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Should the laboratory play policeman?

What does the clinical laboratory profession have in common with the huge oil companies? Like those corporate giants during the last decade's oil crisis, we now find ourselves in the strange position of asking people not to be our services.

One of the canon lws of prospective payment is that physicians must cut back on unnecessary testing for hospital inpatients. The media have hammered away at the ever-rising cost and volume of testing as prime contributors to our spiraling national health care bill. Physicians who use the laboratory to the hilt--once considered the hospital's good guys--have seen their white hats quickly turn to black. These days, the hospital has no infinite supply of dollars to replenish those freely spent on tests.

It's easy to say that physicians should cut back on ordering, but who decides what constitutes excess? All too often the laboratory assumes that unenviable role by default. Laboratory managers are reluctant to face staff and budget cuts, and eager to get the most from expensive automated instrumentation. Yet many find themselves in the role of policeman, trying to whittle down the number of test procedures. Often this produces a halfhearted attempt to eliminate a handful of esoteric tests--an effort that may be more costly than performing them.

Although these new demands may make us uncomfortable, we can't ignore them. But we can try to take a more constructive tack and turn from our role as policeman to that of educator. As the hospital's authorities on laboratory medicine, we have a primary responsibility to inform physicians of the most appropriate and cost-effective procedures available for diagnosing and treating a particular condition.

This education should not be limited to medical school and residency training alone. All members of the medical staff need regular updates and refereshers. A laboratory newsletter makes an excellent vehicle to deliver this information. The newsletter can regularly present new methodologies, point out obsolete tests or ordering patterns, and suggest optimum diagnostic sequences for specific illnesses.

Nor should the education process be limited to medical topics alone. Physicians must be made more aware of the costs of hospital services they order. My institution once issued a pocket reference card listing various hospital costs, ranging from an adhesive bandage to a surgical procedure, in an effort to promote more conscientious use of limited resources.

The laboratory should also take an active part in the hospital's utilization review committee. Instead of remaining a voice in the wilderness, the lab can use this group as a forum to promote its views on the prudence of various ordering habits.

Physicians are not entirely responsible for overutilization, however. Our own actions sometimes contribute to the problem. A delay in reporting results often prompts the ordering of a duplicate test, usually on a Stat basis. We must give physicians reasonable response times for each procedure and then adhere to them ourselves.

Some laboratory practices make overordering unnecessarily easy. Most laboratories still use a menutype form that allows physicians to order dozens of tests simply by checking off boxes. We can diplomatically limit testing by modifying these forms. A revised version listing only the commonest tests can produce the desired effect without ruffling any feathers.

Another contributing factor for which the clinical lab is partly accountable is the technological boom in diagnostic techniques over the last two decades. In 1960, the average hospital laboratory offered about 75 tests; the list has grown more than twice as long since then. Physicians make fewer educated guesses and rely more heavily on test results in making a diagnosis.

Of course, we are in business to provide diagnostic information with state-of-the-art techniques. But we also have an obligation to make physicians aware of the specificity of each procedure. All too often, physicians ask the lab to perform tests with such a low level of clinical significance that the costs far outweigh the benefits.

When we must play policeman, the most difficult job along our beat is questioning a physician's judgment after an order has been written and a specimen collected. That task is usually passed to the pathologist or pathology resident. It usually consumes an inordinate amount of time, delays patient treatment, stirs up hard feelings between laboratory and physician, and fails to put a dent in lab volume and costs. It's inefficient to say no after the fact. We would do better to channel our efforts into preventing needless orders in the first place.

The importance of good laboratory utilization will undoubtedly grow as the health care dollar continues to shrink. Instead of patrolling the medical staff and telling them what they can and cannot do, the lab should act more like a traffic controller--helping our consumers get from point A to point B by the most efficient route possible.
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Copyright 1985 Gale, Cengage Learning. All rights reserved.

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Title Annotation:the role of the laboratory in cost-saving procedures
Author:Maratea, James M.
Publication:Medical Laboratory Observer
Article Type:editorial
Date:May 1, 1985
Words:793
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