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Laboratory/Clinician Stewardship Results in Cost Savings and Improved Patient Care

Gary W. Procop, MD, MS, FCAP

Laboratory test utilization initiatives introduced since 2011 have saved the Cleveland Clinic $5.0 million. The cost avoidance in 2017 alone (the last year for available data) was $835,317.

Gary W. Procop, MD, MS, FCAP, director of the Cleveland Clinic’s molecular microbiology, virology, parasitology, and mycology laboratories, has found creative ways to leverage data-driven, evidence-based best practices regarding laboratory testing to influence systemwide costs. As medical director and co-chair of the Cleveland Clinic Enterprise Laboratory Stewardship Committee, he has found that clinicians are eager to work for initiatives that will benefit their patients. It’s just a matter of putting some thought into how people think and what motivates them in their work.

Most people go into health care because they want to be a part of healing, Dr. Procop says. They will support systems-based change when they have seen up close that their patients do best when all the moving parts act in concert.

As a past president of the American Board of Pathology Board of Trustees, Dr. Procop has seen how big-picture thinking can play out. Good systems serve the common good, an insight that prompted him to rebrand the former Test Utilization Committee. The Laboratory Stewardship Committee is a multidisciplinary team that draws upon resources and personnel within the hospital information system, laboratory, and clinical staff to improve patient care. He has also been joined by an energetic clinical co-chair, whose insights have helped to shape refinements to institutional care paths and enabled the team to recruit clinical champions.

“Utilizing a clinical/pathology dyad as the catalyst for addressing specific challenges appears to be a successful model,” he says.

Dr. Procop is a professor of pathology at the Cleveland Clinic Lerner College of Medicine and holds a joint appointment in the Institute of Medicine’s Department of Infectious Diseases. His microbiology rounds are popular with residents because his enthusiasm for microbiology and infectious diseases is, well, contagious. He looks for ways to include some practice management in the day’s learning, emphasizing communication, professionalism, and a system-based approach to problem solving. People will adopt best practices, Dr. Procop says, when they have made the connection between intention and outcome.

While people who work in hospitals may not get up in the morning thinking about how they can save money for the institution, Dr. Procop says, they do know that Cleveland Clinic could not fund the good work that it does without a healthy bottom line—no margin, no mission, as the saying goes. Cost metrics have to be on the radar because they reveal essential, readily tracked outcomes that can wrap and seal the survival of a project. A few examples come to mind.

The Laboratory Stewardship Committee’s first project, introduced in 2011, was the same-day hard stop, a clinical decision support tool that blocks repeat orders for tests that are never needed more than once in 24 hours. (Launched with a menu of 12 tests, it now covers more than 1,200.) Same-day hard stop has prevented action on more than 33,000 orders and saved more than $522,000 in seven years. Less than 10% of those providers whose orders were blocked have called the laboratory to override the intervention.

The extended hard stop, part of a systemwide intervention to decrease the rate of C. difficile infection, activates when certain test requests are repeated within a select timeframe. This intervention, which went live in 2014, was applied to (a) once-in-a-lifetime constitutional genetic tests, (b) once/twice per lifetime hepatitis C virus genotyping, (c) repeat polymerase chain reaction (PCR) testing for C. difficile within seven days, and (d) HbA1c diabetes testing more often than monthly. The extended hard stop has deterred more than 38,000 tests, saving $337,818.

Expensive test notification, another example, flags tests that cost more than $1,000. In 2017, those who placed 131 of these orders decided not to pursue them after reading the warning, saving $186,849.

Orders for ambulatory genetics test orders at Cleveland Clinic are restricted to members of designated deemed user groups. Inpatient molecular genetics tests may only be ordered by an individual who is board certified in medical genetics. A laboratory-based genetics counselor intervenes when genetic testing may be inappropriate and, importantly, provides guidance. Genetic counseling and test restriction prevented 1,704 unnecessary genetic tests over the past seven years, saving over $2.8 million.

The pathologist/clinician dyad, Dr. Procop says, will be the shape of our collective future, and to that end, the stewardship committee has become an engine for team building. There are now committee members from all the clinical departments—12 to 15 people at the table each month and more who call in. A project manager from the department of medical operations creates a channel to the administration. Thoughtful structural changes have flipped the dynamic. For example, when Infectious Diseases clinicians encountered a surge in false positive Lyme disease tests last year, they knew where to go. The Infectious Diseases chair provided a clinical champion who presented to the Laboratory Stewardship Committee, which provided feedback and subsequently approved a best-practice algorithm. The laboratory provided a champion and a team that worked to implement the best practices decided upon. A best-practice solution was proposed by experts, vetted by a multidisciplinary subcommittee, and implemented in record time.

At the Cleveland Clinic, experience has shown that doing the right thing, can save money, both at the bedside and in the laboratory, Dr. Procop says. Their teams have made the connection between systems that work, patient safety, and improved patient care. Once that connection is made, when someone says “systems-based thinking,” they won’t think buzzword. They’ll think teamwork. And they’ll be all in, because when open minds engage, positive energy spills out.

“The future of pathology will depend upon how well we demonstrate the value of the pathologist in the system rather than just in the laboratory,” Dr. Procop says. “Laboratory/clinical partnership is changing practice. I get pretty jazzed about that.”

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