Laboratory Stewardship Christopher Petrilli MD CHFP Michigan Medicine

Laboratory Stewardship Christopher Petrilli, MD, CHFP Michigan Medicine

Objectives • Understand the root causes for unnecessary laboratory ordering practices • Describe motivations of providers and costs to health systems and patients regarding laboratory test utilization • Understand importance of a multi-disciplinary laboratory stewardship committee model

Macro vs Micro health econ… FOCUS on Health Spending @ OECD Health Statistics 2015 https: //www. oecd. org/health-systems/Focus-Health-Spending-2015. pdf

Defining the “Value” of a Lab Test Value = Appropriateness * Quality Cost So what exactly does this mean for patients, providers, hospitals, insurers?

Reframing “Value” I don’t want to go bankrupt to pay for my healthcare…or even forgo other expenses Adapted from Neal Shah (Costs of Care) I may want and have the money for “every” lab test but what are risks? Bone Marrow Biopsies may not have co-pay and are safe but OUCH… (esp if not appropriate)

Approach to lab ordering • Let’s look at an common example…

“Morning Labs” (CBC/BMP/Mg/PO 4) aka What some trainees (and attendings) erroneously thinks of as “the 7 th vital sign”

Why do residents order “daily labs”? (n=61) 70. 0% Patient's clinical status Ease of ordering standing labs versus daily reordering 63. 3% ttending preference for daily labs/data is expected to be presented on rounds 46. 7% 41. 7% Personal preference for daily labs Fear of missing something without data 40. 0% Practice habit (i. e. you were trained to order daily labs) 26. 7% Admission order set includes standing labs 13. 3% Other: 11. 7% 0% 20% 40% 60% 80%

Moving away from “academic” ordering

Choosing Wisely® ` 83 of 547 (15%) Choosing Wisely recommendations related to appropriate lab ordering

How strong are CW recommendations? • Many cite clinical practice guidelines (CPG) • Referenced CPGs varied widely in quality and also in support of the recommendation citing them. • 1 in 6 cite lower quality evidence as their highest level of evidence Admon AJ et al. Appraising the Evidence Supporting Choosing Wisely© Recommendations. Academy. Health Annual Research Meeting, 6/28/2016

So…. this is awkward…. • Well, not really… – CW has take a very important and innovative step – It is critical that you use these recommendations along with your clinical judgment. – It also means this field is wide open in terms of defining what is and what isn’t “Low Value”

Sometimes you don’t need a CPG Society for Hospital Medicine Choosing Wisely Sources: 2 small retrospective observational studies and 1 small single-center prospective study

Re: Ordering Labs How not to be “That guy [girl]”

s Ye Do NOT order Has there been stability? No Order Common Ye Order No Do NOT order s Do I expect a change? Is this a common or uncommon lab? Is my pre-test probability high or low? Moderate Order Very Low or Very High Do NOT order Uncommon s Will the test change management? Ye No Order Do Not Order

Complete Blood Count / Basic Metabolic Panel s Ye Do NOT order Has there been stability? No Order Common Ye Order No Do NOT order s Do I expect a change? Is this a common or uncommon lab? Is my pre-test probability high or low? High Order Low Do NOT order Uncommon s Will the test change management? Ye No Order Do Not Order

Clinical Example… • 36 M is diagnosed with a post-operative DVT. He had previous one at age 26 (unprovoked) • No family history of clotting disorders, DVT/PE • Tx: Started on DOAC • What should be ordered as an inpatient to investigate his 2 nd VTE?

Would it be helpful to find out? • What changes if tests are positive? • What changes if tests are negative?

Does testing this patent for thrombophilia add value to his care?

Does testing this patent for inherited thrombophilia add value to his care? Christiansen JAMA 2005 Benefit for screening for thrombophilia is unknown. Does this actually affect prognosis? Baglin Lancet 2003 Recurrent VTE does not seem to be influenced by thrombophilia status. Patients who are prone to form clots tend to form

What is the cost? Well it depends… Bank Psychological effects of FVL carriers Somma Inaccurate test results (in the case of protein C, protein S)

FYI - Guideline Recommendation Lifelong anticoagulation recommended in patients with 2 nd blood clot and low risk of bleeding

s Ye Do NOT order Has there been stability? No Order Common Ye Order No Do NOT order s Do I expect a change? Is this a common or uncommon lab? Is my pre-test probability high or low? Moderate Order Very Low or Very High Do NOT order Uncommon s Will the test change management? Ye No Order Do Not Order

Genetic Tests for Thrombophilia s Ye Do NOT order Has there been stability? No Order Common Ye Order No Do NOT order s Do I expect a change? Is this a common or uncommon lab? Is my pre-test probability high or low? Moderate Order Very Low to Very High Do NOT order Uncommon s Will the test change management? Ye No Order Do Not Order

Helping to Frame Why This is Important

When a Doctor Is Given Information… • You are traveling on an airplane and respond to the appeal “Is there a doctor on board? ” Apparently, a 60 - year-old male passenger experienced 15 to 20 minutes of “crushing” chest pain during takeoff (now resolved). Past medical history is unremarkable. The patient looks sick. The heart rate is about 80. The first-aid kit has a blood pressure cuff. You obtain a systolic pressure of 120 (cabin too noisy for auscultation). In this situation, would you recommend • OPTION 1: land the airplane for medical reasons • OPTION 2: continue the flight as scheduled

When a Doctor Asks for Information… • …The first-aid kit does not have a blood pressure cuff, but the flight attendant knows there is one in a second kit elsewhere in the plane. In this situation, would you recommend • Option 1: Land the airplane for medical reasons • Option 2: Continue the flight as scheduled • Option 3: Ask for the blood pressure cuff before making a decision

• If you chose to have the blood pressure cuff, answer the following: You obtain a systolic pressure of 120 (cabin too noisy for auscultation). In this situation, would you recommend • Option 1: Land the airplane for medical reasons • Option 2: Continue the flight as scheduled?

89% were given BP and it was normal decided to land the plane 82% who “ordered” BP and it was normal decided NOT to land the flight

Primacy Bias • Primacy Bias - Information sought or more recent information is valued more than other information. • We assume that more information must be better to make a wise decision.

How can we work to fix it? Laboratory Stewardship Committee

c. 2015 The Lab Stewardship Committee is an institution-wide initiative rooted in a collaboration between Medicine and Pathology

Committee Members Chris Petrilli Robert Chang Internal Medicine Lee Schroeder Dave Keren Pathology Lauren Heidemann Lindsay Petty Migdalia Musler Internal Medicine Chief Operations Officer Scott Owens Brian Tolle Sarah Taylor Pathology Nursing

Mission Statement Initial Guiding Resources To improve resource allocation and patient outcomes by ensuring appropriate utilization of laboratory testing throughout Michigan Medicine. Choosing Wisely Dr. Raymond Konger of Indianapolis VA Dr. Gary Procop of Cleveland Clinic

Our Proposed Method Develop A standardized approach to identify high-impact tests Prioritize Targets for intervention based on need, value, and feasibility Assign Responsibility for implementing interventions to appropriate champions Monitor Progress in ordering behavior and adherence to guidelines Share Scholarly works centered on value-added patient care and Test Utilization

Support Network Michigan School of Art and Design Quality Analytics Michigan Program on Value Enhancement HITS Tableau Team

Development of “Right. Care Report" 40, 000 97% 35, 000 30, 000 78% 25, 000 20, 000 15, 000 10, 000 5, 000 0 27% 34% 13% 9% 27% 3% 21% 2% 3% 2% 2% 2% 0%

Provider Dashboard

Focusing on What is Important (are we really trying to save that $3 -4 on a CBCs or BMP assay? )

The Patient Experience Woken up between 3 am and 6 am To be painfully poked, often many times And frequently not told why tests ordered or the results

Each tube = 4 -6 m. L SHM Choosing Wisely “Source”

Downstream impacts Iatrogenic anemia 1 Unnecessary CBCs Spurious Values 2 Anemia Workup Ferritin, iron, transferrin, B 12/Folate, reticulocytes, TSH, peripheral smear, haptoglobin Endoscopy Colonoscopy Upper endoscopy Complicated by low blood pressure from sedation 3

4 Troponin Ordered Cardiology consult Left heart catheterization Cardiac Stent Placed 5 Not indicated for asymptomatic coronary artery disease 6 Placed on Antiplatelet Therapy Aspirin and Plavix or more expensive Ticagrelor for at least 1 year

Cardiac Rehab 7 Per protocol after stent placement 8 Insurance Premium Increase Life/Health Patient’s family may pay higher premiums as well

Measuring What’s important: Downstream Impact

Pilot Projects

Works in Progress: Ordering Interventions Vitamin D ●●●●●●●●●●●●●●●●● ● Heparin Induced Thrombosis ●●●●●●●●●●●●●●●● Routine Daily CBCs Study Control Argatroban Use (Y/N) with PF 4 OD <0. 4 No Yes PF 4 Optical Density Distribution 300 250 124 8 24 120 100 200 80 150 255 60 100 40 50 20 0 14 18 18 No Yes 0 No OD<0. 4≤OD≤ 2. 0 Yes PF 4 OD O<0. 4 (Yes/No)

Qualitative Approaches: Behavioral Study

Take Home Points • Past / learned behavior drives ordering patterns but this can be unlearned – But it takes a village (culture change) • Ordering providers want to do all they can for patients without doing more than they need…but we need your help!

Exciting Opportunity

Open Discussion

Thank you!