LD3

CRI and COLA do not endorse, directly or indirectly, the presentations given at this conference or the products or services provided by the exhibiting vendors. Presentations are intended to be free of bias. The use of any particular product is for demonstration purposes only, and does not imply an endorsement of the product by the presenter or the sponsors of the symposium. © 2017 CRI

Practical Utilization

James Hernandez, MD Pathologist, May Clinic

Phoenix, AZ

Verlin Janzen, MD, FAAFP Family Physician & Laboratory Director

Hutchinson Clinic, Hutchinson, KS

John Daly, MD COLA Chief Medical Officer

DESCRIPTION:

This session provides an overview of tools that can be used to effectively order laboratory tests and discussion of those tools you should be requesting be made available to optimize laboratory test ordering. OBJECTIVES: At the end of the session, participants will be able to:

Understand the need to determine where tests are most efficiently performed i.e. POS vs. Reference Laboratory

Provide practitioners with knowledge of those tools which are available to assist them in ordering the >4000 analytes available

Emphasize the necessity of a robust IT laboratory system to incorporate the laboratory utilization tools

Provide information on effect of improper laboratory test utilization

Friday April 7, 2017

1

1

James S Hernandez, MD Pathologist - Mayo Clinic

Phoenix, AZ

Verlin K Janzen, MD, FAAFP Family Physician & Laboratory Director

Hutchinson, KS

John Daly, MD COLA Chief Medical Officer

“..ensuring adequate utilization of needed tests in some patients and discouraging superfluous tests in other patients” (1)

Superfluous Too frequent

Routine anything

Wrong test – wrong reason

Any test that won’t change action

Underutilization(2) – less frequently studied, could be > overutilization

(1) Geoffrey Baird - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4083574/ (2) Zhi M - http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0078962#s5

3

2

A major component of US healthcare expenditure is an estimated $65 billion spent each year to perform more than 4.3 billion laboratory tests (1)

Estimated that $6.8 billion of medical care in the US involves unnecessary testing and procedures that do not improve patient care and may even harm the patient (2)

(1) Alexander B. Reducing healthcare costs through appropriate test utilization. Critical Values 2012; 5: 6-8 (2) Holladay EB. Test right. Critical Values 2012; 5: 3.

5

Transition to ‘Value-based” reimbursement

Value = Outcome / Cost

Diagnostics including lab become ‘cost’ center, not revenue generator

Down-stream costs of ‘false positives’

More not always better, can be harmful

Waste – duplicative testing

Evidence is building in some areas

6

3

“Where are the morning labs, Jim??”

“You want to change when we can order CBC’s??”

Because medical students and residents have very little authority or control, ordering lab tests are some of the only actions that have not been highly scrutinized in the past

Ordering lab tests is considered one of the “fun” activities of being a student or resident

Attending physicians often order many tests

Physicians who order few tests may be regarded as not as comprehensive/compulsive (not as smart)

4

OK in the past when there were 40 tests, now there are 4,000!

All doctors want to emulate “House” – a case of “vitamin deficiency”

5

Lab is still most often a revenue generator Lack of administration support

Why change – we’ve always done it this way

Tolerance of uncertainty – some have less

Takes time to do it right – change habits, think about if test is needed

Evidence still lacking for many tests

Malpractice concerns ‘if I’m not thorough’

Patients like thorough doctors – more is better If I don’t do it – their employer (or someone else) will –

I’ll look bad

11

Lack of knowledge

Lack of systems – reminders

Doctor’s favorites – need to review & update regularly

12

6

Lack of knowledge – laboratorian trained physicians tend to order less FPs – uncertain about what test (14.7% encounters) or

interpretation (8.3% encounters) (1)

Mid-level providers tend to order more

Lack of knowledge to explain ‘why not’

OCD – more Junior, less schooled Historical patterns from training/previous practice

Swimming against the tide is hard

Lack of time Easier to order what the patient wants rather than to

explain why not

Faster to do the test before I see the patient “just in case”

Duplicate testing – no system to detect

(1) J Am Board Fam Med 2014;27:268–274.)

13

Lack of evidence – what is right frequency, when should we stop

If I don’t … malpractice, patient satisfaction, someone else will

Shotgun testing – ordering all tests you think of rather than focusing initial testing

Not understanding/agreeing with risk of harm of false positive result Patient anxiety, lack of trust

Lab testing only 3-5% of healthcare spending, BUT downstream activities are $$$ (Rx, XR, surgery, hospital stays, etc)

14

7

Mainly problem with low volume – esoteric testing

Vitamin D

Celiac testing

Coag workups

Genetic testing – right test/panel

SHOULD I TEST

Genetic testing

Will the result change what I do?

15

16

8

72 involve lab testing Don’t obtain routine blood work (e.g., CBC, liver function

tests) other than a CEA level during surveillance for colorectal cancer

Don’t perform urinalysis, urine culture, blood culture or C. difficile testing unless patients have signs or symptoms of infection. Tests can be falsely positive leading to over diagnosis and overtreatment.

Don’t obtain a C. difficile toxin test to confirm “cure” if symptoms have resolved.

Don’t order multiple tests in the initial evaluation of a patient with suspected thyroid disease. Order thyroid-stimulating hormone (TSH), and if abnormal, follow up with additional evaluation or treatment depending on the findings.

http://www.choosingwisely.org/clinician-lists/

17

Don’t test for myoglobin or CK-MB in the diagnosis of acute myocardial infarction (AMI). Instead, use troponin I or T.

Don’t order an erythrocyte sedimentation rate (ESR) to look for inflammation in patients with undiagnosed conditions. Order a C-reactive protein (CRP) to detect acute phase inflammation.

Don’t obtain baseline laboratory studies in patients without significant systemic disease (ASA I or II) undergoing low-risk surgery – specifically complete blood count, basic or comprehensive metabolic panel, coagulation studies when blood loss (or fluid shifts) is/are expected to be minimal.

Don’t routinely screen for prostate cancer using a prostate-specific antigen (PSA) test or digital rectal exam.

http://www.choosingwisely.org/clinician-lists/

18

9

It’s change – we’ve always done it this way

Lab is still source of $$

Patients still want it – more is better

Low tolerance for uncertainty – pt & Dr

No evidence – no benchmarks/norm

Moves toward population health, value, and bundling of reimbursement is huge opportunity to start discussions with providers & patients OP hospital Medicare patients in many parts of the

country are bundled – move to bundling everywhere

19

Physician Champion – multi-specialty task force Outpatient – Office-based: VJ

Hospital – System-based: JH

Start small w/small group – expand as able

Evidence-based when available

Need for transparency

Tools http://www.mayomedicallaboratories.com/articles/reso

urces/algorithms.html

https://arupconsult.com/algorithms

Reduction in reimbursement – PAMA effect

20

10

21

22

11

23

How can my IT system help:

Order sets

Cost

Highlight given test which brings up more info on a test or orderable algorithm

Information @ provider’s fingertips

Ability to type in disease and get blurb on it

Algorithms for testing

24

12

Education

Data

Test order pattern comparison in group

Audit w/feedback

Cost-awareness

Financial incentives / risk sharing

Change test ordering procedures

Mandated protocols for test ordering

25

NT-proBNP

Total protein/albumin

CBC

Basic metabolic panel

Magnesium

Ionized calcium

Urinalysis

Complete metabolic panel

26

13

Fecal occult blood testing – use Hemoquant, Fecal Immunochemical Testing (FIT), or Cologuard (not quick, but accurate)

Tzanck smear – Polymerase chain reaction (PCR)

for Herpes

Sed rate – use CRP

AST - use ALT only

27

28

14

Tests ordered (no.)

Bleeding time Single-standard DNA Total T4 and T3 uptake

PCR tests for microbiology Psychiatric genomic tests for monitoring depression

Myoglobin CK-MB

Overuse or misuse

Evidence-based use

Time to adopt newer tests

29

Many sed rates

Most uses of CKMB in the USA

Most requests for O&P (ova and parasites)

Any low volume tests, especially if you are running more quality control samples than patient specimens

Large chemistry panels except for Medicare approved panels

Routine ordering of electrolytes in outpatients

Routine use of CBC with differential instead of CBC

Routine use of rapid strep test/throat culture if physician intends to treat the patient regardless of the result (and times when other tests

add no value)

Routine use of PT and PTT before surgery without supporting history

30

15

Post guidelines on test requisition

Computerized reminders regarding guidelines

Utilization report cards

Changes to manual requisition or CPOE

Utilization report cards with peer review

Higher level approval or consultation required

Utilization report cards with leadership review and incentives or penalties to encourage behavior

Forbidding tests

Gentle Guidance

Strong Guidance

Adapted with permission from Dr. Michael Astion, Seattle

Children’s Hospital

31

Guaiac testing is associated with high false-positive rates due to dietary and pharmaceutical interferences, and multiple stool collections are needed to achieve even moderate sensitivity.

Guaiac testing on specimens obtained from digital rectal exam by a provider are potentially misleading due to the risk of traumatic collection.

32

16

Rationale: EBM-Based on clinical evidence of superiority over guaiac tests, on patient convenience, and on multiple societal guidelines, we recommend switching to fecal immunochemical testing (FIT) or to Cologuard for those choosing to use stool testing for CRC screening.

Use instead: FIT and Cologuard have been shown to be more specific and sensitive than guaiac tests for CRC detection. FIT detects human hemoglobin and is less affected by interferences, eliminating the need for dietary and medication restrictions. Cologuard detects both human hemoglobin and cellular DNA from shed intestinal cells. Both FIT and Cologuard demonstrate superior clinical specificity over guaiac for CRC screening.

33

To evaluate occult GI bleeding in patients with anemia or iron deficiency, the “Stool HemoQuant MML” test (test code HQ) should be used.

Warning! Guaiac testing cannot reliably detect upper GI bleeding because globin and heme are degraded during intestinal transit. In contrast, HemoQuant detects occult bleeding equally well from all sources within the GI tract.

34

17

Occult Blood Test

Detection of GI bleeding Indication

Charge

FIT or Cologuard

Lower GI only Colorectal cancer

screening

$118 (FIT), up to $650 (Cologuard,

sent to Exact Sciences in WI)

HemoQuant Upper and lower GI Anemia, iron

deficiency, other

$129

35

Lab tests utilization is more mainstream now

Can help each other change – using evidence

More guidance available

Not easy

Value-based reimbursement will drive the discussion

36