Gurmukh Singh, MD, PhD, MBA. FCAP, CPE, FAAPL, Brandy Gunsolus, DCLS, MLS(ASCP)CM, Kellie A. Foss, FACHE, MBA, MT(ASCP)SH
It is generally accepted that 60 to 70 percent of clinical decisions are based on laboratory data. It has also been documented that there is an overuse of laboratory tests by 30 to 50 percent. Equally important has been the documentation that there is inappropriate use of laboratory tests in about 25 percent of instances.
A large number of strategies have been employed by various institutions to reduce laboratory utilization. The outcomes depend on the commitment of the personnel executing the program. Our emphasis has been on promoting appropriate utilization rather than curtailing use of lab tests per se. Here, we address the promotion of appropriate utilization of send-out tests. Tests sent out of a reference lab constitute one to percent of the test volume but usually account for about 10 percent of the lab costs.
The Doctor of Clinical Laboratory Science program
Augusta University Medical Center Laboratory is in the unique position of having trained and employed the country’s first Doctor of Clinical Laboratory Science (DCLS) graduate. She is now serving as the lab’s pathology utilization manager. The three existing programs for DCLS are at Rutgers, University of Texas Medical Branch (UTMB) at Galveston, and University of Kansas Medical Center. Dr. Brandy Gunsolus was the first graduate and her alma mater, Rutgers, will graduate two candidates this year, while five individuals have graduated from the UTMB program. The programs consist of two years of educational activities, either on-site or online and one year of residency training.
Reference laboratory test audit process
In collaboration with Augusta University Medical Center Laboratory’s administrative director, medical director, and a genetic counsellor, the DCLS (Dr. Gunsolus) formalized a process for audit of reference laboratory tests. There are three main components to this process: (a) Screening of reference lab test requests by technical personnel, (b) Identification of previously vetted specialty specific requests, and (c) Investigation of potential outliers by a combination of pathology residents, genetic counsellor, the DCLS, and a clinical pathologist if needed.
All tests that need to be sent out to reference laboratories are screened by technical personnel. Tests costing <$200 are automatically approved with exception of some commonly misordered tests, e.g. Vitamin K, HCV viral load, and HIV genotyping. A list of more expensive tests has been vetted in consultation with various specialists, e.g., autoantibody panels for neurologic disorders when ordered by a staff neurologist are automatically approved but must be reviewed if ordered by a resident or a non-neurologist. A list of tests for other specialties, e.g., rheumatology, hematology/oncology, pediatrics, and transplantation service, have also been identified for automatic approval. All genetic tests with the exception of Factor V Leiden and Prothrombin G20210A mutations are reviewed by a genetic counsellor who will often recommend alternative, more appropriate tests.
The above described screening and pre-work still leaves an average of five to 10 tests per day that require review. As the first step, these cases are referred to a pathology resident on clinical pathology rotation. The tests referred to pathology residents are limited to no more than three per day to allow time for detailed review of the patient’s medical record, communication with the requesting person, and review of relevant literature. Once the pathology residents have reached their daily limit, the DCLS reviews all remaining cases. The residents are supported by the DCLS and clinical pathologists. In all instances, the benefit of the doubt is resolved in favor of the request.
If it is determined that the course of treatment of a hospitalized patient would not be affected by an otherwise appropriate test request, for administrative reasons the test is postponed to the outpatient care setting. The denial and the reason for denial are communicated to the person ordering the test, and, as appropriate, alternative tests are recommended.
How the DCLS program has helped
The DCLS program has produced the following beneficial results:
- Due to hands-on involvement of the DCLS, including participation in patient rounds, clinical pathology is now recognized as the source of expertise for test selection and laboratory utilization at our medical center. This favorable change in the perception of clinical colleagues has been garnered, in no small part, by the dedication of the DCLS practitioner.
- Improvement in clinical pathology training of the residents has been an important fringe benefit of the program. There has been a statistically significant improvement in the resident in-service examination (RISE) results in clinical chemistry, above and beyond the general improvement in the residency training program.
- During the past fiscal year, the program resulted in a cost avoidance of greater than $1 million. A parallel effort by the DCLS for improving billing resulted in an increase of >$70,000 in revenue generation with clinical pathology having achieved the highest improvement in revenue enhancement next to radiology.
- The current DCLS candidate at Augusta University has examined the role for establishing hypercritical values and implemented laboratory driven activation of rapid response teams, when appropriate.