STRATEGIES TO REDUCE HEALTHCARE COSTS THROUGH APPROPRIATE TEST UTILIZATION: COLLABORATION BETWEEN THE HOSPITAL-BASED HTA UNIT AND THE LABORATORY Fatma Meric Yilmaz, Altan Aksoy, Rabia Kahveci, E. Meltem Koc, Tezcan Akın, Nurullah Zengin Reducing healthcare costs with the maintainance of patient safety and improved quality is one of the main targets in most healthcare reform efforts. It is difficult to decide how to achieve this goal. One thing most experts agree on, however, is that eliminating unnecessary tests and procedures is a good place to start with. It has been reported that an approximate amount of $6.8 billion of medical care in the United States has involved unnecessary testing and procedures that do not improve care and may even harm the patient (1). American Society for Clinical Pathology dedicated April 2012 edition of Critical Values to the issue of appropriate laboratory testing and pointed out the aim as ‘‘right test, right patient, right time, at the right cost (2). It is important to decide hospital based strategies in reducing healthcare costs. ANHTA is the first Hospital based HTA Unit in Turkey. The unit aims to support hospital managers for evidence-based investment or disinvestment decisions regarding technology use in the hospital. Hospital based committess including laboratory professionals and clinians can define the hospital based problems and can lead to a standardized approach to test utilization that can help clinicians improve the quality and reduce laboratory costs through the hospital. In this study, our aim was to define strategies to rationalize laboratory use in Ankara Numune Training and Research Hospital (ANH) and identify ways to disseminate and implement the defined strategies. INTRODUCTION METHODS A hospital committe was created including clinicans from internal medicine, general surgery, family medicine, emergency department and the laboratory directors of biochemistry and microbiology departments. In the first step, a utilization review was performed to understand how various laboratory tests were used and whether the use was appropriate. A follow up procedure was planned and a laboratory utilization report including mean number of ordered tests per patient and total lab cost of every department has been constituted. In the second step a hospital meeting has been carried out in order to create an awareness and the doctors were informed about the approppriate use of laboratory. Laboratory utilization reports were sent to the departments for every month. In the third step, a rearrangement for lab test utilization process was performed and all of the test panels were deleted at the end of February after informing the clinicans about the reasons. Test ordery page was divided into two separate pages which were in different tabs and the tests which give less information, ordered more than expected or observed to be mis-used were taken to the second tab. The number of ordered tests for these second stage tests and total lab costs of the hospital were compared between January-February and March-April periods. RESULTS The results of the “Utilization Review” study showed that major use was in internal medicine. Mean number of tests per patient was The laboratory use differed enormously among clinics. The budget impact of all tests per month was 230,800 Euro. Unnecessary testing for Chloride, Lactate dehydrogenase, misusage of ELIZA, severe distance from guideline recommendations for preoperative routine testing were observed. There has been a significant decrease in the number of the tests which have been taken to the second tab with the decision of Hospital Committee when January-February and March-April periods has been compared. The amount of total lab costs for each month is shown in Figure 1, and the reduction in second stage tests after the rearrangement at the end of February is given in Table 1 as the total test orders in time and % Reduction. Total lab costs of the hospital were , ; ; Euro for January, February, March and April; respectively. Two month impact of the rearrangement of the test ordery page has been calculated as Euro. Figure 1. Total Lab Costs of the hospital (Euro) DISCUSSION This study reflects the first results from an ongoing HTA program on Appropriate Test Utilization in Ankara Numune Education and Research Hospital. Our six months’ experience showed that a colloborative plan might have significant effects in reducing laboratory costs. A variety of studies have been performed with the aim of “appropriate utilization”, however most of them have focused on reducing the ordery of limited number of laboratory tests (3-6). The results of an organizational utilization management program have been published recently and reported that a reduction of 26% in inpatient tests per discharge has been managed during a 10-year period (7). Our results in this study confirmed that hospital committees or organizations may provide a higher impact than focusing on specific limited tests. Hospital specific utilization review is an important step to define the strategies and decide the route. It has been reported that the utilization behaviour and the practices for medical care and tests might be different according to the region and geography (8). Our initial results showed that creating a hospital committee and performing utilization review provides important information about the priority of the hospital in appropriate utilization and this priority might differ in different institutions. Our priority has been identified as prohibition of the clinician test panels because there have been a wide variety between used panels which lead to overuse or misuse of the tests. An example was electrolyte testing. All of the panels involving electrolyte testing have included Na-K-Cl tests independent from the diagnosis although chloride test has recommended to be used in specific conditions (9). After prohibition of the panels chloride test has been moved to the second ordery tab, which inhibits the quick-pick of the test and a reduction of 50% has been observed. Same strategy provided a 44% reduction for free PSA and 71% reduction for folic acid. The reason for overuse of these tests has just seemed to trip off the tongue and separation Cl form Na-K, folic acid from Vitamin B12 and free PSA from total PSA have thought to decrease this effect. In conclusion In conclusion, our initial results showed that hospital-based committees including laboratory professionals and clinicians can define the hospital based problems and can lead to a standardized approach to test utilization that can help clinicians improve quality and reduce laboratory costs. Hospital-based HTA Units might have an important role in being a part of these processes in order to ensure evidence-based and rationalized laboratory testing. JanuaryFebruaryMarchApril% R Uric Acid13,3759,5736,2935,67048 Lipase Chloride20,17716,5029,4918,79450 Pre Albumin2, ASO1,0921, RF2,7003,1742,4972,27119 Ig G Ig M Ig A C C Free PSA1,5331, CA 15-31,5731, CA 1251,5931, CA 19-91,7911,3861,1661,11328 Folic Acid6,4593,7791,4721,46271 Anti TG Ab A.HBc IgM A.HAV IgM A.HBc Total Anti HBs1,9922, AntiHAV IgG HBeAg Anti HBe CMV IgG Toxo IgG Rubella IgG Toxo avidite CMV avidite Table 1. Total test orders in time for the tests taken to the second tab. REFERENCES 1.The Good Stewardship Working Group. The “top 5’lists in primary care: meeting the responsibility of professionalism. Arch Intern Med. 2011;171(15): Holladay EB. Test Right. Critical Values 2012; 5: 3. 3.Robinson A. Rationale for cost-effective laboratory medicine. Clin Microbiol Rev. 1994;7: Benson ES. Initiatives toward effective decision making and laboratory use. Hum Pathol. 1980;11: Kumwilaisak K, Noto A, Schmidt UH, et al. Effect of laboratory testing guidelines on the utilization of tests and order entries in a surgical intensive care unit. Crit Care Med. 2008;36: Lee-Lewandrowski E, Laposata M, Eschenbach K, et al. Utilization and cost analysis of bedside capillary glucose testing in a large teaching hospital: implications for managing point of care testing. Am J Med. 1994;97: Kim JY, Dzik WH, Dighe AS, Lewandrowski KB. Utilization management in a large urban academic medical center. Am J Clin Pathol. 2011;135:108– Ashton CM, Petersen NJ, Souchek J, et al. Geographic variations in utilization rates in Veterans Affairs hospitals and clinics. N Engl J Med. 1999;340: DuBose TD Jr. Disorders of acid-base balance. In: Brenner BM, ed. Brenner and Rector's The Kidney. 8th ed. Philadelphia, Pa: Saunders Elsevier;2008:chap 14.