CEO SUMMARY: Delivering more value with lab tests requires going beyond simply working with physicians to improve test utilization by focusing on unnecessary or inappropriate tests. PeaceHealth Laboratories in Oregon successfully executed a two-step strategy to add value with its testing services. First, the lab combined a proprietary test with a new care protocol to improve patient care. Second, the lab staff went outside the lab to engage clinicians to develop new methods to improve patient outcomes.
BY CREATING AN UNUSUAL PROPRIETARY MULTI-ANALYTE LAB TEST, an Oregon laboratory delivered much greater value to office-based physicians, including a reduction in emergency room visits and improved patient compliance with physicians’ orders.
The lab’s two primary goals with this project were to help physicians: a) achieve better outcomes when treating inpatients and ambulatory patients with common chronic conditions; and, b) manage patients on pain medications or abusing drugs. Another goal was to help reduce emergency room visits.
Pathologists at PeaceHealth Laboratories in Springfield, Oregon, developed a test called PtProtect, a comprehensive urine drug test panel that detects more than 38 medications and other substances in a patient. They also developed a patient-management protocol for physician office staff to follow when treating chronic pain patients.
After successfully testing how the PtProtect UDT and the patient-management protocol worked in a physician clinic, the pathologists developed a second panel of tests to detect more than 200 common medications in patients’ plasma and urine. This test is called RxAdhere Medication Safety Panel.
“The RxAdhere test runs on a mass spectrometry analyzer and thus can produce the molecular signature of common medications present in a patient’s blood,” stated Ran Whitehead, the lab’s CEO and Chief Mission Officer.
“We don’t know of any other laboratory in the country that has developed a diagnostic panel that uses mass spec to detect more than 200 common medications used for treating common chronic conditions,” he commented.
Small Study, Big Results
Before the RxAdhere Medication Safety Panel went into development, the pathologists ran a proof-of-concept test for the PtProtect assay and patient-management protocol in a 16-physician primary care clinic with two locations.
The study was small, Whitehead acknowledged, but successful given that it drove down ER visits and increased compliance among patients participating in the protocol.
These two metrics are important to physician groups and health systems as they make the transition away from fee-for-service care and are reimbursed for value-based care.
Market Roll-Out of Test
Now that PHL has had success with the PtProtect protocol, the laboratory sales staff has introduced the RxAdhere test panel and the PtProtect protocol to other physician groups and hospitals in the three states PHL serves: Alaska, Oregon, and Washington.
“In this case study of the lab test and the PtProtect pain medication protocol, there was a 37% decrease in ER visits among patients who had been on long-term prescriptions for pain medications,” explained Whitehead. “There was also a decrease of 11% in our patient discrepancy rates.
“We record discrepancy rates as being the difference between what medications a physician believes the patient is taking and what’s actually onboard in the patient’s system,” he said. “That decrease in discrepancy rates means patients involved in this study had an increase in patient compliance with the prescription regimens those patients got from their physicians.
More Efficient Patient Visits
“We also recorded that these patients had more efficient visits with their physicians and the physicians’ staff,” he added. “This is important because office visits with chronic pain patients often take up more time than visits with most other patients. That causes stress in a busy physicians’ office, since staff members are tied up with patients beyond the normal time. Therefore, it is significant that our study recorded a decrease in staff stress as well.
“Now, the good news is our lab has this test and we know it works because it was evaluated in a clinic setting,” stated Whitehead. “That means we have data that can be used in discussions with providers as we introduce our assay and protocol to other physician clinics. But, as with anything in healthcare, adoption rates can be painfully slow.
“That is why the study we did with the 16-physician clinic is useful,” he added. “It required our lab team to work closely with physicians and other staff to develop a multi-step protocol that would identify patients who would be best suited to have this test, then guide the clinic staff on how to work with those patients over time.
“The program also involved getting certain patients to agree to medication agreements and then assessing the test results from those patients who were being treated under the PtProtect protocol,” noted Whitehead. “Staff following this protocol met with those patients to ensure that they continue to comply with their medication agreements.
Adding Valued Services
“Under the PtProtect protocol, staff do a risk assessment of those patients identified by physicians as being appropriate to participate in the program,” Whitehead explained. High-risk patients would be tested once every three months and low-risk patients would be tested every six months.
Building on its success with the development and implementation of its proprietary PtProtect test and protocol for managing patients taking pain medications or patients abusing drugs, PHL now is evaluating its RxAdhere Medication Safety Panel and the protocol that guides physicians using this test.
“As with PtProtect, RxAdhere is designed to facilitate detection of medication adherence and adverse drug events (ADEs) for medications used when treating patients with common chronic conditions,” explained Whitehead.
“Currently we are working with com- munity pharmacists and the medical executive committees in the various hospitals that we serve to determine how RxAdhere tests will be integrated into the inpatient and ambulatory continuum of care,” he commented. “At $250, the test is reasonably priced, but it’s not inexpensive either. Cost is one reason why a provider does not want to test everyone who walks in through the door.
Solving Similar Problems
“Both our PtProtect and RxAdhere programs solve similar problems that physicians and health systems have in treating patients,” stated Whitehead. “We think these added-value lab services will be well received.
“Currently we are working to develop RxAdhere protocols that are appropriate for use in hospital settings,” he observed. “That would include having order sets programmed into the electronic medical record system in hospitals.
“Use of RxAdhere test panel can reduce inpatient ADE’s, reduce extended hospital stays and expense through identifying common medications that are not in the medical record (such as antiepileptic, anticoagulants, antiplatelets, antihypertensives, antidepressants and antipsychotics) and through identifying non-adherence to outpatient medications,” Whitehead explained.
“Accurately identifying these outpatient medications at admission will improve medication reconciliation and help maintain patients on critical medications. It provides an accurate list of outpatient medications on discharge to help avoid ADEs in the ambulatory setting,” he added.
Peace Health Lab Working on Next Value-Added Service
BUILDING ON ITS SUCCESS WITH THE CREATION and implementation of its proprietary PtProtect test and protocol for managing patients taking pain medications or abusing drugs, Peace Health Laboratories is working to add more value with its pain management service.
It has developed a 200-analyte assay called the RxAdhere Medical Safety Panel. “RxAdhere is an expansion of our pain management program,” observed PHL President Ran Whitehead. “With RxAdhere, we will scan not only for narcotics and drugs of abuse, but for other medications that patients take for a wide variety of ailments.
“RxAdhere is designed to make it easy, fast, and accurate for physicians, hospitals, and health systems to do medication reconciliation among ambulatory patients and hospital inpatients,” commented Whitehead. “As with PtProtect, RxAdhere is designed to record discrepancy rates for all medications that a patient takes regularly.
“We believe RxAdhere will be useful because different doctors often prescribe different medications to patients,” said Whitehead. “But how would a physician determine which medications have been prescribed to his patient by other providers and which of those medications the patient is actually taking?
“If a patient takes medications that can cause an adverse drug event (ADE), physicians need to know that,” he said, adding, “Avoiding patient harm and unnecessary hospital readmissions is critical.”
Study of 300 ER Patients
“Part of the RxAdhere validation included testing more than 300 patients at ED arrival to compare outpatient medications detected by RxAdhere with the patient’s medication reconciliation record,” he said. “The data showed that 41% of these ER patients were non-adherent for at least one prescribed medication and 31% of outpatients used at least one medication not in their medical record.
“We also believe that use of the RxAdhere test could be useful on the outpatient side for improving outcomes for common chronic conditions by improving medication treatment decisions (such as by changing dosage or medications), and by reducing hospital admissions (for patients with congestive heart failure, as an example),” added Whitehead.
“One challenge to introducing a new lab assay and care protocol such as the PtProtect Pain Medication Monitoring Program is that any cost of more than a couple hundred bucks gets physicians nervous about widespread use,” said Whitehead. “Also, physicians here in the Pacific Northwest seem to be very conservative when it comes to the patient’s pocketbook.
“Therefore, our lab is working to introduce RxAdhere and the associated clinical care protocol in the right way with the right population and then demonstrate its value,” he emphasized. “Our expectation—backed by the first study—is that use of the RxAdhere test and the protocol will help hospitals and health system avoid significant downstream costs. This will change how they monitor patients with common chronic conditions and patients will be healthier and need less acute care.
University of Colorado Lab Has Multi-Analyte Drug Test
SINCE 2014, A COLORADO LAB has offered hospitals and physicians a test capable of detecting 112 compounds and more than 500 illicit and brand-name drugs.
CU Toxicology is a nonprofit lab that is part of a public-private partnership with the University of Colorado School of Medicine’s Department of Anesthesiology. Jeffrey Galinkin, MD, Chief Medical Officer of CU Toxicology, developed the test, which utilizes mass spectrometry. (See TDR, February 24, 2014.)
Kaiser Permanente Colorado in Denver uses this assay. “Using CU Toxicology’s multiplexed mass spec method, which is confirmatory testing, thus gives our ordering physicians a one-month drug history window, rather than only a week’s look, which is uniquely important with respect to managing these patients,” stated Michael Sheehan, PhD, the Technical Operations Manager for Kaiser’s central laboratory in Denver, in an interview with THE DARK REPORT.
“For example, if a hospital can prevent a readmission or ADE, that could be several thousand dollars of cost avoidance,” observed Whitehead. “As a result of an intervention that utilizes this lab test and protocol, we hope to begin documenting a number of avoided readmissions as a result of this intervention.
“We have already documented a reduction in inappropriate emergency department visits from patients using narcotics,” he added. “ED visits are expensive and health plans don’t always reimburse adequately for them.
“What’s more, ED staff use up a lot of time that could be dedicated to other patients,” continued Whitehead. “Early evidence shows patient outcomes are better and the savings can be substantial when the PtProtect test is used appropriately. Similar results should occur with the RxAdhere Medication Safety Panel.”
Pathologists and lab executives looking for ways to add value to their lab testing services should take note of the fact that the lab team at PHL identified clinical opportunities where the right lab test—combined with an appropriate care protocol—could document improvements in patient outcomes while also delivering cost reductions that were substantial.
Essentially, the team at Peace Health Laboratories looked outside their lab for this opportunity to add value with lab tests, then engaged referring physicians in ways that were a win-win for the patient, the physician, the health system, and the health insurer.
Contact Ran Whitehead at 541-349-8440 or RWhitehead@peacehealthlabs.org.