CEO SUMMARY: Efforts to help physicians improve their utilization of clinical lab tests paid big dividends at the Johns Hopkins Bayview Medical Center in Baltimore, Maryland. Working collaboratively, physicians and the clinical lab team identified overused or needless cardiac biomarker tests, then designed interventions to improve how physicians used these tests. The result was a 66% drop in the volume of cardiac biomarker tests and a $1.3 million yearly reduction in patient charges.
ON THE SUBJECT OF LABORATORY TEST UTILIZATION, physicians and pathologists in many cities around the nation find themselves united in a common goal of eliminating unnecessary test orders.
This is a welcome development for pathologists and clinical lab administrators who daily see the waste and potential patient harm that can occur when physicians order unnecessary or inappropriate tests for their patients.
Two primary factors motivate physicians today to become proactive about improving their utilization of lab tests. One is acceptance of integrated care (such as ACOs and medical homes) and the other is reimbursement in the form of bundled payment or capitated rates.
The benefits of collaboration between physicians and clinical laboratory professionals to improve the utilization of lab tests can be significant. At the 545-bed Johns Hopkins Bayview Medical Center in Baltimore, Maryland, such a collaboration tackled cardiac biomarker tests. The objective was to identify overused and needless cardiac biomarker tests. Interventions were implemented to ensure appropriate utilization of these tests.
The results were phenomenal. The clinic saw a 66% drop in the volume of cardiac biomarker tests, along with a reduction in patient charges of $1.3 million in one year. The physicians published their results June 28 in the Journal of General Internal Medicine.
“This study has broader implications for the healthcare system, as most hospitals continue to use this redundant way of testing patients with chest pain,” said Jeffrey C. Trost, M.D., Assistant Professor of Medicine and Director of the Cardiac Catheterization Laboratory and Co-Director of Interventional Cardiology at Johns Hopkins Bayview Medical Center. “Implementing these interventions could potentially save patients a significant amount of money,” he noted.
The intervention was the result of an effort Trost started in 2010 with Marc R. Larochelle, M.D., an internal medicine resident at Johns Hopkins Bayview Medical Center and others. Trost, Larochelle, and colleagues founded a group called Physicians for Responsible Ordering to identify wasteful inpatient diagnostic testing at the medical center.
“At the time, we believed that cardiac enzymes were ordered in far higher quantity and frequency than what the professional guidelines suggested,” recalled Trost. “After reviewing data on our test ordering, we recognized the opportunity to reduce inappropriate cardiac enzyme ordering.”
For years, cardiologists used the troponin test as an accurate way to determine if a patient with chest pain has had a heart attack or is about to have a heart attack. “Yet medical center physicians continued to order troponin testing as well as tests for creatine kinase and creatine kinase-MB (CK-MB),” observed Trost.
Trost knew about the work of Allan S. Jaffe, M.D., Chair of the Division of Clinical Core Laboratory Services in the Department of Laboratory Medicine and Pathology at Mayo Clinic. “Jaffe investigated the use of biomarkers to characterize the pathobiology of acute cardiovascular disease,” stated Trost. “He is the co-author of a special report published in 2008 in the journal Circulation that suggested that troponin testing should replace the CK and CK-MB tests.”
Seeking Guidance From Labs
“When we began this initiative, we sought advice from our lab director, Stefan Riedel, M.D., Ph.D.,” Trost said. Riedel is an Assistant Professor in the Department of Pathology, Division of Microbiology, and Director, Clinical Laboratories, at Johns Hopkins Bayview Medical Center.
“As clinicians, our perspective is patient care,” he stated. “Having the lab director’s perspective was helpful. He helped us understand the actual costs in the lab, how cardiac tests are run, throughput of such tests, and useful insights about the sensitivity and applicability of the different cardiac tests. As clinicians, we know little about these aspects of lab testing.
“In his paper, Jaffe gave compelling arguments why the troponin is a far superior test to the CK-MB,” he explained. “Jaffe recommended that hospitals should stop ordering it. In fact, Jaffe and his co-authors concluded the Circulation article by saying, ‘We’ve stopped ordering it and we think others should too.’
New CK-MB Guidlines
“That hit a nerve for me because patients here get both tests ordered every day!” noted Trost. “This was an opportunity for our institution to take a lead role in this area of clinical care. Thus, we crafted an intervention that could reduce—if not eliminate—cardiac testing with CK-MB.
“We also spotted another opportunity,” recalled Trost. “As we studied lab test utilization data, we noticed that physicians ordered the troponin test far more than the two to three times that are necessary to make the diagnosis.
“Our estimate was that, in a given setting, about 25% of our patients got many more troponin tests,” he stated. “Our physicians recognized that there was no clinical justification for this. Riedel concurred and advised us about the specific interventions the lab could offer our physicians.
“Ultimately, we decided to eliminate the CK-MB test from the default order sets,” comment Trost. “As part of this change, a soft stop was created in the CPOE for any physician who tried to order troponin more than three times in 24 hours.”
From August to October 2011, Trost and Larochelle introduced new guidelines into the computerized physician order entry (CPOE) system that is part of the hospital’s Meditech EHR. Education sessions with the internists and ER physicians took place to explain the change.
For patients suspected of having acute coronary syndrome, the guidelines suggest troponin testing alone and that the test be done no more than three times in 24 hours. “The CK and CK-MB tests were removed from the medical center’s standard order sets,” explained Trost. “If a physician attempts to order a troponin test within six hours of a previous troponin test, the system issues a warning.”
Over 12 months, physician use of the new guidelines increased from 57.1% to 95.5%. As this happened, there was a 66% drop in the number of tests ordered.
“Obviously there was the question of whether patients were harmed by this intervention,” he added. “That’s difficult to determine directly. We knew that the intervention did not have much of a risk of underuse because we continued to use the troponin test.
“We assessed this by looking at the diagnostic rate of patients with heart attacks or about to have a heart attack (that’s what the troponin test tells you),” Trost explained. “These patient diagnoses were listed under the umbrella of acute coronary syndrome.
“The diagnostic rate before the change in the cardiac laboratory test guidelines was compared to the rate during the intervention,” commented Trost. “There was no appreciable difference in patient outcomes. Had there been underuse of cardiac marker testing, the diagnostic rate would have gone down because our physicians were not utilizing cardiac biomarker testing as aggressively as they had in the past.
“Enormous challenges lie ahead to reduce costs and improve overall treatment. Changing the way we order lab tests is a great place to start,” concluded Trost. “For us, it boils down to the incentives for choosing wisely and the incentives for not choosing wisely.”
Today’s Financial Incentives in Healthcare Do Not Support Efforts to Eliminate Needless Lab Tests
MANY MORE PHYSICIANS would seek to eliminate redundancies in their utilization of clinical laboratory tests if the proper financial incentives were in place, stated Jeffrey C. Trost, M.D., an assistant professor of medicine at Johns Hopkins Bayview Medical Center in Baltimore, Maryland.
“Were you to ask why this protocol for improved utilization of troponin testing has not been more widely implemented, my answer would be that perverse financial disincentives discourage more appropriate use of these tests,” noted Trost. “A similar problem affects the Choosing Wisely campaign despite the fact that those recommendations were issued through the specialty societies.
“That’s why we created a group called Physicians for Responsible Ordering,” he continued. “At our institution, we are evaluating other lab tests and clinical procedures where we might intervene to ensure that lab test usage is more appropriate.”
Another organization concerned about the rising financial burden on patients is Costs of Care, a group of physicians, nurses, and other caregivers who seek to protect patients from financial harm. A recent article on the Costs of Care website addressed the issue of lab testing costs. Michael J. Misialek, M.D., a pathologist at Newton-Wellesley Hospital, which is part of Partners Healthcare in Boston, wrote about the role pathologists can and should play in protecting patients from financial harm.
“Each test ordered could result in harm and unnecessary expense to the patient,” explained Misialek. “We must do everything possible to minimize these occurrences and be more proactive to drive down the underused and overused tests, which leads to cost savings in medicine as a whole. Enormous challenges lie ahead to reduce costs and improve overall treatment; however, changing the way we order lab tests is a great place to start.”