel tests for common bacterial, viral and parasitic cases of diarrhea 4 Submit 3 stool collected on separate days for maximum sensitivity 2016 MFMER 3281918-42 21

Laboratory Testing for Infectious Causes of Diarrhea Community-acquired diarrhea 7 days duration OR Travel-related diarrhea OR Diarrhea with warning signs/risk factors for severe disease 1 Community-acquired diarrhea 7 days duration OR NEGATIVE POSITIVE Travel-related diarrhea OR If diarrhea persists: Diarrhea with warning signs/risk factors for severe disease 1 No additional testing required unless clinical picture indicates Consider: STL / Enteric Pathogens Culture, Stool GIAR / Giardia Antigen, Feces LCMSP >2 / weeks Microsporidia of symptoms species, Molecular 4 Detection, PCR (immunocompromised patients) OAP / Parasitic Examination 4 GIP / Gastrointestinal Pathogen Panel, PCR, Feces 3 Consider OAP / Parasitic Examination if traveler with 3 GI Pathogen Panel tests for common bacterial, viral and parasitic cases of diarrhea 4 Submit 3 stool collected on separate days for maximum sensitivity 2016 MFMER 3281918-43 Laboratory Testing for Infectious Causes of Diarrhea Community-acquired diarrhea, <7 days duration WITHOUT warning signs or risk factors for severe diseases 1,2 Community-acquired diarrhea 7 days duration OR Travel-related diarrhea OR Diarrhea with warning signs/risk factors for severe disease 1 Health care-associated diarrhea (onset after the 3 rd inpatient day) or patients with recent antibiotic use Testing not generally indicated If diarrhea persists: GIP / Gastrointestinal Pathogen Panel, PCR, Feces 3 Consider OAP / Parasitic Examination if traveler with >2 weeks of symptoms 4 NEGATIVE POSITIVE CDFRP / Clostridium difficile Toxin Molecular Detection, PCR, Feces NEGATIVE If diarrhea persists: No additional testing required unless clinical picture indicates If diarrhea persists: Consider: STL / Enteric Pathogens Culture, Stool GIAR / Giardia Antigen, Feces LCMSP / Microsporidia species, Molecular Detection, PCR (immunocompromised patients) OAP / Parasitic Examination 4 Use clinical judgment to guide the need for additional testing. 1 Warning signs and risk factors for severe disease include fever, bloody diarrhea, dysentery, severe abdominal pain, dehydration, hospitalization, and immunocompromised state. 2 During the summer, consider ordering STFRP / Shiga toxin, Molecular detection, PCR, Feces on children with diarrhea even if they don t have frankly bloody diarrhea, are not toxic-appearing, and diarrhea has been present <7 days. 3 GI Pathogen Panel tests for common bacterial, viral and parasitic cases of diarrhea 4 Submit 3 stool collected on separate days for maximum sensitivity Note: in outbreak scenarios with a known organism, consider ordering a specific test for that organism (CYCL / Cyclospora Stain, CRYPS / Cryptosporidium Antigen, Feces, GIAR / Giardia Antigen, Feces, bacterial stool culture) Mayo Foundation for Medical Education and Research (MFMER), All rights reserved. MAYO, Mayo Medical Laboratories and the triple-shield Mayo logo are trademarks and/or service marks of MFMER. 2016 MFMER 3281918-44 06/2015 22

Laboratory Testing for Infectious Causes of Diarrhea Health care-associated diarrhea (onset after the 3 rd inpatient day) or patients with recent antibiotic use Health care-associated diarrhea (onset after the 3 rd inpatient day) or patients with recent antibiotic use CDFRP / Clostridium difficile Toxin Molecular Detection, PCR, Feces 2016 MFMER 3281918-45 Laboratory Testing for Infectious Causes of Diarrhea Health care-associated diarrhea (onset after the 3 rd inpatient day) or patients with recent antibiotic use Health care-associated diarrhea (onset POSITIVE after the 3 rd NEGATIVE inpatient day) or patients with recent antibiotic use No additional testing required unless clinical picture indicates If diarrhea persists: CDFRP / Clostridium difficile Toxin Molecular Detection, PCR, Feces Use clinical judgment to guide the need for additional testing. 2016 MFMER 3281918-46 23

Laboratory Testing for Infectious Causes of Diarrhea Community-acquired diarrhea, <7 days duration WITHOUT warning signs or risk factors for severe diseases 1,2 Community-acquired diarrhea 7 days duration OR Travel-related diarrhea OR Diarrhea with warning signs/risk factors for severe disease 1 Health care-associated diarrhea (onset after the 3 rd inpatient day) or patients with recent antibiotic use Note: in outbreak scenarios with a known organism, Testing not generally indicated GIP / Gastrointestinal Pathogen Panel, PCR, Feces consider ordering a specific test for that organism 3 CDFRP / Clostridium difficile Toxin Consider OAP / Parasitic Examination if traveler with Molecular Detection, PCR, Feces >2 weeks of symptoms If diarrhea persists: (CYCL / Cyclospora Stain, 4 CRYPS / Cryptosporidium NEGATIVE POSITIVE NEGATIVE Antigen, Feces, GIAR / Giardia Antigen, Feces, If diarrhea persists: No additional testing required If diarrhea persists: unless clinical picture indicates bacterial stool culture) Consider: STL / Enteric Pathogens Culture, Stool GIAR / Giardia Antigen, Feces LCMSP / Microsporidia species, Molecular Detection, PCR (immunocompromised patients) OAP / Parasitic Examination 4 Use clinical judgment to guide the need for additional testing. 1 Warning signs and risk factors for severe disease include fever, bloody diarrhea, dysentery, severe abdominal pain, dehydration, hospitalization, and immunocompromised state. 2 During the summer, consider ordering STFRP / Shiga toxin, Molecular detection, PCR, Feces on children with diarrhea even if they don t have frankly bloody diarrhea, are not toxic-appearing, and diarrhea has been present <7 days. 3 GI Pathogen Panel tests for common bacterial, viral and parasitic cases of diarrhea 4 Submit 3 stool collected on separate days for maximum sensitivity Note: in outbreak scenarios with a known organism, consider ordering a specific test for that organism (CYCL / Cyclospora Stain, CRYPS / Cryptosporidium Antigen, Feces, GIAR / Giardia Antigen, Feces, bacterial stool culture) Mayo Foundation for Medical Education and Research (MFMER), All rights reserved. MAYO, Mayo Medical Laboratories and the triple-shield Mayo logo are trademarks and/or service marks of MFMER. 2016 MFMER 3281918-47 06/2015 Test volumes since implementation GI Panel implemented on October 12, 2015 Stopped flipping testing for the following EIAs at the end of March Tests performed 800 700 600 500 400 300 200 100 0 Antigen Volumes Use your DATA! CRYPS GIAR ROTA 2016 MFMER 3281918-48 24

Additional Approaches (NOT STOOL!) 2016 MFMER 3281918-49 Use Residents and Fellows to control use of expensive molecular multiplex platforms Multiplex Respiratory PCR panel: Lab staff first confirm the medical service that ordered the test is one of the approved services Providers who are NOT on the approved list will receive a call from the Clinical Microbiology fellow Then a discussion about testing ensues, based on a script that we created 2016 MFMER 3281918-50 25

Script for ordering intervention The Clinical Microbiology lab received a nasopharyngeal swab collected from your patient, <patient name>, that included an order for the Multiplex Respiratory Pathogen PCR Panel. I just wanted to provide some information before we proceed with testing. First, I wanted to make sure you were aware that this test is very expensive and also tests for a number of viral pathogens for which there is no treatment available. Can you tell me a little bit about the patient s clinical presentation so that we can determine whether this is the right test? Based on the patient s clinical presentation, there may be some molecular alternative tests that may be more appropriate and cost effective (e.g. Influenza A/B PCR, RSV PCR) 2016 MFMER 3281918-51 Whatever approaches you use, be sure to capture your data Share data with lab and institutional leadership and attach dollar amounts (money saved, potential for savings) This is an excellent approach for getting the support you need to start and/or continue utilization efforts Gather pre- and post-intervention data You may find out that your intervention isn t working (time to try something new) Share ordering data with your clinicians This can be very powerful for identifying outliers clinicians who order far more tests than the others and getting them to change their practices 2016 MFMER 3281918-52 26

Summary There are many different approaches for tackling test utilization issues some with more impact than others. It is important to identify and partner with clinicianchampions Create and implement algorithms based on data and best practice The test ordering system can be a powerful tool to guide test usage. Don t aim for perfection any progress is good! Monitor your results and share successes with leadership 2016 MFMER 3281918-53 Thank you! 2016 MFMER 3281918-54 27

Test Utilization Strategies in Anatomic Pathology Joaquin J. Garcia, MD Vice Chair of Laboratories, Anatomic Pathology Mayo Clinic Rochester 2016 MFMER 3281918-55 Disclosures Relevant financial relationship(s) with industry: None. 2016 MFMER 3281918-56 28

Laboratory Medicine & Pathology Cytogenetics Microbiology Biochemistry Anatomic Pathology Transfusion Hematopathology Molecular Genetics 2016 MFMER 3281918-57 Pathology Anatomic Pathology 2016 MFMER 3281918-58 29

Laboratory Medicine: Chain of Events Laboratory Requisition Interpretation 2016 MFMER 3281918-59 Laboratory Medicine: Chain of Command Clinician Pathologist 2016 MFMER 3281918-60 30

Anatomic Pathology: Chain of Events Laboratory Laboratory Requisition Laboratory Interpretation 2016 MFMER 3281918-61 Anatomic Pathology: Chain of Command Clinician Trainee Technician Pathologist 2016 MFMER 3281918-62 31

Anatomic Pathology: Chain of Command 2016 MFMER 3281918-63 Anatomic Pathology: Behavior Modifiers Experience Training Preference Confusion Fear 2016 MFMER 3281918-64 32

Tissue Screening Tissue Submission Immunohistochemistry Education 2016 MFMER 3281918-65 Education 5% 2016 MFMER 3281918-66 33

Education 16,000 Slides 2016 MFMER 3281918-67 Education 4,000 Slides 2016 MFMER 3281918-68 34

Immunohistochemistry 2016 MFMER 3281918-69 Immunohistochemistry 300,000 Slides 2016 MFMER 3281918-70 35

Immunohistochemistry 100,000 Slides 2016 MFMER 3281918-71 Tissue Submission 2016 MFMER 3281918-72 36

Surgical Margin Assessment Tissue Submission 2016 MFMER 3281918-73 2016 MFMER 3281918-74 37

2016 MFMER 3281918-75 2016 MFMER 3281918-76 38

2016 MFMER 3281918-77 2016 MFMER 3281918-78 39

2016 MFMER 3281918-79 Tangential Method Perpendicular Method 2016 MFMER 3281918-80 40

2016 MFMER 3281918-81 Tangential Method Perpendicular Method 2016 MFMER 3281918-82 41

2016 MFMER 3281918-83 513 BCS 18 mos 414 Margin Assess 259 Positive Margin 2016 MFMER 3281918-84 42

Perpendicular Tangential 2016 MFMER 3281918-85 Surgical Margin Assessment Tissue Submission 3-fold Slide Volume Decrease 2016 MFMER 3281918-86 43

Tissue Screening 2016 MFMER 3281918-87 Genetic Testing Approval Process Tissue Screening 2016 MFMER 3281918-88 44

Cytogenetics Microbiology Biochemistry Anatomic Pathology Transfusion Hematopathology Molecular Genetics 2016 MFMER 3281918-89 Cytogenetics Microbiology Anatomic Pathology Hematopathology Molecular Genetics 2016 MFMER 3281918-90 45

H&E Mucicarmine p63 2016 MFMER 3281918-91 H&E Mucicarmine p63 2016 MFMER 3281918-92 46

H&E p63 FISH 2016 MFMER 3281918-93 Cytogenetics Anatomic Pathology Molecular Genetics 2016 MFMER 3281918-94 47

100 Cases/Day 5 Cancelled 5 Modified Tissue Screening 2016 MFMER 3281918-95 Tissue Screening Tissue Submission Immunohistochemistry Education 2016 MFMER 3281918-96 48

Question Answer Discuss 2016 MFMER 3281918-97 49