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Cost-containment strategies for the diagnostic microbiology laboratory
Clinical Microbiology Newsletter Vol. 9, No. 15
August l, 1987
Cost-Containment Strategies for the Diagnostic Microbiology Laboratory Paul D. Ellner, Ph.D. Clinical Microbiology Service The Presbyterian Hospital Columbia Presbyterian Medical Center New York, New York 10032
Under the Prospective Payment System for Medicare implemented in 1983, reimbursement for delivered hospital services, including laboratory services, is no longer based on a retrospective summation of charges. Instead, Medicare has established a payment level for each specific Diagnosis Related Group (DRG), and hospitals are paid only this amount regardless of the duration and/or intensity of the services rendered. It has been estimated that at least one-third of hospital funding in the United States derives from Medicare. The effect of this reimbursement system on clinical laboratories has been profound, and has caused apprehension in laboratory directors envisioning or encountering severe budgetary restrictions as laboratories transition from profit centers to cost centers. However, these economic constraints may actually be salutary for laboratories, hospitals, and physicians, The new reimbursement system encourages shorter patient stays in the hospital and maintenance of high occupancy rates. These factors can lead to an increased specimen load for the laboratory without a commensurate increase in collectable laboratory
CMNEEJ 9(15)117-124,1987
income. This looming economic paradox has stimulated laboratory directors to actively explore avenues of reducing the costs of laboratory operation. Cost-containment means different things to different laboratories. Among laboratories in the United States, approximately 6,000 are hospital-based, 8,000 are independent, and perhaps 80,000 are in physician's offices. Microbiology usually accounts for 10 to 12% of the total clinical laboratory activity; 17% if serology is included, Even among hospital laboratories there is great diversity between one located in a small isolated rural hospital and one in a large metropolitan medical center. Because of this heterogefieity, general statements regarding clinical laboratories have the potential for error. Nevertheless, certain fundamental problems and principles affect laboratory medicine and clinical laboratories of all types. The corrective action for one type, however, may be inappropriate for another, Historically, laboratories have been obliged to perform tests on all specimens submitted by clinicians, regardless of specimen quality or the relationship of the test to patient care. In many instances, inappropriate or redundant tests and replicate or inadequate specimens used a major portion of the clinical laboratory resources, These practices were often ignored, condoned, or encouraged by pathologists and hospital administrators moti-
Elsevier
vated by profit and the hope of keeping the staff physician satisfied with ancillary services. The mission of the clinical laboratory remains unchanged; to provide test resuits that can assist in diagnostic and therapeutic decisions. In microbiology, the primary mission is to demonstrate and identify microorganisms and determine their antimicrobial susceptibilities. The laboratory should provide guidelines for specimen selection, collection and transport, and the interpretation of results. Findings should occur rapidly enough to affect patient management (20).
In This Issue
Cost-Containment Strategies for
the Diagnostic Microbiology Laboratory . . . . . . . . . . . . . . . . . . 117 Recommendations for reducing laboratory expenses in the face of DRGs Aeromonas-Associated Diarrhea . 121 Evidence for the "Aeromonas hydrophila group" as an etiologic agent of diarrhea
Septic Arthritis Due to StreptobaeiUus moniliformis . . . . . 123
0196-4399/87/$0.00 + 02.20
A p p r o a c h e s to C o s t R e d u c t i o n Winkelman et al (25) have outlined four possible responses to reduced laboratory funding:
1. Straight cost cutting within the laboratory. This approach does not require alterations or changes in current test ordering behavior. It requires a close scrutiny and careful cost accounting of laboratory expenses. These may involve changes in vendors of supplies, service contracts, and reference laboratories; elimination of redundant proficiency testing; superfluous quality assurance practices; and freeing technologists from tasks that can be performed by technicians, clerks, or laboratory assistants. It is important to recognize that fixed costs (equipment, overhead, computer services) remain constant regardless of volume, while variable expenses (salaries and supplies) increase in direct proportion to the number of procedures performed, Technical salaries usually account for 50 to 65% of a laboratory's operating cost. A graph of total expenses and revenues by costs and numbers of procedures can indicate the breakeven point for any particular test. This break-even analysis is helpful in making decisions regarding the volume needed for a test to be cost-
development of laboratory resources (8). 2. Selective degradation of laborator3' services and functions. This approach involves reducing the frequency of testing to increase batch size and thus reduce labor and materials costs as well as certain overhead items. (Certain procedures, such as viral isolation and some other microbiological tests, cannot be delayed for technical reasons.) Limiting "stats" to certain procedures and allowing only emergency or acute care units to order such tests without specific approval can be effective, A number of other intralaboratory modifications have been proposed to
that required for diagnosis or therapy may gratify the ego of the laboratory director, but can involve additional cost and delay the report. The director should review identification practices with physicians to ensure that unnecessary expense is not incurred in identification exceeding clinical requirements. Examples of this would be typing of
Neisseria meningitidis, Klebsiella pneumoniae, pneumococci, and Haemophilus influenzae other than b, or speciating yeasts from mixed cultures (2, 3). New techniques can significantly improve laboratory responsiveness and shorten turnaround times on certain specimen types. Examples
help control costs (6, 11, 16, 23) and are listed in Table 1. In the author's laboratory, for example,
include the radiometric detection and susceptibility testing of mycobacteria, direct antigen detection in
culture of vaginal specimens for GardnereUa vaginalis has been replaced by microscopic examination of the specimen for organisms consistent with bacterial vaginosis. In one laboratory, adoption of some of the procedures listed in Table 1 has resulted in a reduction of technician time by almost 20% (1). Microbial identification beyond
spinal fluids, DNA probes for Legionella and Mycoplasma pneumoniae, and certain methods for bacteriuria screening. These newer methods are often more expensive and labor-intensive than conventional methods and the technician workload can significantly increase while specimen counts remain constant. The elimination of new
Table 1 Some Proposed Strategies for Cost-Containment
effective, whether to adopt a new methodology, whether automated equipment will enhance productivity
Elimination of check-off boxes from laboratory requisition form.
or decrease the cost of the test, or
Rejection of inadequate and replicate specimens.
whether the test should be referred to another laboratory (19, 22). Cost-analysis of test procedures can
Elimination of terminal subculture on radiometrically-negative blood cultures.
have some additional value because
Use of biplates rather than two plates for urine cultures.
third-party payers may base future reimbursement on costs rather than charges (17). It has also been suggested that an effective way to control expenditures for laboratory services would be to correct hospital accounting practices that set inflated laboratory charges and lead to uneconomical
Identification of common pathogens by simple, rapid methods including colonial and/or microscopic morphology or direct fluorescent antibody staining.
Screening to check specimen quality, e.g., sputa.
Elimination of broth media from the initial culture of most specimens.
Limiting identification and susceptibility testing to two organisms per specimen. Reduction in the overidentification of certain isolates, e.g., speciating coagulase-negative staphylococci or anaerobic cocci. Elimination of telephone reports before 10 a.m. Elimination of many interim reports.
Chnicul Microbiology Newsletter (ISSN 0196-4399) is issued t',~ice monthly in one indexed volume b> Elsevier Science Publishing Co.. 52 Vanderbilt Avenue, New York, NY 10017. Subscription prices per year: $78.00 including postage and handling in the United States. Canada. and Mexico. Add $35.00 for postage in the rest of the world. Second-class postage pending. Postmaster: send address changes to Clinical Microbiology Ne~letter~ Elsevier Science Publishing Co.. Inc.. 52 Vanderbih Avenue. New York. NY 10017
118
0196-4399/87/$0.00 + 02.20
~: 1987 Elsevier Science Publishing Co.. Inc.
Clinical Microbiology, Newsletter 9:15.1987
method development or improvement may produce short-term gains but long-term loss, as method changes could result in cost savings by simplification or automation, The microbiology laboratory can provide very significant cost savings to the hospital by selectively reporting antimicrobial susceptibility results. In our institution, secondgeneration cephalosporin results are reported only if the isolate is resistant to cefazolin, and third-generation drugs are reported only if the organism is resistant to the secondgeneration agents. Similar programs are in effect for aminoglycosides and other newer antimicrobial agents. This type of reporting discourages the use of expensive antibiotics in situations where a cheaper drug would be equally effective, 3. Decreased use of the laboratory, This approach assumes misuse and overuse of the laboratory by clinicians. "Routine" cultures and antibiotic susceptibilities are often ordered without adequate indications; physicians do not take steps to make certain that collection of specimens and their subsequent handling are carried out in a way that ensures maximum validity of the test results (15). In one study, diagnosis was the reason for only 37% of tests; an additional 7% of tests were obtained only because of liberal third-party reimbursement practices and would not have been ordered otherwise (24). Benson noted that most studies show that physician factors predominate in increasing laboratory use (4). In teaching hospitals, peer pressure, curiosity, standing orders, inappropriate interpretation of test results, and long turnaround time are factors contributing to excessive laboratory use (18). Everett et al found that social, economic, and professional pressures favor excessive testing (12). It has also been determined that laboratory factors contribute to overuse; the two problems often cited are long turnaround times (14) and unsolicited laboratory results given to physicians that may exceed
Clinical Microbiology Newsletter 9:15,1987
their ability to use them well (5). In addition, comprehensive laboratory request forms with check off boxes for ordering tests are an open invitation to the user to check off excessive numbers of tests (26). Two different kinds of intervention have been proposed to contain costs by reducing test volume. The first is behavioral, and is based upon the education of medical students, house officers, and attending physicians (14). However, subsequent studies have found that education of physicians is not a successful strategy (12, 21). The other type of intervention is regulatory, which limits the tests a laboratory can perform. Both approaches assume that a decrease in the volume of tests ordered will lead to a decline in laboratory costs. This assumption is an oversimplification and may not apply to all laboratories (13). Nevertheless, as long as prohibition against any restriction of laboratory use remains operative, the laboratory director is placed in the untenable position of supplying inadequate laboratory services at excessive prices (8). The College of American Pathologists has published guidelines listing basic, common, and less common tests appropriate for 24 of the 25 DRGs that account for a large majority of hospital admissions in this country (7). It has also been recommended that institutions establish a policy for controlling laboratory use (10). Any control measure depends upon the cooperation of the chiefs of clinical services as well as authoritarian support by the hospital administration. Optimal laboratory use requires that explicit criteria be defined as to when laboratory tests should be used and that methods be developed to ensure that the resuiting data are used properly (9). Cost-containment measures will not be successful if they are initiated by administrative fiat. Conscientious physicians will rebel against constraints they see as deleterious to patient care. Clinicians and laboratory directors
© 1987 Elsevier Science Publishing Co., Inc.
should jointly define the types and numbers of tests appropriate for various clinical situations. Tests that possess sufficient sensitivity, specificity, and predictive values to provide relevant information to the physicians within a realistic time frame should be selected. When agreement has been reached, the decision should be approved by the Medical Board and made hospital policy by the administration. All staff physicians should be advised of the new policies and assured that appropriate exceptions can be made by consultation with the laboratory director. An example of the limits in patient microbiology specimens at the author's institution is shown in Table 2. The laboratory director must have the authority to decline inappropriate requests that include replicate or redundant cultures, routine environmental surveillance cultures, complete reevaluation of a polymicrobial infection, tests done by standing orders or routine protocol, nonstandard tests, susceptibility testing of usually susceptible isolates, and speed--when not required for a clinical decision. It is sometimes helpful to require the approval of an infectious disease specialist for performing esoteric or labor-intensive tests of questionable value. 4. Reorganization of the laboratory. These alternatives include allocated testing by sharing services with laboratories in other hospitals; "going public," in which the laboratory becomes a for-profit entity (sometimes separate from the hospital and competing with commercial laboratories); or "going private" by transferring the ownership of the hospital laboratory to an existing corporation. Summary The goal of any cost-containment program should be to minimize operational expenses without reducing the quality of patient care. At present, microbiology is essentially a manual function; therefore, increases in specimen load and additional work per
0196-4399/87/$0.00
+ 02.20
1 19
'[able 2 Suggested Limits on Microbiology Specimens
Specimen,~
Limits
Urine, stool, genital, expectorated sputum, wounds
One per day, not to exceed three per week
Upper respiratory
One per day, not to exceed three per week
Blood
Three per day, not to exceed six per 48 h
Stool for ova and parasites
Three per patient admission or illness
Specimens tbr systemic fungi and serology
Three per patient admission
Specimens for viral isolation
One of each type per patient admission
Specimens for AFB (sputum or gastric aspirate)
Three of each type per patient admission
Urine or cerebrospinal fluid for acid-fast bacilli
Done only following infectious disease (ID) consult
Serum bactericidal test
Done only following ID consult
Specimens obtained by invasive procedures
No limit
specimen lead to increased operating costs. Effective strategies are those that improve the efficiency of the laboratory by supplying only relevant infor-
4. Benson, E. B. 1978. Clinical laboratory utilization and the cost of health care. Postgrad. Med. 63:20-21. 5. Benson, E. B. 1980. Initiatives toward effective decision making and laboratory use. Hum. Pathol. 11:440-448. 6. Caudill, G. D., et al. 1985. Modifications for expense reduction; Part 5. Microbiology. Laboratory Medicine 16:41-44. 7. College of American Pathologists. 1985. Effective laboratory testing, Skokie, Illinois. 8. Conn, R. B. 1978. Clinical laboratories. Profit center, production industry, or patient-care resource? N. Engl. J. Med. 298:422-427. 9. Corm, R. B. 1980. Optimal utilization of the laboratory in making clinical decisions. Hum. Pathol. 11:407-412. 10. Dolan, et al, (eds.). 1977. Proceedings of the 1975 Aspen conference on clinical relevance in microbiology. College of American Pathologists. Skokie, Illinois. 11. Ellner, P. D. 1985. A dozen ways to achieve more cost-effective microbiology. Med. Lab. Observer 17:40-44. 12. Everett, G. D. et al. 1983. Effect of cost education, cost audits, and faculty chart review in the use of laboratory
mation as quickly as possible and limit tests to those that impact directly on patient management. Educational efforts to alter the ordering behavior of physicians should be instituted, but regulatory measures must be in place that permit the laboratory director to restrict excessive or inappropriate testing,
References 1. Bartlett, R. C., and C. Rutz. 1980. Processing control and cost in bacteriology. Am. J. Clin. Pathol. 74:287296. 2. Bartlett, R. C. 1982. Making optimum use of the microbiology laboratory. 1. Use of the laboratory. J. Am. Med. Assoc. 247:857-859. 3. Bartlett, R. C. 1982. Making optimum use of the microbiology laboratory. II. Urine, respiratory, wound, and cervicovaginal exudate. J. Am. Med. Assoc. 247:1336-1338.
] 20
0196-4399/87/$0.00 + 02.20
,~ 1987ElsevierSciencePublishingCo.. Inc.
I~, Finkelstein, S. N. 1980. An approach Io studying the cost behavior of changing utilization of a hospital laboratory. Hum. Pathol. I 1:435-439. 14. Griner, P. F., and the Medical House Staff, Strong Memorial Hospital. 1979. Use of laboratory tests in a teaching hospital. Long-term trends. Reduction in use and relative cost. Ann. Intern. Med. 90:243-248. 15. Griner, P. F., and R. J. Glaser. 1982. Misuse of laboratory tests and diagnostic procedures. N. Engl. J. Med. 307:1336-1339. 16. Harris, P. C., and L. B. Sealey. 1986. Practical cost savings in microbiology. Med. Lab. Observer 18:33-41. 17. Krieg, A. F. et al. 1978. An approach to cost analysis of clinical laboratory services. Am. J. Clin. Pathol. 69:525536. 18. Lundberg, G. D. 1983. Perseveration of laboratory test ordering: A syndrome affecting clinicians. J. Am. Med. Assoc. 249:639. 20. Neu, H. C. 1978. What should the clinician expect from the microbiology laboratory? Ann. Intern. Med. 89:781784. 21. Schroeder, S. A. et al. 1984. The failure of physician education as a cost-containment strategy. Report of a prospective controlled trial at a university hospital. J. Am. Med. Assoc. 252:225-230. 22. Sharp, J. W. 1984. A DRG survival plan for the laboratory budget. Med. Lab. Observer, 16:38-48. 23. Washington II, J. A. 1985. The clinical microbiology laboratory. Utilization and cost-effectiveness. Am. J. Med. 78(suppl. 6B):8-16. 24. Wertman, B. G. et al. 1980. Why do physicians order laboratory tests? A study of laboratory test request and use patterns. J. Am. Med. Assoc. 243:2080-2082. 25. Winkleman, J. W., and R. B. Hill. 1984. Clinical laboratory responses to reduced funding. J. Am. Med. Assoc. 252:2435-2440. 26. Wong, E. T., M. M. McCarron, and S.T. Shaw, Jr. 1983. Ordering of laboratory tests in a teaching hospital. Can it be improved? J. Am. Med. Assoc. 249:3076-3080.
ClinicalMicrobiologyNewsletter9:15.1987
August l, 1987
Cost-Containment Strategies for the Diagnostic Microbiology Laboratory Paul D. Ellner, Ph.D. Clinical Microbiology Service The Presbyterian Hospital Columbia Presbyterian Medical Center New York, New York 10032
Under the Prospective Payment System for Medicare implemented in 1983, reimbursement for delivered hospital services, including laboratory services, is no longer based on a retrospective summation of charges. Instead, Medicare has established a payment level for each specific Diagnosis Related Group (DRG), and hospitals are paid only this amount regardless of the duration and/or intensity of the services rendered. It has been estimated that at least one-third of hospital funding in the United States derives from Medicare. The effect of this reimbursement system on clinical laboratories has been profound, and has caused apprehension in laboratory directors envisioning or encountering severe budgetary restrictions as laboratories transition from profit centers to cost centers. However, these economic constraints may actually be salutary for laboratories, hospitals, and physicians, The new reimbursement system encourages shorter patient stays in the hospital and maintenance of high occupancy rates. These factors can lead to an increased specimen load for the laboratory without a commensurate increase in collectable laboratory
CMNEEJ 9(15)117-124,1987
income. This looming economic paradox has stimulated laboratory directors to actively explore avenues of reducing the costs of laboratory operation. Cost-containment means different things to different laboratories. Among laboratories in the United States, approximately 6,000 are hospital-based, 8,000 are independent, and perhaps 80,000 are in physician's offices. Microbiology usually accounts for 10 to 12% of the total clinical laboratory activity; 17% if serology is included, Even among hospital laboratories there is great diversity between one located in a small isolated rural hospital and one in a large metropolitan medical center. Because of this heterogefieity, general statements regarding clinical laboratories have the potential for error. Nevertheless, certain fundamental problems and principles affect laboratory medicine and clinical laboratories of all types. The corrective action for one type, however, may be inappropriate for another, Historically, laboratories have been obliged to perform tests on all specimens submitted by clinicians, regardless of specimen quality or the relationship of the test to patient care. In many instances, inappropriate or redundant tests and replicate or inadequate specimens used a major portion of the clinical laboratory resources, These practices were often ignored, condoned, or encouraged by pathologists and hospital administrators moti-
Elsevier
vated by profit and the hope of keeping the staff physician satisfied with ancillary services. The mission of the clinical laboratory remains unchanged; to provide test resuits that can assist in diagnostic and therapeutic decisions. In microbiology, the primary mission is to demonstrate and identify microorganisms and determine their antimicrobial susceptibilities. The laboratory should provide guidelines for specimen selection, collection and transport, and the interpretation of results. Findings should occur rapidly enough to affect patient management (20).
In This Issue
Cost-Containment Strategies for
the Diagnostic Microbiology Laboratory . . . . . . . . . . . . . . . . . . 117 Recommendations for reducing laboratory expenses in the face of DRGs Aeromonas-Associated Diarrhea . 121 Evidence for the "Aeromonas hydrophila group" as an etiologic agent of diarrhea
Septic Arthritis Due to StreptobaeiUus moniliformis . . . . . 123
0196-4399/87/$0.00 + 02.20
A p p r o a c h e s to C o s t R e d u c t i o n Winkelman et al (25) have outlined four possible responses to reduced laboratory funding:
1. Straight cost cutting within the laboratory. This approach does not require alterations or changes in current test ordering behavior. It requires a close scrutiny and careful cost accounting of laboratory expenses. These may involve changes in vendors of supplies, service contracts, and reference laboratories; elimination of redundant proficiency testing; superfluous quality assurance practices; and freeing technologists from tasks that can be performed by technicians, clerks, or laboratory assistants. It is important to recognize that fixed costs (equipment, overhead, computer services) remain constant regardless of volume, while variable expenses (salaries and supplies) increase in direct proportion to the number of procedures performed, Technical salaries usually account for 50 to 65% of a laboratory's operating cost. A graph of total expenses and revenues by costs and numbers of procedures can indicate the breakeven point for any particular test. This break-even analysis is helpful in making decisions regarding the volume needed for a test to be cost-
development of laboratory resources (8). 2. Selective degradation of laborator3' services and functions. This approach involves reducing the frequency of testing to increase batch size and thus reduce labor and materials costs as well as certain overhead items. (Certain procedures, such as viral isolation and some other microbiological tests, cannot be delayed for technical reasons.) Limiting "stats" to certain procedures and allowing only emergency or acute care units to order such tests without specific approval can be effective, A number of other intralaboratory modifications have been proposed to
that required for diagnosis or therapy may gratify the ego of the laboratory director, but can involve additional cost and delay the report. The director should review identification practices with physicians to ensure that unnecessary expense is not incurred in identification exceeding clinical requirements. Examples of this would be typing of
Neisseria meningitidis, Klebsiella pneumoniae, pneumococci, and Haemophilus influenzae other than b, or speciating yeasts from mixed cultures (2, 3). New techniques can significantly improve laboratory responsiveness and shorten turnaround times on certain specimen types. Examples
help control costs (6, 11, 16, 23) and are listed in Table 1. In the author's laboratory, for example,
include the radiometric detection and susceptibility testing of mycobacteria, direct antigen detection in
culture of vaginal specimens for GardnereUa vaginalis has been replaced by microscopic examination of the specimen for organisms consistent with bacterial vaginosis. In one laboratory, adoption of some of the procedures listed in Table 1 has resulted in a reduction of technician time by almost 20% (1). Microbial identification beyond
spinal fluids, DNA probes for Legionella and Mycoplasma pneumoniae, and certain methods for bacteriuria screening. These newer methods are often more expensive and labor-intensive than conventional methods and the technician workload can significantly increase while specimen counts remain constant. The elimination of new
Table 1 Some Proposed Strategies for Cost-Containment
effective, whether to adopt a new methodology, whether automated equipment will enhance productivity
Elimination of check-off boxes from laboratory requisition form.
or decrease the cost of the test, or
Rejection of inadequate and replicate specimens.
whether the test should be referred to another laboratory (19, 22). Cost-analysis of test procedures can
Elimination of terminal subculture on radiometrically-negative blood cultures.
have some additional value because
Use of biplates rather than two plates for urine cultures.
third-party payers may base future reimbursement on costs rather than charges (17). It has also been suggested that an effective way to control expenditures for laboratory services would be to correct hospital accounting practices that set inflated laboratory charges and lead to uneconomical
Identification of common pathogens by simple, rapid methods including colonial and/or microscopic morphology or direct fluorescent antibody staining.
Screening to check specimen quality, e.g., sputa.
Elimination of broth media from the initial culture of most specimens.
Limiting identification and susceptibility testing to two organisms per specimen. Reduction in the overidentification of certain isolates, e.g., speciating coagulase-negative staphylococci or anaerobic cocci. Elimination of telephone reports before 10 a.m. Elimination of many interim reports.
Chnicul Microbiology Newsletter (ISSN 0196-4399) is issued t',~ice monthly in one indexed volume b> Elsevier Science Publishing Co.. 52 Vanderbilt Avenue, New York, NY 10017. Subscription prices per year: $78.00 including postage and handling in the United States. Canada. and Mexico. Add $35.00 for postage in the rest of the world. Second-class postage pending. Postmaster: send address changes to Clinical Microbiology Ne~letter~ Elsevier Science Publishing Co.. Inc.. 52 Vanderbih Avenue. New York. NY 10017
118
0196-4399/87/$0.00 + 02.20
~: 1987 Elsevier Science Publishing Co.. Inc.
Clinical Microbiology, Newsletter 9:15.1987
method development or improvement may produce short-term gains but long-term loss, as method changes could result in cost savings by simplification or automation, The microbiology laboratory can provide very significant cost savings to the hospital by selectively reporting antimicrobial susceptibility results. In our institution, secondgeneration cephalosporin results are reported only if the isolate is resistant to cefazolin, and third-generation drugs are reported only if the organism is resistant to the secondgeneration agents. Similar programs are in effect for aminoglycosides and other newer antimicrobial agents. This type of reporting discourages the use of expensive antibiotics in situations where a cheaper drug would be equally effective, 3. Decreased use of the laboratory, This approach assumes misuse and overuse of the laboratory by clinicians. "Routine" cultures and antibiotic susceptibilities are often ordered without adequate indications; physicians do not take steps to make certain that collection of specimens and their subsequent handling are carried out in a way that ensures maximum validity of the test results (15). In one study, diagnosis was the reason for only 37% of tests; an additional 7% of tests were obtained only because of liberal third-party reimbursement practices and would not have been ordered otherwise (24). Benson noted that most studies show that physician factors predominate in increasing laboratory use (4). In teaching hospitals, peer pressure, curiosity, standing orders, inappropriate interpretation of test results, and long turnaround time are factors contributing to excessive laboratory use (18). Everett et al found that social, economic, and professional pressures favor excessive testing (12). It has also been determined that laboratory factors contribute to overuse; the two problems often cited are long turnaround times (14) and unsolicited laboratory results given to physicians that may exceed
Clinical Microbiology Newsletter 9:15,1987
their ability to use them well (5). In addition, comprehensive laboratory request forms with check off boxes for ordering tests are an open invitation to the user to check off excessive numbers of tests (26). Two different kinds of intervention have been proposed to contain costs by reducing test volume. The first is behavioral, and is based upon the education of medical students, house officers, and attending physicians (14). However, subsequent studies have found that education of physicians is not a successful strategy (12, 21). The other type of intervention is regulatory, which limits the tests a laboratory can perform. Both approaches assume that a decrease in the volume of tests ordered will lead to a decline in laboratory costs. This assumption is an oversimplification and may not apply to all laboratories (13). Nevertheless, as long as prohibition against any restriction of laboratory use remains operative, the laboratory director is placed in the untenable position of supplying inadequate laboratory services at excessive prices (8). The College of American Pathologists has published guidelines listing basic, common, and less common tests appropriate for 24 of the 25 DRGs that account for a large majority of hospital admissions in this country (7). It has also been recommended that institutions establish a policy for controlling laboratory use (10). Any control measure depends upon the cooperation of the chiefs of clinical services as well as authoritarian support by the hospital administration. Optimal laboratory use requires that explicit criteria be defined as to when laboratory tests should be used and that methods be developed to ensure that the resuiting data are used properly (9). Cost-containment measures will not be successful if they are initiated by administrative fiat. Conscientious physicians will rebel against constraints they see as deleterious to patient care. Clinicians and laboratory directors
© 1987 Elsevier Science Publishing Co., Inc.
should jointly define the types and numbers of tests appropriate for various clinical situations. Tests that possess sufficient sensitivity, specificity, and predictive values to provide relevant information to the physicians within a realistic time frame should be selected. When agreement has been reached, the decision should be approved by the Medical Board and made hospital policy by the administration. All staff physicians should be advised of the new policies and assured that appropriate exceptions can be made by consultation with the laboratory director. An example of the limits in patient microbiology specimens at the author's institution is shown in Table 2. The laboratory director must have the authority to decline inappropriate requests that include replicate or redundant cultures, routine environmental surveillance cultures, complete reevaluation of a polymicrobial infection, tests done by standing orders or routine protocol, nonstandard tests, susceptibility testing of usually susceptible isolates, and speed--when not required for a clinical decision. It is sometimes helpful to require the approval of an infectious disease specialist for performing esoteric or labor-intensive tests of questionable value. 4. Reorganization of the laboratory. These alternatives include allocated testing by sharing services with laboratories in other hospitals; "going public," in which the laboratory becomes a for-profit entity (sometimes separate from the hospital and competing with commercial laboratories); or "going private" by transferring the ownership of the hospital laboratory to an existing corporation. Summary The goal of any cost-containment program should be to minimize operational expenses without reducing the quality of patient care. At present, microbiology is essentially a manual function; therefore, increases in specimen load and additional work per
0196-4399/87/$0.00
+ 02.20
1 19
'[able 2 Suggested Limits on Microbiology Specimens
Specimen,~
Limits
Urine, stool, genital, expectorated sputum, wounds
One per day, not to exceed three per week
Upper respiratory
One per day, not to exceed three per week
Blood
Three per day, not to exceed six per 48 h
Stool for ova and parasites
Three per patient admission or illness
Specimens tbr systemic fungi and serology
Three per patient admission
Specimens for viral isolation
One of each type per patient admission
Specimens for AFB (sputum or gastric aspirate)
Three of each type per patient admission
Urine or cerebrospinal fluid for acid-fast bacilli
Done only following infectious disease (ID) consult
Serum bactericidal test
Done only following ID consult
Specimens obtained by invasive procedures
No limit
specimen lead to increased operating costs. Effective strategies are those that improve the efficiency of the laboratory by supplying only relevant infor-
4. Benson, E. B. 1978. Clinical laboratory utilization and the cost of health care. Postgrad. Med. 63:20-21. 5. Benson, E. B. 1980. Initiatives toward effective decision making and laboratory use. Hum. Pathol. 11:440-448. 6. Caudill, G. D., et al. 1985. Modifications for expense reduction; Part 5. Microbiology. Laboratory Medicine 16:41-44. 7. College of American Pathologists. 1985. Effective laboratory testing, Skokie, Illinois. 8. Conn, R. B. 1978. Clinical laboratories. Profit center, production industry, or patient-care resource? N. Engl. J. Med. 298:422-427. 9. Corm, R. B. 1980. Optimal utilization of the laboratory in making clinical decisions. Hum. Pathol. 11:407-412. 10. Dolan, et al, (eds.). 1977. Proceedings of the 1975 Aspen conference on clinical relevance in microbiology. College of American Pathologists. Skokie, Illinois. 11. Ellner, P. D. 1985. A dozen ways to achieve more cost-effective microbiology. Med. Lab. Observer 17:40-44. 12. Everett, G. D. et al. 1983. Effect of cost education, cost audits, and faculty chart review in the use of laboratory
mation as quickly as possible and limit tests to those that impact directly on patient management. Educational efforts to alter the ordering behavior of physicians should be instituted, but regulatory measures must be in place that permit the laboratory director to restrict excessive or inappropriate testing,
References 1. Bartlett, R. C., and C. Rutz. 1980. Processing control and cost in bacteriology. Am. J. Clin. Pathol. 74:287296. 2. Bartlett, R. C. 1982. Making optimum use of the microbiology laboratory. 1. Use of the laboratory. J. Am. Med. Assoc. 247:857-859. 3. Bartlett, R. C. 1982. Making optimum use of the microbiology laboratory. II. Urine, respiratory, wound, and cervicovaginal exudate. J. Am. Med. Assoc. 247:1336-1338.
] 20
0196-4399/87/$0.00 + 02.20
,~ 1987ElsevierSciencePublishingCo.. Inc.
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ClinicalMicrobiologyNewsletter9:15.1987