Clin Chem Lab Med 2015; 53(5): 731–742
Pim M.W. Janssens*, Wilma Staring, Kirsten Winkelman and Gert Krist
Active intervention in hospital test request panels pays DOI 10.1515/cclm-2014-0575 Received May 30, 2014; accepted September 17, 2014; previously published online October 10, 2014
Abstract Background: Ordering laboratory tests by means of test panels is a convenient way of requesting tests, prevent ing necessary tests from being forgotten. However, it also leads to redundant test ordering, as not all tests in a given panel are required for each patient. As test panels pro posed by doctors may contain redundant, o verlapping or infrequently used tests, the active involvement of know ledgeable laboratory staff in the organisation of test panels is advisable to promote efficient test use. Methods: Laboratory staff initiated an intervention in the organisation of test panels at our hospital in 2009. After a review of the existing panels and the proposals for new panels, we established a total of 60 panels (down from 171 previously). We also stipulated that the laboratory is to be involved with all proposals for new test panels in the future. Results: The reorganisation reduced the number of tests in the test panels by 17.7% (n = 60), which theoretically should have resulted in 4.5% fewer tests being ordered. However, as an estimated 14% of the tests removed were then ordered individually in addition to the panels, 3.9% fewer tests were ordered, yielding an annual saving of about €58,000 (4.5% of the costs of all tests ordered in test panels). The savings amount to 7–8% if the frequently ordered metabolic panel (which was left unchanged) was excluded from the survey. Conclusions: Active intervention by the laboratory in the organisation of test panels results in a reduction in the use of tests and in interesting savings. *Corresponding author: Pim M.W. Janssens, PhD, Laboratory of Clinical Chemistry and Haematology, Rijnstate Hospital, PO Box 9555, 6800 TA, Arnhem, The Netherlands, E-mail:
[email protected] Wilma Staring: Laboratory of Clinical Chemistry and Haematology, Rijnstate Hospital, Arnhem, The Netherlands Kirsten Winkelman and Gert Krist: Department of Functional Application Management, Rijnstate Hospital, Arnhem, The Netherlands
Keywords: cost reduction; intervention; laboratory man agement; ordering behavior; preanalytic phase; test panel.
Introduction The growing demand for healthcare in Western coun tries presents a constant challenge to the qualitative and logistical reliability, and the financial viability of diagnostic tools provided by clinical laboratories. Understandably, doctors tend to see the laboratory as a necessary facility that provides accurate and timely services, with minimal effort and consideration on their part. When doctors are not party to the financial conse quences of their test-ordering behavior, as is the rule in the Netherlands, it is hardly surprising that test orders are often redundant [1–4]. Typically, in systems like ours where hospital and laboratory costs are budgeted, clinical laboratories are held responsible for managing appropriate test use. In a previous overview, we identi fied 11 approaches for the management of laboratory test ordering [3]. However, data on the effectiveness of these approaches was limited. We therefore launched an initia tive to investigate the effectiveness of the different man agement tools in 2009. To date, we have reported on the use of stat phlebotomy, repetitive testing and test use by the emergency department [5–8]. One suggested approach for managing laboratory test ordering involves interference with test request pro tocols, also known as test panels [3]. Test panels cluster the different tests used to diagnose common conditions, thus increasing convenience and preventing necessary tests from being overlooked [3, 4, 9]. It has been suggested that test panels may lead to increased test use [10], but this depends, naturally, on whether the contents of the test panels are strictly delimited or include a degree of redundancy. Test panels are a promising management tool for laboratories as they fall well within the scope and often even under the direct responsibility of the labora tory [3]. In an effort to come to optimized use of labora tory test panels we systematically reviewed all test panels programmed in the ordering module of the hospital infor mation system (HIS), and introduced the rule that all
732 Janssens et al.: Management of laboratory test panels requests by doctors for new test panels must be reviewed by a laboratory specialist. The aim of these two interventions was to: –– Reorganize the panels, eliminating test panels in the HIS that were rarely used, or were similar in content and clinical application (different special isms sometime used the same panels under differ ent names). –– Improve efficiency by reducing the number of tests within test panels and eliminating tests with low diagnostic value or similar diagnostic information as other tests within the panel. –– Make the panels better fit the intended diagnostic purpose, often resulting in the elimination of tests but sometimes also the introduction of new tests. This paper reports on the results of our effort to opti mize the test panel usage in our hospital, showing which results and savings can be obtained by this laboratory testing management approach.
Materials and methods Study site and ordering facilities The study was performed at Rijnstate Hospital in Arnhem, The Neth erlands, a general care and teaching hospital. The considered test panels were ordered by clinicians for inpatients and outpatients from the Clinical Chemical and Haematological Laboratory. The labora tory carries out about 3.5 million tests annually. Both the hospital and laboratory have been described in detail elsewhere [5]. Largely excluded from the present analysis were orders made by primary care physicians, as well as orders for microbiological, serological and auto-immunological testing, which are done by another depart ment. Only four of the 60 considered test panels included these tests (all together 6 tests amounting to an annual of 32 tests with a value of €6626). Compared to the 82 clinical chemical-hematological tests in all 60 test panels (totalling about 550,000 tests annually valued €1,200,000) these tests represented a negligible proportion of all tests investigated. The organisation of test panels in our hospital revolves around the HIS, (CS EZIS.net, produced by Chipsoft BV, Amsterdam, version 5.2, since March 2012) and the laboratory information and manage ment system (LIMS; Glims, produced by MIPS NV, Ghent, version 8.9.6, since September 2012). The electronic ordering in the HIS is administered by the Department of Functional Application Man agement. The LIMS is managed by the laboratory. The HIS screens for laboratory test ordering consist of a number of general ordering screens, sorted by body fluids (e.g., blood and urine) and investiga tion types (clinical chemistry/hematology, immunology/serology, microbiology, pharmacology/toxicology). In addition, all medical specialisms have own screens that assess the tests and test panels they frequently or specifically use.
Prior to 2011, doctors typically ordered tests using hard-copy order forms; on 3 October 2011 electronic ordering became available via the HIS. All test panels on the hard-copy order forms were sub sequently transferred to the HIS. The last hard-copy order was regis tered in January 2012. All orders are registered in the LIMS. Panels previously ordered on hard copy were introduced into the LIMS using automatic paper scanners; panels ordered electronically in the HIS are sent to the LIMS electronically. In the LIMS, tests ordered as part of a panel can not be distinguished from tests ordered individually. Data for the present evaluation of test panel usage were extracted from the data management modules of the HIS and the LIMS.
Review of existing test panels To review the ordering of laboratory tests by way of the existing test panels, we made an overview of all test panels present in the HIS in 2011. This overview consisted of 171 panels, the tests included in them and the numbers ordered by the different medical specialists and hospital departments. Most panels had been used by multiple medical specialisms and departments, though in the majority of cases one medical specialism was by far the most frequent user. To reorganize the test panels, we first deleted all panels that had been ordered five times or fewer in the preceding year (97 panels). We then examined the individual tests that made up the remaining 74 panels. Next, we met with stakeholders from the medical specialisms that had used test panels more than five times during the preceding year (cardiology, gastroenterology, geriatrics, gynecology, internal medicine, neurology, pediatrics, psychiatry, pulmonary diseases and surgery) to discuss panels and to bring to their attention potentially redundant testing, that is, their use of tests or test combinations that potentially provided relatively little information for diagnostic issues. In cases where we had reached an agreement with one medical spe cialism on the reorganisation of a certain test panel, we informed the medical specialists we next spoke with of our conclusions in an effort to gather momentum over reorganized panels. Occasionally we approached specialists a second time with suggestions that arose in consultation with other specialists. The aim was to achieve consen sus among all requestors on the reorganisation of the test panels. The series of meetings with the specialists lasted from January 2011 to March 2012. Thereafter, 22 of the 74 panels remained. Between March and June 2012 the changes were implemented in the HIS; that is, either test panels were deleted or their content was changed in line with the conclusions reached in consultation with the specialists.
Obligatory consultation for new test panel requests Following a decade in which test panels requested by doctors were introduced by laboratory personnel without question, in 2009 the laboratory management stipulated that all new proposals must be inspected and approved by clinical (bio)chemical laboratory special ists, knowledgeable about the different areas of laboratory testing (i.e., clinical chemistry, hematology, endocrinology, immunology). This measure was agreed upon with the Department of Functional Application Management, which programs the ordering facilities in the HIS. As a result, clinical (bio)chemical laboratory specialists are required to seek contact with doctors who have proposed new test
Janssens et al.: Management of laboratory test panels 733 panels to discuss the proposed panel contents. In short, the routing of new request for test panels is as follows: –– Doctors propose new test panels, or changes to existing ones, either at the laboratory or the Department of Functional Appli cation Management. –– All test panel requests are referred to the one laboratory special ist responsible for organizing laboratory test ordering. –– The laboratory specialist contacts the doctor who requested the test panel(s). This must be someone authorized to speak for the whole specialism. (If an assistant or nurse made the request, the doctor who initiated the request will be contacted). –– The laboratory specialist and doctor speak briefly, by tele phone, e-mail or face-to-face and reach a consensus about the proposal(s). –– The laboratory specialist instructs the Department of Functional Application Management to program the new test panel(s) or change existing one(s) in the ordering screen of the medical specialism concerned. The present survey takes into account all proposals for new test pan els made between August 2009 and November 2012. In this period 15 panel proposals were made on hard copy (later transferred to the HIS) and 23 were made electronically. We kept a detailed log of all requests for test panels and the panels introduced as a result. Together with the 22 panels remaining from the pre-study period (previous para graph), this makes the 60 panels for which the effect of our interven tion was evaluated.
Evaluation of test panels with doctors Our objective was to encourage doctors to appraise the contents of their proposals and to consider whether the proposed tests were genuinely essential. We identified tests that could be elimi nated, suggested alternatives and, naturally, also pointed out tests that appeared to have been overlooked. To check for redundancy, attention was paid to test ‘pairs’ in the panels, which often pro vide overlapping clinical information. Examples include eryth rocyte sedimentation rate and C-reactive protein (CRP); urea and creatinin; total protein and albumin; free thyroxine (fT4) and thy roid-stimulating hormone (TSH); the assorted liver function tests γ-glytamyltransferase (γ-GT), alkaline phosphatase (ALP), aspartate aminotransferase (AST), alanine transferase (ALT) and bilirubin and the pancreas function tests amylase and lipase [3, 11]. The diagnostic information of these tests is largely similar, although not identical. It is our experience that doctors are often only interested in the main, most well-known application of these tests and do not use them in more detail (or are even aware of the more subtle diagnostic mean ing). However, if doctors had good reasons for tests, that overlapped but were non-identical, to be represented simultaneously in test pan els, they were of course permitted. We also drew doctors’ attention to esoteric, rarely requested, expensive and outdated tests, which in our opinion do not deserve a place in routinely ordered test panels. Examples are vitamin A and methemoglobin (esoteric), sex hormone binding globulin (SHBG) (rarely requested), carbohydrate deficient transferrin (CDT) (rather expensive) and creatin kinase-MB and bleeding time (outdated, at least in our hospital). Although this way of characterizing tests is more or less arbitrarily, depending on per sonal views and the local situation, it provided a useful starting point for discussing the ordering of tests and test panels.
In our experience, the doctors were generally open to the efforts of the laboratory staff to increase the efficiency of test panel orders. The key here was a straightforward and concise approach: consul tations for new test panels took no more than a couple of minutes, while reviews of existing panels took 15–45 min per medical special ism, depending on the number of test panels involved.
Estimation of the effects of intervention and data processing We evaluated the effects of our intervention with the existing test panels and the newly proposed panels on three levels: the number of tests per panel, the annual test numbers and the financial value of the panels and tests. To estimate the effect of our intervention on the ordering and savings of individual tests, the tests in each panel before and after the intervention were multiplied by the numbers of annually ordered test panels. The results of these multiplications were added together, providing the numbers of each test collectively ordered in the unmodified and altered test panels. In other words, we calculated the effect of our intervention using one set of annu ally ordered panel numbers rather than the actual ordering numbers before and after the intervention. For the annually ordered panel numbers actual ordering data were used from 2012. In a few cases the new panel was introduced in the course of 2012; the annually ordered panel number was then calculated by extrapolation based on the fig ures for at least 3 months. The order ‘complete blood count’ was counted as three separate tests: hemoglobin/hematocrit/red blood cell indices; thrombocyte counting; and leukocyte counting/automatic leukocyte differen tiation. Manual leukocyte differentiation was counted as a separate test, as were sodium and potassium. To estimate the costs of the tests and test panels, the official ratings for laboratory testing provided by the Dutch Government for 2012 were used [12]. To evaluate the persistent use of individual tests eliminated from test panels, a sample of 12 ordered tests was used, as the order ing system in our HIS does not allow for a complete overview of the simultaneous ordering of individual tests and panels; nor was it pos sible to investigate whether eliminated tests were ordered around the time the test panels were ordered, not just simultaneously. Our selec tion of tests was purely pragmatic, determined by the test panels and individual, simultaneously ordered tests that we could retrieve reliable data for from the HIS. As such, we compared the ordering of test panels and the individual tests ALT, amylase, AST, blood group typing, cross matching, erythrocyte sedimentation rate (ESR), iron, fT4, follicle-stimulating hormone (FSH), γ-GT, lactate dehydrogenase (LDH) and urea in 2011 and 2013, the years well before and after the mentioned tests were eliminated from the test panels. Statistical test ing was done using the one-sided Student t-test.
Results Laboratory tests in test panels The test panels each consisted of 3–30 tests. Table 1 lists the 82 clinical chemical and hematological tests that were
Blood Activated partial thromboplastin time (APTT) Alanine aminotransferase (ALT) Albumin Alkaline phosphatase Amylase Apolipoprotein A1 Apolipoprotein B Aspartate aminotransferase (AST) Bilirubin Bleeding (or coagulation) time Blood gases Blood group typing Calcium Carbohydrate deficient transferrin (CDT) Chloride Cholesterol Collagen 1 telopeptide (ICTP) Coombs indirect, antibody screen irr blood gr antigens Cortisol C-reactive protein (CRP) Creatin kinase (CK) Creatinin Cross matching Erythrocyte sedimentation rate (ESR) Estradiol Ferritin α Fetoprotein Folic acid Follicle stimulating hormone (FSH) free T4, free Thyroxin (fT4) Glucose γ Glutamyl transferase (γ–GT) Hemoglobin, erytrocytes and cell indices Hemoglobin A1c (HbA1c) High and low density lipoprotein (HDL and LDL)
Test
3.45 1.76 1.76 1.76 2.35 10.36 10.36 1.76 1.76 10.36 4.84 3.45 1.76 27.64 1.76 1.76 10.36 4.84 3.45 4.84 1.76 2.35 3.45 1.76 10.36 10.36 10.36 8.29 8.29 8.29 1.76 1.76 1.76 8.29 3.45
Rate, €
10.1 63.3 23.3 46.7 10.0 1.7 1.7 43.3 21.7 1.7 3.3 10.0 20.0 3.3 3.3 26.7 5.0 3.3 5.0 26.7 8.3 73.3 5.0 30.0 1.7 1.7 3.3 3.3 3.3 11.7 35.0 43.3 83.3 6.7 13.3
2370 13,996 1680 7486 4396 686 686 12,908 5120 62 176 4332 1976 140 52 7318 534 112 246 9230 5426 94,656 3804 7528 186 180 90 220 234 810 10,512 6528 19,958 512 6094
Before intervention Panels that Annual test include number test, % total #
Table 1 Laboratory tests in the 60 remaining test panels after intervention (data for entire year 2012).
8.3 46.7 16.7 21.7 5.0 1.7 1.7 28.3 11.7 0.0 3.3 8.3 18.3 0.0 1.7 26.7 5.0 3.3 1.7 21.7 8.3 68.3 3.3 21.7 0.0 1.7 1.7 3.3 0.0 6.7 36.7 40.0 83.3 5.0 11.7
Panels that include test, % 2358 12,668 1272 4748 3784 686 686 11,330 3758 0 176 3876 1856 0 12 7318 534 112 12 9292 5426 94,360 3348 3760 0 180 12 220 0 306 10,552 6536 19,958 972 6086
Annual test number total # 83.3 73.7 71.4 46.4 50.0 100 100 65.4 53.8 0.0 100 83.3 91.7 0.0 50.0 100 100 100 33.3 81.3 100 93.2 66.7 72.2 0.0 100 50.0 100 0.0 67.1 105 92.3 100 75.0 87.5
Change in presence in panels, % 12 1328 408 2738 612 0 0 1578 1362 62 0 456 120 140 40 0 0 0 234 –62 0 296 456 3768 186 0 78 0 234 504 –40 –8 0 –460 8
Decrease in number of testing, n
41 2337 718 4819 1438 0 0 2777 2397 642 0 1573 211 3870 70 0 0 0 807 –300 0 696 1573 6632 1927 0 808 0 1940 4178 –70 –14 0 –3813 28
Savings, €
After intervention
734 Janssens et al.: Management of laboratory test panels
IgA IgG IgM International normalised ratio (INR) Iron Lactate dehydrogenase (LDH) Leukocyte differentiation Leukocytes Luteinising hormone (LH) Magnesium Methemoglobin NT-proBNP Osmolarity Parathyroid hormone (PTH) Phosphate Potassium Procollagen 1 N-terminal propeptide (PINP) Prolactin Protein (total) Protein spectrum (for M-proteins) Prothrombin time (PT) Sex hormone binding globulin (SHBG) Sodium Testosteron Thrombocytes Thyroid stimulating hormone (TSH) Thyroid screening: reflex testing of TSH followed by fT4 Transferrin Triglycerides Troponin Urea Uric acid Vitamin A Vitamin B1 Vitamin B12 25-OH Vitamin D
Test
(Table 1 Continued)
8.29 8.29 8.29 11.1 2.35 1.76 1.76 1.76 8.29 3.45 3.45 20.73 3.45 10.36 1.76 1.76 10.36 8.29 1.76 13.82 3.45 10.36 1.76 10.36 1.76 6.91 8.29 6.91 2.35 8.29 1.76 1.76 6.91 10.36 10.36 10.36
Rate, €
1.7 1.7 1.7 5.0 5.0 26.7 46.7 76.7 3.3 6.7 1.7 1.7 3.3 6.7 16.7 56.7 5.0 0.0 11.7 3.3 10.0 3.3 56.7 3.3 75.0 20.0 5.0 5.0 30.0 3.3 40.0 8.3 1.7 1.7 3.3 6.7
78 78 78 528 1092 10,304 5498 17,928 234 770 8 12 52 714 2266 92,768 534 0 548 234 2472 234 92,768 234 20,430 2092 442 1092 7490 4898 91,728 2098 180 40 220 714
Before intervention Panels that Annual test include number test, % total # 1.7 1.7 1.7 0.0 3.3 18.3 41.7 75.0 1.7 5.0 1.7 3.3 1.7 6.7 11.7 48.3 5.0 1.7 6.7 3.3 10.0 1.7 48.3 1.7 66.7 10.0 15.0 3.3 30.0 3.3 20.0 8.3 0.0 1.7 3.3 6.7
Panels that include test, % 78 78 78 0 406 9552 5076 17,782 48 730 8 64 12 714 1148 92,454 534 48 240 234 2472 48 92,454 48 19,504 828 1706 406 7490 4898 85,372 2098 0 40 220 714
Annual test number total # 100 100 100 0.0 66.7 68.8 89.3 97.8 50.0 75.0 100 200 50.0 100 70.0 85.3 100 nd 57.1 100 100 50.0 85.3 50.0 88.9 50.0 300 66.7 100 100 50.0 100 0.0 100 100 100
Change in presence in panels, % 0 0 0 528 686 752 422 146 186 40 0 –52 40 0 1118 314 0 308 0 0 186 314 186 926 1264 –1264 686 0 0 6356 0 180 0 0 0
Decrease in number of testing, n
542 0 0 1927 553 1927 1630 8734 –10,479 4740 0 0 11,187 0 1244 0 0 0
0 0 0 5861 1612 1324 743 257 1542 138 0 –1078 138 0 1968 553 0
Savings, €
After intervention
Janssens et al.: Management of laboratory test panels 735
nd, not determined (test included in 0 panels before intervention and 1 panel after intervention, i.e., an infinite percentage increase). The rate for each test is based on the Dutch national NZA rates for hospital tests 2012.
–2819 0 0 0 0 0 234 0 422 0 –155 68,028 –686 0 0 0 0 0 12 0 240 0 –66 912 12 12 60 12 12 0 8 0 12 3760 568,576 3.4 1.7 1.7 1.7 1.7 1.7 0.0 1.7 0.0 1.7 17.2 226 12 12 60 12 12 12 8 240 12 3694 595,400 1.7 1.7 1.7 1.7 1.7 1.7 1.7 1.7 1.7 1.7 15.5 4.11 1.76 2.35 4.84 3.45 1.76 19.48 1.76 1.76 1.76 2.35
Rate, €
200 100 100 100 100 100 0.0 100 0.0 100 111
Savings, € Decrease in number of testing, n
Urine Albumin: creatinin ratio (simultaneous test) Chloride Creatinin Micro-albumin Osmolarity Potassium Pregnancy test Protein quantitave Sediment inspection by microscopy Sodium Strip test Total
Test
(Table 1 Continued)
Before intervention Panels that Annual test include number test, % total #
Panels that include test, %
Annual test number total #
Change in presence in panels, %
After intervention
736 Janssens et al.: Management of laboratory test panels included in the test panels before our intervention, their frequency of use in the panels, their annual test numbers and the savings per test. Table 2A shows the 20 tests included in the highest number of the original panels, together with their yearly test numbers in raw numbers and value. The tests with the highest annual test numbers were the hematological tests and creatinin.
Effects of intervention on contents and value of test panels Figure 1 shows the numbers of tests included in the dif ferent test panels and the values of the test panels before and after our intervention. The intervention resulted in a reduction of the number of tests per test panel from 12.5 ± 6.7 to 10.3 ± 5.7 (means ± sd, n = 60). This represents a reduction of 17.7 ± 9.9% (p