Clinical Laboratory Utilization Management

What is Laboratory Utilization or Lab Stewardship?

Clinical laboratory utilization management is concerned with the effective use of resources while ensuring benefit to patients through the administration of appropriate tests at cost-effective rates. It requires the involvement of diverse parties including administrators, clinicians, laboratory personnel, and quality control professionals.

In the recent past, the term laboratory stewardship has been preferred for its more patient-centered approach, whereby the quality of service provided is of primary importance as compared to cost-cutting measures associated with laboratory utilization management. Effective lab stewardship can ensure that the diagnosis, treatment, and monitoring of disease are optimized and any downstream adverse events associated with errors in test ordering, retrieval or interpretation of results, and unnecessary incurred costs are mitigated.

Clinical Laboratory Utilization Programs

In a clinical setup, there are five common programs of laboratory utilization stewardship/management, namely;

1. Test utilization management
2. Antimicrobial stewardship
3. Pharmacy utilization management
4. Blood utilization management
5. Radiology utilization management

1. Test Utilization Management

The laboratory is an integral component of clinical utilization management. There is a wide variety of tests available and clinicians may have difficulty efficiently navigating them, leading to medical testing overuse, misuse, and/or underuse. A collaborative effort between practitioners and the laboratory expertise with regard to the necessity of tests through a test utilization management program would ensure cost-effective use of laboratory tests and optimal patient care.

Ways in which the laboratory can help clinicians avoid underuse, overuse, and misuse of clinical laboratory services

• Laboratories reduce diagnostic uncertainty through rapid and appropriate testing.
• Microbial culture results from the laboratory can be used to change, reduce, or augment antibiotic prescriptions.
• Laboratory requirements for prior test authorization or justification from a specific specialist can help curb misuse of high-cost tests e.g. requiring prior authorization from oncologists for expensive mutation tests.
• The laboratory director, usually a pathologist, can act as a gatekeeper by approving tests, requesting test justifications, or denying test requests.
• Laboratories can offer training programs for clinicians to improve test ordering.

Test utilization management tools

There are a number of tools that a clinical laboratory can use to enforce utilization management and encourage proper and efficient use of tests. This includes the use of;

1. Reference laboratories
2. Laboratory formularies
3. Electronic medical record
4. Test restrictions

a. Reference laboratories

Reference laboratories perform tests on behalf of other labs. They mainly handle complex, non-routine tests while the institutional (local/home) labs perform routine, high-volume tests.

Outside lab testing can play a complementary role in test utilization management because of certain unique advantages, as follows;

• Access to a large scope of data sets across multiple clinical settings can form a basis for analysis and benchmark.
• Reference labs usually have more resources than local (hospital) labs and therefore offer more services like training to physicians, analytics services, and information technology.
• The large expertise available in a reference lab can offer real-time professional consultation for multiple specialties that can help clinicians choose the most appropriate tests.

b. Laboratory formulary for test restrictions

A lab formulary contains a list of tests physicians can order. It is a system, first utilized in pharmacy and drug prescription departments, to lower costs by encouraging the use of generic, instead of specialized, drugs. Laboratory formularies can be used to regulate both the tests performed locally in the establishment or those sent to reference labs.

The formulary is not set in stone and it should be evaluated and updated at least annually to identify changes such as the frequency of test requests, for example, non-crucial low volume tests can be removed from the formulary and transferred to reference labs. Other changes include the development of new tests, rendering the ones in the formulary obsolete. This is true, especially for those tests in the rapidly developing diagnostic areas.

Prior to addition to the formulary, tests are thoroughly reviewed and vetted by a committee that must include clinicians and laboratory staff. This is to ensure its diagnostic and therapeutic value, medical necessity, and the cost-effectiveness of the diagnostic/monitoring procedure.

c. Electronic medical record

This can be a useful tool in the monitoring and control of test utilization. Measures like;

• Limitations on selectable frequency of ordering of laboratory testing,
• Expanded duplicate checking,
• Removal of the generic ‘send-out’ test warning,
• Introduction of a variety of targeted test warnings based on data analysis, and posting of laboratory test charges in the computer order entry,
• Implementation of a send-out test formulary.

These options limit misuse of tests, correct errors such as duplication of test orders or selection of wrong tests with similar names, for instance, a common mix-up occurs between the magnesium and manganese tests where beta-2-glycoprotein and beta-2-microglobulin are the test factors, respectively. An automatic prompt warning can pop-up wherever either of the two tests is selected to reduce the chances of a mistake.

d. Restriction on frequency and number of tests

Various reports have shown that clinicians often use too many diagnostic tests, both in variation and order frequency. This may be due to knowledge limitations of test expectations and scope, redundant lab test requests, or simply because they are trying to be rigorous.

There are various ways to limit this overuse, including;

• Having administrative barriers on certain types of complicated or expensive tests. This will ensure that the test requests are justified to hospital administrators, insurance companies, or lab personnel.
• Reducing reliance on over bundled tests. These are a variety of tests ordered as a panel, which can be wasteful since only a few of the component tests are necessary to give certain patient information.
• Limiting automated test orders and requiring clinicians to evaluate the orders daily. The unnecessary wastage resulting from these tests on ‘’autopilot’’ outweigh their convenience.
• Introducing test frequency filtering. This sets a limit on how soon successive tests may be requested. The agreeable period should be set through consultative discussions between the ordering clinicians, laboratory personnel, and hospital administrators.

2. Antimicrobial stewardship

This is when healthcare systems work to decrease antimicrobial resistance in the population by limiting the unnecessary use of antibiotics. It involves the use of guidelines, training, and appeals on prescribers to use evidence-based prescription of antimicrobials and appropriate tests.  It is important to appoint a pharmacy expert to this stewardship program to lead, manage, and keep prescribers accountable through regular audits. They are also responsible for monitoring antibiotic prescriptions, tracking the impact of various interventions and reporting prescription trends and antibiotic resistance. Pharmacy experts leading the program are also in charge of educating patients and clinicians on the importance of optimum prescription, the dangers of antibiotic misuse, as well as side effects.

3. Pharmacy utilization management

This encompasses a variety of interventions to improve drug therapy, most notably the use of pharmacy formularies that seek to substitute less expensive, but equally effective, drugs for more expensive drugs (generic substitution). Management techniques include;

1. quantity limits,
2. prior authorization from the patients’ plan, and
3. step therapy, where the doctor is required to use low-cost drugs first.

4. Blood utilization committees

This addresses the ordering, distribution, handling, dispensing, and administration of blood components. In addition, it also monitors the effects of transfusion on patients. Blood utilization committees have led to significant decreases in unnecessary transfusions as well as motivating the discovery that most patients have better outcomes when more conservative thresholds for red cell transfusion therapy are implemented.

The committee is composed of representatives of the departments that do the most ordering and transfusing of blood and blood components.

5. Radiology utilization management

This includes a variety of interventions to decrease unnecessary and harmful imaging. Restrictive guidelines and interventions have led to the exposure of less cancer-causing radiation without a change in health outcomes… One such guideline is the implementation of the principle of “as low as reasonably achievable” where the radiologist is required to optimize image quality at the lowest reasonable dose. In addition, targeted educational curriculum with the cost and utilization data can influence the ordering practices of physicians and radiologists.

What are the Overall Goals and Benefits of Lab Stewardship?

The eventual goal of laboratory stewardship programs is to help clinicians improve the quality of patient care while reducing costs to patients, hospitals, and health systems.

The main benefits of laboratory stewardship/utilization management are as follows;

• It reduces the case of unnecessary tests by relying on evidence-based test requests. The utilization management program is as a result of a consultative and collaborative effort that incorporates strategies that have been evaluated and shown to work.
• The team gives guidance on testing by creating laboratory formularies, removing, or restricting tests with little clinical value.
• It ensures the training of clinicians on appropriate testing choices. This is important because of the rapid changes in technology and test efficiency.
• It has been shown that unnecessary tests, especially invasive ones involving blood retrieval, have led to increased risks for hospital-acquired anemia, leading to increased patient mortality. Thus, the use of utilization management models alleviates these risks.
• It frees up clinical and laboratory personnel to focus on more dire patient needs because unnecessary overutilization keeps staff and equipment busy.
• Utilization management offers a platform to track the team’s effort through tools like utilization scorecards for all the initiatives introduced to manage costs and ensure proper patient care.

Structure and Scope of Practice of a Laboratory Utilization Team

The structure of a laboratory utilization team is as follows;

Laboratory utilization team leader

Ideally, the laboratory utilization team should be headed by a physician because physicians have in-depth medical knowledge to make judgments on what is best for the care of the patient. However, where one is not available, other laboratory personnel or administrators can lead the team.

Effective leadership and management require the following;

• sharp organizational skills,
• consistent communication,
• tenacity, and
•  

Ongoing measurement and communication of progress are critical attributes of successful utilization management programs.

Laboratory utilization team members

The utilization management team should be composed of smaller hospital/laboratory committees like the general executive council, medical policy committee, and the clinical laboratory advisory committee. The laboratory advisory committee, which is composed of those with technical and applicability knowledge on tests approves the various utilization management initiatives and forwards them to the medical policy committee for final approval.

The members of the laboratory utilization management committee should;

• Have the knowledge and understanding of the use and limitations of laboratory testing.
• Understand the cost and reimbursement structure of laboratory testing.
• Have the ability to analyze test volume, trends, and patterns.

Conclusion

Increased healthcare spending continues to be an issue of major concern to hospitals, patients, and medical insurance enterprises. Utilization management offers a series of methods to ensure the best patient outcomes through the appropriate use of healthcare resources. The focus of utilization management is the effective and appropriate utilization of resources, not the lowering of costs, through decreasing utilization. Whereas the overuse of high-cost facilities, like imaging, leads to losses to insurers, an overload of personnel, and underutilization, which has significant risks for patients. The implementation of clinical laboratory utilization stewardship endeavors to reduce variations in patients’ treatments and promote cost-effective clinical decision making.

References

1. Naugler C and Church DL. Clinical laboratory utilization management and improved healthcare performance. Critical Reviews in Clinical Laboratory Sciences. 2018 55:8, 535-547
2. Utilization Management in the Clinical Laboratory and Other Ancillary Services. Springer publishers, USA 2017. Edited by Lewandrowski K and Sluss PM.
3. Stehling L, Luban NL, Anderson KC, Sayers MH, Long A, Attar S, Leitman SF, Gould SA, Kruskall MS, Goodnough LT, et al. Guidelines for blood utilization review. Transfusion. 1994 34:5, 438-448
4. Otero HJ, Ondategui-Parra S, Nathanson EM, Erturk SM, Ros PR. Utilization management in radiology: basic concepts and applications. Journal of American College of Radiology 2006 3:5, 351-357
5. Janssens PM and Wasser G. Managing laboratory test ordering through test frequency filtering Clinical chemistry and laboratory medicine 2013 51:6, 1207–1215