how to develop an effective utilization management programchoosing wisely • american academy of...
TRANSCRIPT
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How to Develop an Effective Utilization Management Program
Department of Pathology & ARUP Laboratories, University of UtahDirector, Center for Evidence-Based TestingMedical Director, Clinical Laboratory, Huntsman Cancer Institute
Robert L Schmidt, MD, PhD, MBA
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My backgroundFormer Life:
• Business School Professor
• Specialized in Operations Analysis, Analytics
Present Life:
• Director, Center for Effective Medical Testing
• Apply Analytics to Testing Problems
• Cost-Effectiveness Analysis
• Utilization
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Learning Objectives
List key attributes of successful utilization programs.
Recognize situations where improvement metrics are counterproductive.
Explain how to identify strong utilization projects.
Describe several classes of interventions to improve utilization.
Identify common barriers to successful utilization management.
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The REAL Objective:
– Make UM easier!
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TAKE HOME MESSAGE:
– Utilization management is not difficult
– You already know how to do it• Continuous Improvement
• Plan Do Study Act Cycle
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The Opportunity
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Plebani et al AJCP 2011; 136:829-833
How does the lab contribute value?
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Plebani et al AJCP 2011; 136:829-833
WithinLab
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Plebani et al AJCP 2011; 136:829-833
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Orders
Reports
Samples
Laboratory as Service Factory
Goals: Efficiency
LaboratoryEHR
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SourcesofLabValue
Plebani et al AJCP 2011; 136:829-833
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LaboratoryTest Order
Process
Test Interpretation
LaboratoryAnalytical
PhaseEHR
Orders
Reports
SamplesClinicians
Sampling &Transport
Old Approach:
New Approach:
Clinicians Clinicians
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Managing Utilization
• Organization
• Process
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Utilization Improvement Process
TargetIdentification
InterventionPlanning and Management
Measurement
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Utilization Improvement Process
TargetIdentification
InterventionPlanning and Management
Measurement
PLANIdentification
DOIdentification
STUDYIdentification
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Utilization Improvement Process
TargetIdentification
InterventionPlanning and Management
Measurement
PLANIdea generationProject Selection
Identification
DOImplement Intervention
Identification
STUDYAssess ImpactIdentification
Data CollectionData AnalysisDomain Knowledge
Change ManagementCommunicationIntervention Knowledge
Data CollectionData AnalysisDomain Knowledge
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Structure
Leadership(Clinician/Executive)
Analysis
Domain Knowledge
DataCollection Informatics
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1. UM is nothing new – process improvement
2. Laboratory Medicine does not have a natural monopoly on utilization management
3. Utilization management is an opportunity for laboratory medicine
KEY POINTS:
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Generating ideas for improvement
• Review send out testing
• Obsolete tests– Common culprits
• Helicobacter antibodies
• Myelin basic protein for multiple sclerosis
• Culture vs NAAT for microorganisms
• HVA and MVA for pheochromocytoma
• CKMB
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More common culprits
• Thyroid testing– T3 uptake
– Free T4 is preferred to Total T4
– T3 testing should be relatively rare compared to T3 testing
– Reverse T3
(See forthcoming CLSI document on utilization management)
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More common culprits
• Thrombotic disorders– Functional vs Antigen testing for Proteins C and S
– Lupus anticoagulant
• Beta-2 glycoprotein IgA
• Cardiolipin antibody IgA
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Choosing wisely
• Recommendations for 20 different medical societies
• See summary in forthcoming CLSI document on Developing and Managing a Laboratory Test Utilization Program
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Choosing wisely
• American Academy of Family Physicians– No routine screening for prostate cancer using PSA
– No pap test for women younger than 21
– Do not screen women younger than 30 with HPV testing
• American Academy of Allergy, Asthma and Immunology– No routine diagnostic tests for those with chronic urticaria
– Do not perform unproven diagnostic tests such as IgG testing or battery of IgE tests for evaluation of allergy
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Choosing wisely
• American Society for Clinical Pathology– Do not use bleeding time
– Use troponin rather than CKMB for AMI
– Avoid routine preoperative testing for low risk surgeries without a clinical indication
– Low risk HPV tests
– Population based screening for Vit-D deficiency
– Only order vit K if patient has abnormal INR and does not respond to vit K therapy
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Generating ideas for improvement
• Guideline adherence– Secondary tests second
• PSA, Free PSA
• Total Testosterone, Free Testosterone
• TSH, Free T4
• Questionable cost-effectiveness– CVD tests
– Genetic tests
• Testing Intervals– Once in a lifetime tests (germline genetic tests, HAV)
– Tests with Guidelines (see Royal College)
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Repeat Testing Guidelines
• Royal College of Pathologists (UK)– National Minimum Re-testing Interval Project
– 50-60 suggested intervals
– https://www.rcpath.org/asset/BBCD0EB4-E250-4A09-80EC5E7139AB4FB8/
• Orth M, et al. Recommendations for the frequency of ordering laboratory testing. LaboratoriumsMedizin. 2014;38(5) in English
• Janssens PMW, et al. Managing laboratory test ordering through test frequency filtering. Clin Chem Lab Med 2013;51(6): 1207-1215.
• Konger RL, et al. Reduction in Unnecessary Clinical Laboratory Testing Through Utilization Management at a US Veterans Affairs Hospital Am J Clin Pathol 2016; 145: 355-364. See Supplementary Document – List of ~60 recommended repeat intervals
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When guidelines are not available
• Benchmarking
• Test Yield
• Frequency profiles
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Ratio of vitamin D to CBC
Median
0.2
.4.6
.81
Pro
porti
on o
f Site
s
18
1522
2936
4350
5764
7178
85S
ite
0 .1 .2 .3 .4Overall Testing Intensity, Vit D/Blood Count
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Median
0.2
.4.6
.81
Pro
porti
on o
f Site
s
14
710
1316
1922
2528
31S
ites
0 .05 .1 .15 .2Relative Testing Intensity
Ratio of 1,25 (OH)2 Vitamin D orders to 25-OH-Vitamin D
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Practice Variation in Thyroid Testing
T4/TSH0
.2.4
.6.8
Frac
tion
0 .2 .4 .6 .8 1
T3/TSH
0.2
.4.6
.8
Frac
tion
0 .2 .4 .6 .8 1
T3U/TSH
0.2
.4.6
.8
Frac
tion
0 .2 .4 .6 .8 1
rT3/TSH
0.2
.4.6
.8
Frac
tion
0 .2 .4 .6 .8 1
Test Selection Intensity Ratio, Test Volume/TSH Volume
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Order patterns by hospital
0.0
5.1
.15
T3U
/TS
H
.5 .6 .7 .8 .9 1
FT4/T4
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Test Yield Comparison by Hospital(HFE mutation)
0.0
5.1
.15
Frac
tion
0 .05 .1 .15 .2Positivity Rate
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Test Yield by HospitalAPCR, n=109
05
1015
Freq
uenc
y
0 .05 .1 .15 .2 .25 .3
PTGM, n=266
020
4060
Freq
uenc
y
0 .05 .1 .15 .2 .25 .3
FVL, n=284
010
2030
40Fr
eque
ncy
0 .05 .1 .15 .2 .25 .3Percent Positive
Activated Protein C
Prothrombin Mutation
Factor V Leiden
Percent Positive
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Organizational Effect Across Three TestsAPC, PTGM, FVL
-.04
-.02
0.0
2.0
4E
stim
ated
Clie
nt E
ffect
, 95%
CI
0 100 200 300 400Client
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Decerebrate order patterns(time interval between orders)
12 24 36Time, hours
Freq
uenc
y
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Testing on Autopilot
Time period prior to discharge Testing rate Relative rate<24 hr 249 per hour 71%24‐48 hr 349 per hour 100%
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Compare distribution of TAT of sendout tests to distribution of LOS
TAT
LOS
24 hrs 48 hrs Prob (Order + TAT < Discharge)
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Picking projects
Results = Potential Impact x Manageability
Potential Impact• Financial (cost x volume)• Medical
Manageability• Diffuse or concentrated problem
- Planned intervention• Specific problems (personnel, organizational)
Sustainability• Education• Hard stops, eliminating tests
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Financial Impact
• 80/20 rule– Most tests offer very little savings
Strata Numberof Tests
% of Tests
% of Cost
% total testingvolume
1 58 3% 60% 56%2 190 9% 26% 29%3 359 17% 10% 11%4 1463 71% 3% 4%
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Financial Impact
• Charges
• Costs
• Marginal cost
10% reduction in volume 2% reduction in cost
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Manageability
• Engage key opinion leaders– Avoid voting (lowest common denominator)
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Manageability
• Easy system-based interventions– Eliminate unordered tests
• 1000 of 3500 never ordered in one year
• 700 of 3500 ordered once in one year
– Show “price” data
• Feldman et al JAMA 2013 8.6% reduction
• Easy educational interventions– Feedback on relative volume, cost
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Interventions
• System based (IT)– Cost info
– Present last result
– Restrictions (formularies)
– Decision Support (links to algorithms)
• Education– Targeted (individuals, departments)
– Broad based (residents)• Hidden curriculum favors zebra workups
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Interventions
• Feedback– Individuals, Groups
– Public vs private
• Rewards & Penalties
References on interventions: • Kobewka et al. CCLM 2015;53(2):157-183
• Baird, G. The laboratory test utilization management toolbox. Biochemica Medica 2014; 24(2):223-224
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Metrics
• Standards of proof
– Before and after study sufficient for business
– Academic publication will slow you down
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Metrics - costing
• Charges
• Variable vs Fixed Costs– Most testing costs are fixed
– What would you save if you sent the test out?
Good references:– Huck & Lewandrowski, Utilization Management in the clinical laboratory: An
introduction and overview of the literature Clinica Chimica Acta 2014;427:111-117.
– Melanson, Establishing benchmarks and metrics for utilization management. Clinica Chimica Acta 2014; 427:127-130.
– Forthcoming CLSI document (chapter on metrics by Jason Baron and Kent Lewandrowski)
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Should you measure?
A hospital is considering whether to implement a cost feedback program on their test menu. Previous studies have indicated that one might expect a 7% reduction in testing. Overall lab budget is $14 million/yr. Should the hospital conduct a study to measure the impact?
• Expected savings = $14,000,000 * 0.07 * 0.33 = $323,000 per year
• Estimated variable costs = 33%
• Cost feedback is unlikely to do harm. Not costly to implement.
• Cost of study:
– Control arm = 50% of tests (no savings)
– Interventional arm = 50% of tests ($160,000 savings)
• Bottom line: Pay $160,000 to see how big the savings were
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Summary
• What we know– Process improvement methodology
– Interventions
– Targets with good metrics and guidelines (N ~50)
• What we don’t know– Need more guidelines, targets
– How to evaluate downstream impact (patient outcomes)
• Keys: – Effective Project Management
– Sharing Knowledge (don’t reinvent the wheel)
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