Controlling Laboratory Overutilization Through Formularies
overutilization of laboratory tests continues to be the bane of laboratory and
hospital management. Overutilization is troublesome for several reasons, of
-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.
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.
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.
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.
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.
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.
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.
today’s climate of high cost, innovative operational methods and
overutilization of lab tests that this is an approach worth pursuing.