An effort at Vanderbilt University Medical Center (VUMC) to enhance clinical decision making through cross-departmental collaboration and effective use of diagnostics has improved patient care and saved the institution more than $1 million in 2016, VUMC officials reported this week.
Three years ago VUMC created a Laboratory Formulary Committee charged with evaluating and approving all tests offered to patients. The goal was to eliminate obsolete tests and tests lacking strong evidence and to create a laboratory formulary — a list of approved tests and guidelines for ordering them.
Since then the committee has eliminated several tests of limited clinical value, cut by half orders for inpatient tests that often don’t return results until after the patients are discharged, and established a genetic test review system staffed by genetic counselors and pathologists to avoid inappropriate and overly costly testing.
The initiative was driven primarily by the desire to improve quality of care, said Mary Zutter, M.D., Vice President for Integrative Diagnostics at VUMC, who co-authored the report for NEJM Catalyst, an online publication of The New England Journal of Medicine.
“That’s the most important thing: quality,” said Zutter, the Louise B. McGavock Professor in the Department of Pathology, Microbiology and Immunology.
Health care’s yawning budget is a close second. The cost of advanced diagnostic testing in the United States is rising up to three times more rapidly than the 4 to 5 percent annual increase in overall health care spending.
“Ensuring that the right laboratory tests are being ordered for the right patients at the right time is an issue of national importance,” Zutter said.
Genetic testing is especially expensive. Some genetic tests cost more than $10,000 per patient. Current efforts at Vanderbilt to streamline how genetic testing is contracted out to vendors could generate another $900,000 in annual savings, she added.
Pathology departments in other medical centers are building laboratory formularies for inpatients. But VUMC’s is an institutional endeavor not limited to pathology. It also covers out-patient ordering, said co-author Julie Field, Ph.D., translational research manager in the Vanderbilt Institute for Clinical and Translational Research.
The third co-author, Gordon Bernard, M.D., is Executive Vice President for Research at VUMC, Melinda Owen Bass Professor of Medicine and founding chair of the Laboratory Formulary Committee. He now co-chairs the committee with Tina Hartert, M.D., MPH, the Lulu H. Owen Professor of Medicine.
Importantly, though the Pathology department works closely with the committee, only one of the nine members of the committee is a pathologist; the others are savvy, lab-using physicians from outside the Pathology department who provide important insight into the clinical value of laboratory testing.
An operational team implements the committee’s initiatives with the help of VUMC’s clinical laboratory faculty and administration, health IT (information technology), Lab Information Systems Support (LIS) and the VUMC Department of Finance.
“Because we have that collaborative operational underpinning we are able to fulfill the committee’s charge by affecting solutions throughout the test ordering process,” Field said.
A big part of the effort is educating physicians about the comparative cost and potential yield of the tests they’re ordering; often, physicians don’t know how much tests cost.
“This information can lead to a change in the mindset of how clinical care occurs,” Zutter said.
“With the vast explosion of medical knowledge and diagnostic testing options, it’s incredibly difficult for (doctors) to keep up. The lab formulary is a way to provide them with that extra intellect that saves them time and provides better care for their patients.”
In addition to Zutter and Field, the operational team includes:
• Adam Seegmiller, M.D., Ph.D., Eileen Ricker, Holly Pinder and Clyde Hampton in lab services;
• Laura Fairbrother and Alexandra Kovach, M.D., who oversee the genetic review service;
• Dikshya Bastakoty, Ph.D., project manager with Field for the formulary; and
• Shari Just (Health IT), Karena Keesee (LIS), Elana Johnson (Finance), and Megan Youngblood (Strategic Programs).