CEO SUMMARY: Every laboratory recognizes it has the knowledge and expertise to become more of a consultative resource to its referring physicians. At 248-bed J.T. Mather Hospital in Port Jefferson, New York, the laboratory director took advantage of administration’s interest in improving laboratory test utilization by creating an enriched program of education and collaboration. The effort has paid off, as measured by changes in lab test ordering patterns for targeted assays.
EFFECTIVE UTILIZATION of laboratory tests is widely recognized as one path to improved healthcare outcomes. It also helps conserve resources for hospitals and laboratories alike.
But, as every laboratorian knows, it’s a tricky path to interact with physicians and help them do a better job of ordering the right test. Physicians frequently consider advice on lab test ordering to be an intrusion into their practice prerogatives.
That’s why recent improvements in lab test utilization at John T. Mather Hospital, in Port Jefferson, New York, are instructive in how hospital laboratories can successfully collaborate with referring physicians to utilize lab tests in ways that raise patient outcomes while saving money for the hospital.
Twin Trends Fuel Test Demand
“About two years ago, our hospital administrators recognized that regional growth and changing patient demographics were squeezing our resources,” stated Denise Uettwiller-Geiger, Ph.D., DLM(ASCP), Director of Laboratory Services at Mather Hospital. “Among other things, this led to a stated goal of improving how laboratory tests were ordered and how physicians responded to the results of these tests.
“This effort is particularly important because we do almost 2 million tests per year for this hospital, which is a 248-bed facility,” Uettwiller-Geiger explained. “Our primary service area is Suffolk County, an area of Long Island undergoing rapid growth. Currently, about 1.4 million residents live in our service area and this number increased by 100,000 since the last census.
“Such rapid population growth means that the demand for lab tests is growing at a high rate,” she said. “At the same time, the hospital has experienced a shift in patient demographics to an older, frailer population that requires more resources from the healthcare system. Both factors were driving up test volumes.
“We know that the lab plays a critical role in care and patient safety by provid- ing timely test results to clinicians,” Uettwiller-Geiger added. “However, the questions that come up are these: Are all these tests medically necessary? Are they appropriate? Are there better choices?
“As our administration took steps to better align use of resources in response to the trends of increased patient demand and growth in lab testing volumes, I saw this as an opportunity for our laboratory to increase its contribution and become an integral member of the healthcare delivery team,” she observed. “This is particularly appropriate at this time, given the increasing complexity and sophistication of laboratory testing and technology. In other words, there was an opportunity for us to become more like consultants to our physicians.”
Right Test At The Right Time
The laboratory at Mather Hospital launched a special effort to improve lab test utilization and effectiveness. Uettwiller-Geiger and her team has achieved these goals by working closely with physicians to develop a consultative role for laboratorians. It involves educating physicians about how to order the right test at the appropriate time for each patient.
“One way we manage resources is by totaling all the costs saved when we reduce the number of send-out tests,” Uettwiller- Geiger said. “We also periodically monitor the number of reference lab tests sent out to identify the change in physician ordering patterns since the start of this test utilization effort two years ago.
“The thyroid panel is a good example,” she noted. “In the past, physicians would routinely order a thyroid-stimulating hormone (TSH), tri-iodothyronine (T3) free, and thyroxine (T4). In 2004, physicians ordered more than 3,500 of those tests. Recently, we discontinued that thyroid panel and suggested that fewer tests might be appropriate. In 2007, our physicians ordered only 1,000 of those tests. We attribute this improved result to the education provided to the physicians about what tests would be most appropriate for each patient.
“Here’s another example,” Uettwiller- Geiger continued. “We believe physicians should order screening tests before using more sophisticated molecular tests. With Lyme disease testing, which is done frequently here in the Northeast, the screening test should come before a Western blot test. In addition, these are the guidelines of the federal Centers for Disease Control and Prevention, in Atlanta.
“But many times, physicians order every lab test they think they might need because they are seeing the patient as a consultant on the case,” she observed. “We understand they want to look at everything. But it’s much wiser to proceed in a more stepwise fashion.
“That’s why we developed algorithms jointly with our physicians,” explained Uettwiller-Geiger. “For instance, we have an algorithm for hepatitis B and C testing. Before we had the algorithm, doctors ordered everything from A to Z—and not all of these lab tests were necessary. Since everything has a cost and their time has a cost, we recommended that physicians start with a set number of tests and then, based on those lab results, move to the next level.
Cardiology Lab Order Guide
We also developed a chest pain sheet for physicians in our emergency department (ED),” she added. “We have four levels of care for patients who present in the ED for chest pain assessment. Included in the four levels of care is a lab test order sheet that was developed by the lab in collaboration with the hospital’s heart team. This sheet provides physicians with more precision in how to order the most appropriate lab tests for each patient.
“Over the past year, we worked closely with cardiology on a number of initiatives,” continued Uettwiller-Geiger. “That interaction gives us important visibility within the hospital and has opened up dialog with all physicians. Our first collab- oration with the cardiologists involved developing an information sheet on the D-dimer assay. This is used as a marker of thrombotic process. The resulting fact sheet explained the definitions of clinical sensitivity and specificity for the test.
“Recognizing that physicians may not get this information from any other source, our lab test fact sheets incorporate references and data on the clinical significance, predictive values, and what the results from each particular test can tell them,” said Uettwiller-Geiger. “These lab test fact sheets also describe the testing platform and the methodology used in our laboratory. Physicians tell us that they carry these fact sheets with them and refer to them regularly.
“Each of these education efforts creates an opportunity for laboratorians to converse and interact with physicians,” she explained. “We developed these initiatives over the past 12 to 18 months and in that time, the lab staff has begun to serve more as a consultant throughout the hospital,” she said.
“In fact, that’s how I view my role: as a consultant to physicians. The change is noticeable,” she added. “Physicians now regularly call the lab for consultations and for discussion about which specific tests they should order. Each one of these situations represents an opportunity for laboratorians to demonstrate their knowledge, increase their visibility, and ensure that the lab is seen as a valuable consultative resource.
Concise Source of Lab Info
“In our hospital, we work collaboratively with the physicians, and our experience and background is particularly useful when discussing difficult patient issues that arise in the course of treatment,” stated Uettwiller-Geiger. “Often, I will consult with our Laboratory Medical Director John Chumas, M.D., and between the two of us, we can answer most any question that might arise from the physicians about what is the most effective test to use when treating patients and what results physicians might expect from those tests.”
THE DARK REPORT observes that Uettwiller-Geiger is on the cutting edge of laboratory medicine today. She recognizes that it is difficult for physicians to stay up to date with the rate of development in laboratory services. As a result, laboratorians have more of an opportunity than at any time in the past to serve as consultants to physicians, thus increasing their visibility and the importance of having laboratory information at the point of care.
Use of Lab Alert Facts Sheets Helps to Update Clinicians
HELPING CLINICIANS ADOPT new diagnostic tests and reduce their use of older, less effective lab tests is always a challenge. On February 2005, the John T. Mather Hospital laboratory issued an alert to cardiologists and other physicians about new diagnostic markers for myocardial ischemia and injury. The alert explained some of the changes the lab had instituted in an effort to improve patient care.
The alert bulletin highlighted Troponin I, along with Mather Hospital’s adoption of Ischemia Modified Albumin (IMA) for ischemia. “We made changes in our cardiac marker testing to reflect the changing standards, the alert explained. “We have removed the ‘cardiac enzymes’ panel entirely. If you write an order for ‘cardiac enzymes,’ your order will be automatically changed to ‘Troponin I every 6 hours x 3.’
“We are still experiencing physicians expecting Total CK / CK-MB and myoglobin to be measured as part of a ‘cardiac enzyme’ panel,” the alert added. “While these tests are still individually available, they are not a part of any panel and are considered to be below the standard of care for evaluating myocyte death in the U.S. and Europe where we have Troponin I testing.
“Please remember that no biomarker should be used outside the context of clinical findings,” the alert explained. “We want to be sure that you are aware of lab changes as we go forward. Nurses or clerks will be instructed to remind you and prompt you for more specific orders if a ‘cardiac enzyme’ panel is ordered.”