Pathologists Exploring Use of Diagnostic Teams

Diagnostic management teams bring together pathologists and treating physicians

CEO SUMMARY: In the search for ways to add more value to lab testing services, pathologists and lab administrators are considering organizing diagnostic management teams within their hospitals. Such teams focus on complex cases and include both diagnosticians and pathologists. In his pioneering work to develop the diagnostic management team concept, pathologist Michael Laposata, M.D., Ph.D., spoke recently about how such teams improve patient outcomes while reducing the cost of care.

WHEN LOOKING FOR A WAY to deliver more value with lab testing services, a growing number of hospital-based pathologists and laboratory administrators are considering diagnostic management teams (DMTs).

Probably the leading advocate of DMTs is pathologist Michael Laposata, M.D., Ph.D., Chair of the Department of Pathology at the University of Texas Medical Branch. For 30 years, Laposata has promoted the benefits of diagnostic management teams at four different hospitals.

During a presentation at THE DARK REPORTS Executive War College in New Orleans last spring, Laposata made a compelling argument in favor of DMTs, saying they can improve patient safety and patient care while at the same time reducing hospital length of stay and healthcare costs.

Under Laposata’s definition, a diagnostic management team includes diagnostic specialists from pathology and other departments as appropriate, along with clinical laboratory scientists (medical technologists). A DMT meets routinely to synthesize clinical laboratory results, the results of other diagnostic studies, and the clinical presentation to establish diagnoses in support of the referring physicians, especially in complex cases.

For the labs owned by hospitals and health systems, DMTs offer two benefits. First, they allow pathologists and clinical lab scientists to contribute their expertise in the clinical care provided to the institution’s most challenging cases.

Second, the improved outcomes of patients treated by DMTs often can be measured, as can the resulting reduction in the cost of care for those patients. Cost reduction may result from shorter length of stay for patients whose cases were handled by a diagnostic management team because the experts reach a diagnosis rapidly.

Shortening Length of Stay

Specifically, Laposata addressed the issue of length of stay (LOS) and the challenge of attributing shortened LOS to the creation of a diagnostic management team. “Typically, attributing fewer inpatient hospital days to the work of DMTs has been difficult because, while institutions establish DMTs over a number of months, other improvements also are introduced,” noted Laposata. “For example, to date, researchers have collected data only to suggest that a relationship exists between using diagnostic management teams for patients with certain diagnoses and reduced LOS.”

The expanded use of electronic health records and the explosion of big data in healthcare are two factors that will make it easier to document the value of diagnostic management teams in the two key areas of improving patient outcomes and significantly reducing the cost of care, he said.

“At any hospital or healthcare system, there is the potential to organize DMTs that address specific diseases and health conditions and that generate millions of dollars per year in cost savings,” observed Laposata. “At Vanderbilt University Medical Center, just four clinical situations were studied and addressed by DMTs. Yet the cumulative savings were $3 million annually! Therefore, it is possible that, given the large number of clinical disorders, much more would be expected as savings for healthcare institutions.”

DMTs at Vanderbilt

Laposata was at Vanderbilt before moving to the Texas Medical Branch in the summer of 2014. In his presentation, Laposata reported that Vanderbilt used DMTs to do the following:

  • Eliminate unnecessary testing for leukemia, saving $880,000 annually.
  • Reduce length of stay for an estimated 200 Vanderbilt patients who have had a pulmonary embolism, saving $2,000 per case for a total of $400,000 annually.
  • Boost throughput for oncologists, allowing them to see 1,000 more patients annually, thereby generating a minimum of $300,000 in additional revenue.

“One factor that has held back expanded use of DMTs is gathering the data required to document the overall cost savings to the institution,” explained Laposata. “Each such study typically requires dozens of hours to complete.

“However, the data are gradually emerging and that growing body of information consistently shows that use of a diagnostic expert team to help solve complex diagnoses improves patient outcomes and reduces cost,” he continued. “This is a predictable answer, and it is evidence that argues that it is time to reduce diagnostic errors and delays by involving diagnostic experts who are familiar with laboratory test selection and test result interpretation.

More Use of EHRs Is Positive

“The introduction of electronic health records in most hospitals today makes it easier to document the value delivered by a diagnostic management team that is handling complex patient cases,” he stated. “These data are needed to show hospital administration that DMTs are delivering improved patient outcomes, reducing the overall cost of care for those patients, and shortening the average length of stay.

“Studies show that the rate of diagnostic errors or delays is somewhere around one in eight to 10 clinical encounters,” he said. “Many pathologists who see overutilization and underutilization of laboratory tests believe that this rate is likely higher.

On Diagnostic Management Teams, Physicians, Pathologists Work Together

BASED ON HIS YEARS OF EXPERIENCE in providing clinical pathology consultative services to referring physicians, pathologist Michael Laposata, M.D., Ph.D., believes diagnostic management teams are a necessary solution for the needs of today’s healthcare system.

“The concept of a diagnostic management team (DMT) is simple,” stated Laposata, Chair of the Department of Pathology at the University of Texas Medical Branch. “It involves bringing together diagnostic specialists from pathology and sometimes other departments on a routine basis to synthesize all the diagnostic information from all sources and establish diagnoses, especially in complex cases.

“Given the complexity of medicine, particularly with the new molecular and genetic tests that are available, DMTs are a powerful way for pathologists and clinical laboratory scientists to apply their knowledge and experience to support clinicians,” he continued. “The goal is to improve patient outcomes and reduce healthcare costs.”

Physicians and other healthcare providers are the ones to engage the DMT. “As we have organized our DMTs, the process starts when healthcare providers order tests by requesting an evaluation of an abnormal screening test or clinical sign or symptom,” stated Laposata. “Upon receiving that request, the expert physician and colleagues in the DMT evaluate all the clinical and laboratory data and provide a narrative interpretation based on published medical evidence or institutional best practice. This diagnostic information is provided not only when specifically requested by the referring physician—which is typical for clinical pathology—but for every case the DMT handles.”

Laposata did want to distinguish a fullyengaged DMT from other types of case review activities. In his view, it is not a DMT activity if any of the following are true:

• The interpretation does not consider clinical information.

• The service does not meet on a regular schedule.

• The interpretation is not written or is not included in the medical record.

• The interpretation is so self-evident that it is not clinically valuable for the treating physician. (For example: The interpretation provides a report only of test results as abnormal but fails to explain why.)

“Whatever the actual rate is for diagnostic errors and delays, increased utilization of DMTs is almost certain to reduce that rate of diagnostic error,” noted Laposata. “That is definitely to the benefit of patients and the hospitals treating these patients.

“In a diagnostic management team, pathologists and clinical laboratory scientists have the opportunity to work in close collaboration with the treating physicians to consider all aspects of each patient’s case,” noted Laposata.

He offered an example of patients on blood thinners. “This is a complex problem,” he said. “Most patients who have a stent in one or more coronary artery and are being treated with the platelet inhibitor Plavix to keep the stent open will have great results. But for 20% of all patients treated with Plavix, this drug does not work. Instead, they need an alternative drug that works in a similar way to inhibit platelets.

Helping Docs with Lab Tests

“One way to determine with a laboratory test if a patient will do well on Plavix or need an alternative drug is to do a genetics test,” explained Laposata. “But many doctors don’t understand ‘pharmacogenomics’ and so don’t know the right lab test to use to determine if patients need an alternative blood thinner.

“So, when considering the approximate $25,000 cost for a patient’s readmission due to a clotted coronary artery stent, maybe we should do pharmacogenomics testing forfree for every patient about to receive a stent and Plavix,” he explained.

New Emphasis on Diagnostic Errors

HEALTHCARES NEW EMPHASIS on integrated care presents the pathology profession with a perfect opportunity to expand its role in helping physicians to make more accurate and rapid diagnoses and to aid in the selection of appropriate therapies.

“It is becoming more common for hospitals to be paid on outcomes,” stated Michael Laposata, M.D., Ph.D., Chair of the Department of Pathology at the University of Texas Medical Branch. “One example is Medicare’s program to reduce hospital readmissions.

“To achieve better patient outcomes, hospital administrators are recognizing the need to foster more integration of clinical care,” he said. “Diagnostic management teams are one way to bring together the institution’s experts in diagnosis—and that includes pathologists. Take the example of a patient with an undiagnosed bleeding disorder and the large number of lab tests that could be used to diagnose and identify treatment options for that patient. Most physicians don’t know how to order the correct tests and interpret test results for patients with such problems.

“Consider the benefit of the diagnostic expert who makes a quick diagnosis, stops the bleeding and saves thousands of dollars in blood products that would otherwise have been transfused,” concluded Laposata.

“At the outset, this question seemed ridiculous because such testing costs about $300 just for the reagents and supplies!” observed Laposata. “But if this lab test for these patients could prevent 1% (the expected number is as high as 20%) of all adverse events among the 6,400 patients (the number of patients evaluated in a pharmacogenomics study at Vanderbilt) who undergo stenting at a hospital, then we’ve avoided 60 or so adverse events at $25,000 each. That’s a savings of $1.5 million. And the patient has a better outcome! That is far more than the cost of creating a pharmacogenomics laboratory.

Coag-Focused DMTs

“This is an example of where the advice provided by a coagulation-focused DMT supports an increase in the cost of lab tests for these patients in order to reduce the overall cost of care by a significant amount. In the new world of medicine, this is an example of how a DMT can save a bundle of money,” he added. “That’s a win-win because we improved patient outcomes at the same time.”

In Laposata’s view, diagnostic management teams are an effective way for pathologists to have an active and ongoing role in patient care in ways that add significant value to the parent hospital or health system. He provided an example of how cost savings can quickly add up to a huge number.

“Let’s assume that each of the 150 academic medical centers in the United States could save $50 million annually if they used DMTs for all the diseases they encounter (and most diagnostic errors occur in the commonly encountered diseases),” Laposata suggested. “Now the math becomes interesting because $50 million times 150 hospitals is $7.5 billion.

“Next, there are about 5,000 more smaller nonacademic hospitals where similar benefits are possible and where the advantages of more rapid and accurate diagnoses are not yet appreciated,” he continued. “This shows how DMTs have the potential to save billions of dollars nationally while greatly improving patient care.”

Contact Michael Laposata, M.D. at 409-772-1850 or milaposa@utmb.edu.

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