Effective, innovative strategies are revealed
By Michael Samoszuk, MD
For the better part of the last decade, we have been hearing a lot about the advancements in personalized medicine. Boiled down, this ultimately means ensuring the right treatment is given to the right patient at the right time. More recently, attention is being specifically focused on getting the right diagnostic test performed on the right patient at the right time. This growing attention is due, in part, to the realization that the $60 billion-$70 billion cost of clinical and anatomic laboratory tests - which comprises about four percent of the total U.S. healthcare costs - is predicted to double within the next five years or less.
The Increased Cost of Testing
Many elements contribute to this increased cost of testing. Explosive advances in molecular biology have led to a ballooning interest in esoteric molecular and genetic testing, sometimes without adequate understanding of the technical and other limitations of such tests. Unlike earlier generations of clinical laboratory tests that generally cost significantly less than $100, the newer, more sophisticated tests often sport price tags in excess of $1,000 each and sometimes much more. Because of the complexity of these newer tests, clinicians are sometimes not even fully aware of when they should be ordered or how the results should be interpreted, leading to unnecessary inflation of costs for the lab.
Additionally, patients are now empowered by knowledge acquired from the internet and other sources that were not available in the past. Patients are now making their own diagnostic decisions based on their own research and are demanding certain tests, regardless of whether they may be appropriate. An example of this is the burgeoning interest in "recreational genomics," or the desire to know one's entire DNA sequence. While this information may be of value to some patients, there is still considerable controversy about the clinical utility of such testing, and the FDA has recently raised some additional concerns about how such tests are being marketed and interpreted in the U.S.
The Current State
Predictably, the inflation of test orders and the resulting costs have led to widespread attempts to control or optimize physician utilization of lab services in hopes of returning to the days when laboratories functioned as revenue centers rather than as cost centers. Considering that about 70 percent of clinical decisions and treatment options rely on diagnostic testing, streamlining the utilization of lab services is likely to impact the entire hospital.
At diverse institutions throughout the country, various strategies to optimize physician utilization of lab services have been implemented with varying degrees of success.
One common element of these strategies is the deployment of tiered formularies for lab tests, developed jointly by clinicians and laboratory medicine specialists. Typically, such formularies stratify tests into various tiers. One tier, for example, is reserved for routine tests that are generally inexpensive, well-understood and easily performed. Usually, there are few to no restrictions on physicians ordering such tests. Other tests, generally of a more sophisticated nature, either require a clinical justification before they will be performed (tier two) or can be ordered only by certain qualified specialists (tier three). The tests in tier three can include highly restricted tests such as the multi-parameter work-up of lymphomas and leukemias.
Another successful approach to optimize test utilization is to combine electronic-based barriers to ordering certain tests on computerized physician order entry (CPOE) with frequent face-to-face interactions with physicians. The lab ordering system can be used to reduce the frequency of duplicate orders for send-out and in-house testing. Computerized testing algorithms and other creative uses of information technology may also be helpful to avoid unnecessary patient testing. Generally, the operative principal here is to make it progressively more difficult for the physician to order an inappropriate, duplicate or expensive test. Such approaches obviously require the buy-in of the physicians who will be ordering the tests, and they need to understand and agree with the approach. This always requires face-to-face discussions between all of the affected physicians - clinicians, specialists and pathologists.
Straight to the Source
To be successful, each of these approaches will ultimately require working with and educating the clinicians who order the lab tests. Ideally, the laboratory staff should feel empowered to share their knowledge of the diagnostic testing process with the ordering physicians while keeping the varying needs of the patients in mind. This requires frequent communication, mutual respect and an objective view of available evidence. The use of evidence and data reduces the possibility of disagreement and helps to make the discussion more collegial, productive and objective.
In the past, such educational efforts have primarily been the domain of in-house pathologists and other specialists in laboratory medicine. There is, however, another valuable resource that is frequently overlooked - the in vitro diagnostics (IVD) industry itself. The companies that manufacture and distribute IVD are generally the most knowledgeable sources of information about how a test works, when it should be ordered and how the test results should be interpreted. Many IVD companies also maintain medical and scientific affairs teams independent of their sales and marketing functions, which can help doctors to understand when and how to order certain lab tests. Such teams have experts who are available to speak at grand rounds and at other physician conferences.
In the end, optimizing physician utilization of lab tests is all about a partnership between the doctors who order the tests, the laboratories that perform the tests and the IVD companies that provide the tests. A successful partnership will drive evidence-based test utilization that ensures that the right patient gets the right test at the right time.
Dr. Samoszuk is chief medical officer, Beckman Coulter Diagnostics.
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