When I first started in clinical pathology, I thought laboratory test utilization management (UM) was like the old cliché about the weather in that everyone talked about it, but no one did anything about it. Almost every admitted patient in my training institution got a daily complete blood count every morning, needed or not.
After a decade in laboratory medicine, though, and having taken a careful survey of the literature, laboratory medicine professionals, and the programs of national meetings, I have learned that I was very wrong. Clinical laboratory professionals have been fighting the UM battle since before I was born (I’m 41). However, the success of UM interventions has been variable, so a better cliché to describe UM might be “…easier said than done.”
The simplest approach to UM is pure education. “Dr. Smith, this is Dr. Baird from the lab. A 1,25-dihydroxy vitamin D test is not appropriate for healthy adults during a well visit.” Alas, while simplest and perhaps cheapest to accomplish, educational interventions alone are among the least successful UM interventions. Education is highly effective only when paired with structural changes to the test ordering process. The stronger UM interventions involve structural changes, specifically those that assist or direct the most appropriate test to be ordered. As a result of Bayes’ theorem, the information value of any test is always highest when the pre-test probability of the result is neither too small nor too large. Automated mechanisms for optimizing pre-test probability abound. An example is reflexive test algorithms, which use a cheap or simple screening test to pre-select appropriate patients for the costly or complex confirmatory test.
Another is point-of-order decision support, which relies on questionnaires or automated queries to gather pre-existing clinical or laboratory data that validate the pre-test probability. Less palatable to the ordering provider community is the dreaded pop-up—a small window alert built into a computerized order entry system that either discourages or redirects orders when specific criteria are met. While pop-ups are almost universally derided as being abrasive to the user experience, one should remember that the entire purpose of a pop-up is to abrade those in need of abrasion!
An additional UM approach gaining strength in recent years is the provider report card. Distributed with or without supervisory review, the report card provides longitudinal, retrospective data to ordering providers about their individual ordering patterns, ideally with comparison to group behavior or some established norm. One example is a monthly report issued to outpatient providers that shows how many routine laboratory tests they ordered per well visit. Another, recently implemented at my own institution, is a report of routine morning labs utilization broken down by inpatient housestaff team.
As one might expect, and indeed in line with what has been reported in the literature, report cards are far more successful at directing changes in utilization when paired with education, in the form of periodic group review. The downside to report cards is that the recipients often perceive them as criticism, even if that is not the intent. Since people don’t like being criticized, and the perceived criticism comes in the form of report cards delivered as emails that can be deleted and ignored, then most likely the emails and hence, report cards, will be deleted and ignored.
We have approached this dilemma at our institution by presenting our report cards in a blame-free environment as a tool for self-reflection and personal improvement, and they have been accepted as such. The housestaff have been told, however, that as they venture into the real world of clinical practice, their ordering practices likely will be scrutinized by quality monitors and payers, so they might as well get used to using such tools now.
The good news is, with national efforts like the Choosing Wisely campaign now underway, UM has left the confines of the clinical laboratory. While the duties of clinical laboratory professionals have never truly ended at the walls of the laboratory, the truth of this is now more apparent than ever. Addressing UM concerns is simply a matter of:
• reviewing your test menus for obsolete tests;
• creating reflexive test algorithms to ensure appropriate pre-test probabilities;
• crafting targeted pop-up messages;
• starting a laboratory test formulary committee;
• developing and delivering provider report cards; and
• pairing all of this with appropriate education.
Yes, I know, this is easier said than done, but to use another cliché: No pain, no gain!
Geoffrey Baird is director of clinical chemistry at Harborview Medical Center Laboratory, laboratory medical director at Northwest Hospital, and associate professor of laboratory medicine and adjunct associate professor of pathology at the University of Washington, Seattle. +Email: [email protected]