Ola H. ElgaddarMD, PhD, MBA, CPHQ, LSSGBLecturer of Chemical Pathology

Medical Research InstituteAlexandria University

ola.elgaddar@alexu.edu.eg

Laboratory Test Utilization

What about???

They order all the lab tests in the world!!

But here, You can’t “just” order evrything!!!

Laboratory Test utilizationA strategy for performing appropriatelaboratory and pathology testing with thegoal of providing high-quality, cost-effectivepatient care.

Are you financially or medically driven??

If the focus is solely on money, then that testutilization effort will have a short termsuccess.However if good medical practice is thefocus, then test utilization will have longevityand will likely be successful in our changinghealth care environment.

The Good, The Bad & The Ugly• A ‘Good’ test:

– Uses resources but provides information that is useful in patient management decisions

• A ‘Bad’ test:– Uses resources but fails to provide

information useful in patient management decisions

• The ‘Ugly’ test: – Uses resources and provides

information that is misleading or irrelevant

Considerations while addressing the utilization issue:

ØYou can’t provide every test as fast as what everybody wants!

ØOrdering test panels rather than ala carte’!!Ex: Liver functions, Kidney functions, Lipid profile,…..

Considerations while addressing the utilization issue:

ØRedundant tests:Urea & CreatinineALT & ASTTroponin & CK-MB

ØTests that are often ”said” together:PT & PTTCalcium, Phosphorus & Magnesium

Considerations while addressing the utilization issue:

ØPre-analytical concerns that might cause test repetition:Timing, container, labeling, transportation

Ø Appropriateness of the ordered test:Diagnostic performanceAffected by the patient’s conditionEx: Thyroid F. in an ICU patient

HbA1c in hemolytic anemia

Pre – test probability

An estimate of the probability of a disease before any test is ordered

How can it affect test ordering / utilization??

• Troponin ordered for a 15 years old boy complaining of heartburn!

Most probably, this is a wrong testselection due to the very low pre-testprobability that this boy is having acardiac event

So, Clinicians must be aware of thepre-test probability before orderingany test

Considerations while addressing the utilization issue:

ØImpact of the result on management: ex: Haptoglobin, Mumps Abs

Ø How fast do lab results change:Understanding how rapidly a given analyte may change is important to selecting how often it should be ordered

Considerations while addressing the utilization issue:

ØAcknowledge the gap between what clinicians know, and the depth of knowledge necessary to order lab tests.

Ø Patients’ pressure!

Test Utilization Management Tools

1. Meet the clinicians”Education” is the first tool, but if it was the only method being used then it will have a little lasting impact!

2. Laboratories as gate keepersØDetermine the needed testsØSome tests should be obsolete (ex: BT)ØCheck on frequently ordered tests,

especially for in-patients attended by morethan one physician

ØProvide individualized report cards to thephysicians, in a blame free environment,showing their individual ordering pattern

3. IT support systemØEntry pop-ups for repeated tests or for

recently ordered tests with normal results

ØOnline decision support tools

4. Laboratory guidelines and algorithmsØIT-driven:

When clinical data is entered, appropriatelab tests will be suggested

ØLab-driven:Clinicians order initial tests, and accordingto the result, lab doctors initiate a cascadeof further tests

4. Laboratory guidelines and algorithmsØPathologists-driven:

- For some low volume, high cost tests.- Ordered only by a pathologist or a geneticconsultant, after the reviewing the results ofall previously ordered tests

5. The Test Menu as Formulary- Several world class centers had set labformularies, just like pharmacy formulary.- No off-formulary test can be available- Test menu is divided into 3 “tires”, each one

is ordered on a certain clinician level.

We have always been proud of providinghigh-quality, cost-effective care with afocus of providing service to the patientand clinician

Our new laboratory paradigm demandsthat the clinical laboratory also provide:Utilization Management,Clinical Effectiveness, andData Integrationas part of their expected performance

Establishment and Implementation of anImprovement Plan using the Lean SixSigma Methodology to Minimize Variation inthe Ordered Lab Requests in the ChemicalPathology Department of the MedicalResearch Institute

Current project

OLA