Laboratory Stewardship

The current healthcare climate creates a great opportunity for clinical leadership, pathologists, and caregivers to take a role in optimizing the value of laboratory testing.

Test utilization management strategies lead to appropriate and timely diagnoses while helping to decrease unnecessary laboratory testing and phlebotomy. Such initiatives result in increased patient and provider satisfaction and reduced healthcare costs.

Our success has been made possible through an open and transparent process, the support of our health system’s leadership, multidisciplinary participation of individuals throughout our organization, and our committee’s willingness to learn and change.

These are successful strategies we have developed and/or implemented to promote appropriate laboratory testing.

Resources

Laboratory Stewardship Best Practices

Since 2011, several ongoing interventions have been integrated into the Cleveland Clinic practice, including:

  • Genetic Testing Restrictions
  • Hard Stop Alerts
  • Smart (Soft Stop) Alerts
  • Laboratory Genetic Counseling
  • Expensive Test Notifications

These and other strategies have ultimately avoided 209,143 unnecessary tests and saved Cleveland Clinic $5.9 million over eight years.

Avoided Tests

Cost Savings (in $)

Genetic Testing Restrictions

Genetic molecular testing was one of the first areas selected for a test utilization management pilot project within Cleveland Clinic.

Many resources are required for genetic testing: it is typically expensive, complicated to perform and interpret, and has variable insurance coverage, often including prior authorization requirements.

The Laboratory Stewardship Committee proposed that ordering of molecular genetic tests should be restricted in the same way that costly and highly-specialized pharmaceuticals can only be prescribed by select clinical experts (e.g., chemotherapy is only prescribed by oncologists, and certain antimicrobials are limited to infectious disease clinicians).

Based on this framework, the committee limited the ordering of complex molecular genetic tests to providers for whom these tests are a routine part of their practice (e.g., clinical genetics, pediatric neurology).  Through a clinical support decision alert, other providers seeking to order a restricted genetic test are advised to request a consult with the clinical or laboratory genetics teams.

In 2018, 36 unnecessary molecular genetic tests were prevented for a total savings of $45,559.

Prevented Tests

Hard Stop Alerts

This clinical decision support tool (CDST) notifies providers with an alert if they are ordering an ineligible test and displays previous test results if they are available.

Tests that trigger a Hard Stop Alert include those that should not be repeated within a 24-hour period and constitutional/germline genetic tests.

A Hard Stop Alert cannot be electronically bypassed by the provider. If the duplicate test is necessary for patient care, the provider may contact Client Services to override this intervention.

In 2018, the alert fired 4,307 times. As a result, 4,225 unnecessary duplicate tests were prevented for a total savings of $56,122.

Prevented Tests

2018 Total Alerts

  • Prevented
  • Overridden

Smart (Soft Stop) Alerts

This type of alert allows for the flexibility necessary in certain practice settings.

Much like a Hard Stop, a Smart Alert appears when an ineligible order is placed.  This message informs the provider that they are attempting to place a duplicate test order and shows the previous test result information, if available.

The difference between these alerts and Hard Stops, however, is that the Smart Alert soft stop can be bypassed at the point of order entry.

In 2018, 9,654 unnecessary duplicate tests were prevented for a total savings of $76,100.

Prevented Tests

Laboratory Genetic Counselors

Utilizing genetic counselors within the laboratory is a proven laboratory stewardship strategy.

These highly knowledgeable individuals provide pre-analytic value through test selection guidance and triage of incoming orders. Laboratory genetic counselors contribute to post-analytic settings by providing input regarding genetic counseling and follow-up testing.

At Cleveland Clinic, laboratory genetic counselors review genetic test orders, including clinical indications, before testing is performed.  Working with the ordering providers, genetic counselors ensure that the ordered test is the most appropriate option for the patient and will suggest alternative approaches for the provider to consider, if necessary.

In 2018, 465 genetic tests were changed or canceled for a total savings of $213,666.

Prevented Tests

2018 Outcomes

Totals are shown as percentages in the graph above.

Expensive Test Notifications

Expensive Test Notifications were created to alert providers of tests that cost more than $500 to perform.

With the ever-growing list of activities involved in patient care, providers are occasionally unaware of costs associated with the services they recommend. By informing providers of the cost at the time of ordering, they can evaluate other diagnostic approaches and engage the patient in discussions about their options, since their insurance may not cover these costs.

In 2018, 1,121 expensive tests were averted for a total savings of $1,327,325.

Note: Expensive Test Notifications were implemented in 2013.

Prevented Tests

Totals Per Intervention: 2011 – 2018

Avoided Tests

Cost Savings

About the Laboratory Stewardship Committee

Cleveland Clinic’s Laboratory Stewardship Committee is a multidisciplinary team that consists of clinicians, pathologists, administrators, and caregivers at Cleveland Clinic who are committed to improving test utilization within our health system.  Every clinical department from Cleveland Clinic is invited to designate a representative to participate in this committee.

Our team adheres to Cleveland Clinic’s “Patients First” principle: any recommendations are intended to improve patient care without compromising quality for cost savings. If an expensive test is needed to secure a diagnosis or guide therapy, then we support the use of such tests; however, we recognize there is substantial waste in the system, and we believe that it can be improved through better utilization of resources.

Promoting Best Practices with Other Providers

Developing Evidence-Based Guidelines for Optimal Testing

Conscientious Use of Molecular Testing

Decreasing Unnecessary Phlebotomy

Reducing Unnecessary Duplicate Orders

Reducing Cost Through Judicious Use of Resources

Multidisciplinary collaborations, institutional support, good project management & reporting, and great informational technology support have led to results that no singular group could have achieved alone. Our Laboratory Stewardship Committee believes that our efforts have improved the patient experience, decreased unnecessary phlebotomy for the commonly-used tests, improved the use of molecular genetic testing, and have helped to decrease our system’s spend on healthcare costs.

Most importantly, our initiatives have never interrupted patient care. Our committee seeks to implement interventions that promote best patient care; however, we have always provided an avenue for the ordering provider to override the intervention if they believed it was necessary.

The entire process has been an enjoyable lesson in team building and enhancing practice within the Cleveland Clinic health system.  We look forward to developing new solutions together with our colleagues.

The Right Test for the Right Patient at the Right Time.

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Cleveland Clinic Laboratories
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