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Press Start: Lead an Empowered Life as a Clinical Laboratorian

Controlling Laboratory Overutilization Through Formularies

Published August 2, 2014 3:03 PM by Glen McDaniel

The overutilization of laboratory tests continues to be the bane of laboratory and hospital management. Overutilization is troublesome for several reasons, of course.


-Laboratory professionals are frustrated by clear misuse of tests and sometimes needless repitition of previously performed tests e.g. daily profiles or repeat of send out tests before the original are on the chart


-Hospital management are acutely aware that overutilization increases costs. Organizations that receive a per diem rate from Medicare or a managed care policy, for example, are just eating into their profit margin with every service (including laboratory test) that they perform.


Sometimes patients are not discharged as scheduled  in order to perform additional tests or to wait for test results. Some tests are not necessary; others are important but can be performed on an outpatient basis.


-Physicians do not benefit from overutilization because they have to address any abnormal results that turn up during the process. They also are under pressure from administration to keep costs down and to discharge patients ASAP.


-Patients are inconvenienced and suffer discomfort when subjected to frequent lab draws, and they may have a heightened sense of anxiety while waiting for “yet another test result.” They do not always understand why a result will vary from day to day and worry needlessly.. One cause of idiopathic anemia is frequent blood draws while in the hospital.


So what is a laboratory to do? Since physicians drive test ordering it is important to get physician input and to co-opt physician champions to tackle the problem. If you have a strong, knowledgeable pathologist that helps. But even absent such a person, it is possible for the laboratory to gather information regarding the points raised above and also refer liberally  to independent sources describing best practices in laboratory utilization.


One method that a few laboratories have adopted successfully is the use of formularies similar to drug formularies. It is a common concept that just about every hospital pharmacy has a formulary of “acceptable and available medications.” Physicians must pick from that list. Any deviation must be approved by a committee-or at least be honored only after detailed justification and documentation.


The information technology folks play a significant role in forcing physicians to stick to formularies. If they try to order an off formulary drug-or even an off-label drug available in the formulary- they may receive a soft stop or a hard stop in the computer system.


The same concept can be used for laboratory testing. If a physician orders some tests (no longer available, inappropriate, very complex, very costly, ordered too frequently for that patient) they can receive the same hard or soft stop. Either the test is not allowed at all, or the ordering physician needs further documentation and approval in order to have that test done.


It is very likely (as happens in pharmacy with off-formulary and off-label use of medication) that some physicians will protest, be slow adopters or will call the laboratory directly for an explanation of rationale; or even to over-ride the hard stop. They will pull rank and try to be exempt from the rule. Pharmacists are very adept at fielding such calls. In order for laboratory formularies to work it is important for laboratorians to be equally knowledgeable and confident when speaking to possibly frustrated and aggressive physicians.


In today’s climate of high cost, innovative operational methods and overutilization of lab tests that this is an approach worth pursuing.


I am wondering if you have any ideas of any lab that has tried that idea. I think it makes so much sense I am wondering why it is not practiced as the standard for medical laboratories.

Miriam Oyerinde, MT September 7, 2014 11:31 PM

That is a great idea. It is always difficult telling MDs what they cant and cannot have or do. But I do notice doctors have accepte dthe ide aof formularies very well.

They are used to taht idea so maybe if we approach "what's available on the lab menu" the same way that might work.

Who all has tried this approach?

Belinda Carter, MT2 August 4, 2014 4:54 PM
Denver CO

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