S TEWARDSHIP : T AKING THE F IRST S TEPS TO D OWNSTREAM S AVINGS A - - PowerPoint PPT Presentation

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S TEWARDSHIP : T AKING THE F IRST S TEPS TO D OWNSTREAM S AVINGS A - - PowerPoint PPT Presentation

Jan 14, 2023 258 likes •687 views

L ABORATORY S TEWARDSHIP : T AKING THE F IRST S TEPS TO D OWNSTREAM S AVINGS A NDREW F LETCHER MD CONSULTATIVE SERVICES LABORATORY STEWARDSHIP Background 13 Billion test performed 70% decisions based 10-30% unnecessary CONSULTATIVE SERVICES

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SLIDE 1

CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

LABORATORY STEWARDSHIP:

TAKING THE FIRST STEPS

TO DOWNSTREAM

SAVINGS

ANDREW FLETCHER MD

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SLIDE 2

CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

Background

13 Billion test performed 70% decisions based 10-30% unnecessary

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CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

Background

3 most significant causes of patient harm

  • Ordering the wrong test
  • Failing to retrieve a test

result

  • Misinterpreting a test result
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CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

73% 53% 72% 47%

the frequency of unnecessary tests and procedures is a very

  • r somewhat serious problem

that even if they know a medical test is unnecessary, they order it if a patient insists the average medical doctor prescribes an unnecessary test or procedure at least

  • nce a week

their patients ask for an unnecessary test or procedure at least once a week

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CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

Trends in Healthcare

Laboratory Stewardship

Pharmacy Utilization management Antimicrobial Stewardship Blood Utilization Radiology Utilization management

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CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

  • f labs have a

stewardship program

1/3

  • f those labs have a productive

and progressing committee

1/2

Data Analysis Formal Governance Evidence-Based Recommendations IT Engagement and Support Project Management Measurement and Reporting

Success Factors

Creating Successful Laboratory Stewardship

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CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

NCLS Publication

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CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

Test Consolidation

How many reference labs do you use?

Reference test formulary

Creation & Implementation

In-House Testing

Daily recurring labs Inappropriate test intervals

Three Initial areas of Focus

Where to Start?

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CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

Free Phenytoin at Lab X $106 Free Phenytoin at Primary Lab vendor $13

Test Consolidation

How many reference laboratories do you use?

  • 1. Is there a primary Vendor?
  • 2. Why are tests sometimes not consolidated?
  • Physician Request
  • Patient Request
  • Insurance requirement
  • Easier process for lab staff
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SLIDE 10

CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

Test Consolidation

How many reference labs do you use?

Reference test formulary

Creation & Implementation

In-House Testing

Daily recurring labs Inappropriate test intervals

Three Initial areas of Focus

Where to Start?

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CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

Test Formulary

all send out testing performed in 1 year test listing in menu if

  • rdered <4

times in 1 year remaining test on menu to see if reasonable

Review Review Eliminate

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CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

POE Optimization

Vitamin D

  • 1,25-Dihydroxy vitamin D
  • 25-Hydroxy vitamin D

Flu

  • Flu PCR
  • Flu respiratory viral panel
  • Flu screen

Folate

  • Folate (RBC)
  • Folate (serum)

Gonorrhea

  • Gonorrhea culture
  • Gonorrhea DNA probe
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CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

POE Optimization POE Optimization

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CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

Inpatient Reference test cost Monthly average pre Formulary $31,054 Monthly average post Formulary $20,028 Percent decrease 35% Average monthy savings $11,026 Projected yearly savings $132,309

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CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

Commonly Misordered Testing

Test Removal & Reflex Path Implementation

2 4 6 8 10 12 14 16 18 MTHFR 2 Mutations Factor V Leiden APC w/reflex to Factor V Leiden

85% 86%

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SLIDE 16

CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

Test Consolidation

How many reference laboratories do you use?

Reference test formulary

Creation & Implementation

In-House Testing

Daily recurring labs Inappropriate test intervals

Three Initial areas of Focus

Where to Start?

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SLIDE 17

CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

Don’t perform repetitive CBC and chemistry testing in the face of clinical and lab stability. Don’t order diagnostic tests at regular intervals (such as every day), but rather in response to specific clinical questions.

Daily Orders

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CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

Intervention Methods

Proactive

Appropriate order sets Order management Preference list management Physician education Physician report cards

Reactive

Duplicate alerts Formulary restriction alerts Best Practice Alerts Physician education

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CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

76548965 Zyne Cotopaxi, MD 09/04/2016 15:47 76548965 09/04/2016 13:00 Thyroid Stimulating Hormone 4.0 IU/mL

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CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

Test Consolidation

How many reference labs do you use?

Reference test formulary

Creation & Implementation

In-House Testing

Daily recurring labs Inappropriate test intervals

Justification for Stewardship NCLS Recommendations Three Initial areas of Focus:

Summary

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SLIDE 21

CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

13 Billion

laboratory tests performed annually in the U.S.

3%

  • f U.S. healthcare

expenditures spent on Laboratory Services

70%

  • f medical decisions are

influenced by laboratory data

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CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

Downstream impact

  • Length of stay
  • Pharmacy
  • Radiology
  • Others……
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CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

Troponin orders and Chest Pain LOS

23

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CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

Identify order mechanisms that drive the repeat interval Modify the repeat time to be 3-6 hours after

Improve the time-to-decision by improving the test interval by up to 3 hours

TROPONIN I

500 1000 1500 2000 2500 3000 3500 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 5.5 6 6.5 7 7.5 8 8.5 9 9.5 10 10.5 11 11.5 12 12+ 2,965 4,410

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CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

Identify order mechanisms that drive the repeat interval Modify the repeat time to be 3-6 hours after

Improve the time-to-decision by improving the test interval by up to 3 hours

TROPONIN I

500 1000 1500 2000 2500 3000 3500 4000 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0 5.5 6.0 6.5 7.0 7.5 8.0 8.5 9.0 9.5 10.0 10.5 11.0 11.5 12+ 3,587

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CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

Downstream impact

  • Length of stay
  • Pharmacy
  • Radiology
  • Others……
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SLIDE 27

CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

Downstream Impact on Pharmacy

IVIG Argatroban Remicade

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SLIDE 28

CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

Downstream impact

  • Length of stay
  • Pharmacy
  • Radiology
  • Others……
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SLIDE 29

CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

Radiology Services

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CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

CT PE Protocol

30

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CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

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CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

D-Dimer and CT PE Protocol

32

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CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

33

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CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

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CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

45,000

chest x-rays

= 23%

CT Scans

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CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

= 23%

CT Scans

$34.20

per scan

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CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

= 23%

CT Scans

$10,260

cost saving

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CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

= 23%

CT Scans

$1,445,400

savings for patients

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SLIDE 39

CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

= 23%

CT Scans

360 hrs

reduction in LOS

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SLIDE 40

CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

Downstream impact

  • Length of stay
  • Pharmacy
  • Radiology
  • Others……
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SLIDE 41

CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

LABORATORY STEWARDSHIP:

TAKING THE FIRST STEPS

TO DOWNSTREAM

SAVINGS

ANDREW FLETCHER MD