The ever-changing landscape of healthcare delivery has driven laboratorians to bring a value-over-volume mindset to laboratory medicine. Laboratory stewardship refers to systems to ensure the proper ordering, retrieving, and interpreting of laboratory tests. It also encompasses fair payment for labs and fair financial treatment of patients.
Those faced with the daunting mission of overseeing a lab stewardship program look to colleagues in pharmacy, infectious diseases, and radiology for guidance. Successful hospitals have pharmacy formularies, antibiotic stewardship programs, and imaging guidance programs, all of which can lead to the false assumption that laboratory stewardship should easily follow suit.
Our experience has proven otherwise due to pervasive misconceptions about laboratory costs, test indications, and order frequency. We were only able to set the foundation for a successful laboratory stewardship program by engaging administrative, technologic, and physician champions at various points in our program’s evolution.
Administrative Champions: The C-Suite
A sure way to the heart of the executive-level C-suite is through improved financials. This can be a challenge for lab leaders since laboratory testing comprises merely 2.5% of direct healthcare costs, and the downstream effect of inappropriate utilization is often difficult to measure.
We garnered support of top leaders by accumulating small wins and objectively showcasing their cumulative effect. One example involves reducing inpatient duplicate testing. This is a direct cost avoidance that we hardwired into computerized provider order entry (CPOE). The savings are concrete, easy to monitor, and grow continuously. In our institution we demonstrated an average test avoidance of 1,400 per month, which translated into $21,000 in monthly institutional cost avoidance. This raised some eyebrows.
Around the same time, our infection control department was struggling with an increase in catheter associated urinary tract infections (CAUTI), a publicly reported parameter that affects Centers for Medicare and Medicaid Services quality ratings and subsequent reimbursement from government payors. We aligned our lab utilization committee with infection control goals for CAUTI by optimizing urine culture orders via a reflex testing algorithm.
These are just two examples of how a laboratory can align with an institutional mission of value-based care and mitigate some of the effects of capitated payments. Collaborations like this helped us gain administrative champions who now regard our lab as a proactive ally in optimizing our health system’s financial fitness.
Technologic Champions: IT Resources
Information technology (IT) cooperation is a requirement for stewardship success because 87% of office-based physicians use an electronic health record (EHR) for test ordering and retrieval. Unfortunately, limited IT resources are a common and formidable obstacle in implementing a lab stewardship program.
Our approach was to take advantage of the lab’s and IT’s shared love of data, which we used to symbiotic advantage. We showcased this in our blood utilization program. The transfusion medicine team paired with a core group of IT analysts to extract complete blood count and coagulation data from the EHR to provide decision support at the point of order.
Not only did we demonstrate cost savings averaging $63,000 per month, but we also established a strong level of trust and shared accomplishment with our IT colleagues as they realized how their services actively improve patient care by reducing unnecessary transfusions. We are now able to extract monthly utilization reports that allow us to target individual providers and services in need of education and other interventions. This has set the stage for strong lab and IT integration on future data capture projects involving population health, order set optimization, and provider efficiency.
Physician Champions: Collaboration and Engagement
When some physicians hear the term laboratory stewardship, they fear loss of autonomy and onerous restrictions that save money at the expense of diagnostic accuracy. We experienced this throughout our campaign to reduce non-diagnostic peripheral blood flow cytometry.
Our pathologists noticed that specimens were saturating the flow cytometry lab, delaying emergent cases, and providing a false sense of “no disease” while also increasing patients’ laboratory charges. We discussed this with a core group of oncologists with whom we had already established a foundation of trust via case collaboration. We reinforced our patient-centered focus via a retrospective review of more than 200 cases that highlighted flow cytometry results that were either misleading or not diagnostic.
The data were compelling enough to convince the oncologists to ally with hematopathology in establishing a series of evidence-based criteria for peripheral blood flow cytometry. The first rollout of this initiative involved an educational intervention. Predictably, this had little effect since inappropriate utilization is not solely due to lack of knowledge, but rather is often driven by a need for provider efficiency, patient convenience, or fear of litigation.
We tackled these concerns in two ways. First, at the time of order cancelation we offered alternative diagnostic testing such as peripheral smear review or targeted molecular studies (i.e. when a myeloproliferative disorder was a concern). Second, we hardwired the flow cytometry criteria into CPOE so that it requires acknowledgement at the point of order and prompts clinicians to state a diagnostic concern if criteria are not met. The goal is to encourage physicians to consider the capabilities of the test and discuss this with their patients prior to phlebotomy.
Last year we canceled more than 300 flow cytometry orders with no deleterious effects on patient care. However, our task remains as we hire new physicians and form partnerships with established hospital systems that use our laboratory services. It is impossible to please everyone, so we continue to have uncomfortable conversations explaining how interventions that inconvenience one provider enhance the sustainability of the system in which we all work. Lab leaders could not do this without the oncologists who support our efforts in their systemwide departmental meetings and in our utilization committee.
Most importantly, our oncology champions educated laboratorians to be empathetic toward a physician who cannot always focus on the “good of the system” when faced with a unique patient scenario.
Implementing a laboratory stewardship program is very challenging. Developing champions in administration, IT, and among our physician colleagues is foundational to success and has benefits far beyond the laboratory stewardship program.
Elise Occhipinti, MD, is the laboratory medicine director at Ochsner Medical Center in New Orleans. Email: [email protected]
CLN's Laboratory Stewardship Focus is supported by Seattle Children's Patient-Centered Laboratory Utilization Guidance Services