1. Lipase ordering in the UCIMC ED
Cost Conscious Project
2017
Maylyn Martinez, MD

2. Conditions associated with elevated lipase (UpToDate)
Acute/chronic pancreatitis
Renal failure
Acute cholecystitis
SBO/infarction
Duodenal ulcer
Pancreatic calculus/tumor
DKA
HIV
Macrolipasemia
Post ERCP/trauma
Celiac Disease
Trauma
Idiopathic
Drugs

3. When to suspect pancreatitis (Clinical presentation from 2013 ACG guidelines)
“Patients with AP typically present with epigastric or LUQ pain. The pain is usually described as constant with radiation to the back, chest, or flanks…The intensity of the pain is usually severe but can be variable…Pain described as dull, colicky, or located in the lower abdominal region is not consistent with AP and suggests an alternative etiology.”

4. RESULTS Two snapshots 35 patients had lipase result
14 patients c/o abdominal pain (40%)
2 epigastric
1 LUQ
4 lower quadrant
7 nausea and/or vomiting
1 patient with vomiting w/o abdominal pain
1 patient with intractable vomiting after chemo, no abd pain

5. Other diagnoses (NO abdominal pain, nausea, or vomiting)
Cough (4 patients)
Weakness (2 patients)
AMS (2 patients)
BLE edema, abdominal distension
Insomnia
Flank pain
Hematuria
Foot discoloration
IFT for mgmt of SBO
Pain in transplanted kidney
Palpitations
Groin pain
Seizure-like activity
Back pain/discolored urine

6. What is the cost of processing a lipase ordered in UCIMC ED?$5
$10
$50
$100
$200
?????

7. Cost of lipase
$230
This is a quote from the main inpatient lab supervisor to whom I was referred by Dr. Nadeswaran (a.k.a. a trusted source)

8. Yearly cost UCIMC ED 50,000 patients/year (137/day)
Assume 25 abdominal pain patients/24h x 365 = 9,125
9,125 patients x $230 = $ 2,098,750 on lipase test/yr
40% “appropriately” ordered
60% “inappropriately” ordered
For a yearly total of……..

9. WASTE!!!!!!
$1,259,250 of waste/year

10. What can be done? Investigate why the inappropriate lipase was ordered
Perform formal CC analysis
Re-educate at faculty and resident level

11. What can be done?
Nothing when the name of the game is
COVER
YOUR

12. References 2013 ACG pancreatitis guidelines
UpToDate: causes of elevated lipase
UC Irvine Emergency Medicine Residency website
Google (for range of lipase prices)

13. THANK YOU