Demand management and test request rationalization

Utilization management in the clinical laboratory: an introduction and overview of the literature

There is a broad literature addressing the need for improving utilization management in medical care. Numerous review articles and case studies have described approaches to utilization management challenges in the laboratory. This article will present an overview of the literature on laboratory utilization management and will compile a "toolbox" of strategies that can be used to address specific utilization management initiatives. A clear theme among successful utilization management programs is the need to recruit institutional champions both for the overall utilization management program and for ad hoc assistance with specific utilization challenges. It is important that these individuals represent a cross section of laboratory and clinical specialties and that the group be organized as a committee that has been established by the administrative and physician leadership of the organization. The changing nature of healthcare reimbursement will likely provide increased motivation to control laboratory testing and costs. Clinical pathologists are in a unique position to observe testing behavior patterns, suggest alternatives, implement order entry changes, manage testing algorithms and provide interpretive services for laboratory testing. For these reasons, clinical pathologists have a major opportunity to become institutional leaders in utilization management.

The impact of electronic health records on people with diabetes in three different emergency departments

OBJECTIVE

To evaluate if electronic health records (EHR) with prior clinical information have observable effects for patients with diabetes presenting to emergency departments (ED), we examined measures of quality and resource utilization.

MATERIALS AND METHODS

Retrospective observational studies of patients in three ED (A=5510; B=4393; C=3324) were conducted comparing patients with prior information in the EHR to those without such information. Differences with respect to hospitalization, mortality, length of stay (LOS), and numbers of ED orders for tests, procedures and medications were examined after adjusting for age, gender, race, marital status, comorbidities and for acuity level within each ED.

RESULTS

There were 7% fewer laboratory test orders at one ED and 3% fewer at another; fewer diagnostic procedures were performed at two of the sites. At one site 36% fewer medications were ordered. The odds of being hospitalized were lower for EHR patients at one site and hospital LOS was shorter at two of the sites. EHR patient ED LOS was 18% longer at one site. There was no demonstrable impact of an EHR on mortality. Results varied in magnitude and direction by site.

DISCUSSION

The pattern of significant results varied by ED but tended to reveal reduced utilization and better outcomes for patients although EHR patients' ED LOS was longer at one site.

CONCLUSIONS

The presence of prior information in an EHR may be a valuable adjunct in the care of diabetes patients in ED settings but the pattern of impact may vary from ED to ED.

Differences in laboratory requesting patterns in emergency department in Spain

Background

It is necessary to achieve a reduction in the number of requests for laboratory tests by improving the appropriateness of testing behaviour. The aim of the study was, first, to compare laboratory requiring patterns for emergency department (ED) patients in clinical laboratories of different institutions in Spain; second, to design an appropriateness pre-pre-analytical quality control report based on appropriateness indicators.

Methods

A call for data was posted on a website. We obtained production statistics for the year 2010 from emergency laboratories at 36 hospitals. Two types of appropriateness indicators were calculated: test request per 1000 ED admissions or related test requesting ratios. In order to explore the inter-practice variability in tests requests, the ‘index of variability’ was calculated. A pre-pre-analytical quality control report was designed, prepared and sent to each participating laboratory. The savings generated, if each Health-care Department would have achieved the appropriate indicator standard, were calculated.

Results

The rate of request of the stat tests ranged from 44 to 412 per 1000 ED patient admissions. There was a high and peculiar dispersion of related test requesting ratio results. If every single laboratory would have achieved the appropriate indicator, we would have saved 1,019,230 urea, 302,511 AST and 316,161 CK unnecessary tests.

Conclusions

There are large variations of test requesting in the emergency setting. An appropriateness pre-pre-analytical quality control report was useful for comparing requesting patterns. The study shows the need to unify demand. The key to achieve this goal will be interdepartmental cooperation between ED clinicians and laboratory professionals.

Managing demand for laboratory tests: a laboratory toolkit

Healthcare budgets worldwide are facing increasing pressure to reduce costs and improve efficiency, while maintaining quality. Laboratory testing has not escaped this pressure, particularly since pathology investigations cost the National Health Service £2.5 billion per year. Indeed, the Carter Review, a UK Department of Health-commissioned review of pathology services in England, estimated that 20% of this could be saved by improving pathology services, despite an average annual increase of 8%-10% in workload. One area of increasing importance is managing the demands for pathology tests and reducing inappropriate requesting. The Carter Review estimated that 25% of pathology tests were unnecessary, representing a huge potential waste. Certainly, the large variability in levels of requesting between general practitioners suggests that inappropriate requesting is widespread. Unlocking the key to this variation and implementing measures to reduce inappropriate requesting would have major implications for patients and healthcare resources alike. This article reviews the approaches to demand management. Specifically, it aims to (a) define demand management and inappropriate requesting, (b) assess the drivers for demand management, (c) examine the various approaches used, illustrating the potential of electronic requesting and (d) provide a wider context. It will cover issues, such as educational approaches, information technology opportunities and challenges, vetting, duplicate request identification and management, the role of key performance indicators, profile composition and assessment of downstream impact of inappropriate requesting. Currently, many laboratories are exploring demand management using a plethora of disparate approaches. Hence, this review seeks to provide a 'toolkit' with the view to allowing laboratories to develop a standardised demand management strategy.