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A Cost-Effective Interdisciplinary Approach to Microbiologic Send-Out Test Use.

Understanding the economic strain of health care costs in the United States is complicated by estimates that as much as 30% of the delivered health care in the United States is duplicative or unnecessary. (1) To encourage the profession to improve its stewardship of health care resources, health care leaders have proposed adding a seventh general competency," cost-consciousness and stewardship of resources," to the current six competencies defined by the Accreditation Council for Graduate Medical Education and the American Board of Medical Subspecialties. (2) However, a recent survey of practicing physicians found that only a third of those surveyed thought that physicians bear the responsibility for controlling health care costs. (3)

Diagnostic testing often occurs early in the care and management of hospitalized patients, and much of its financial impact is determined by how the test result affects the hospital course of the patient. Estimates suggest that up to 30% of ordered tests are redundant or inadvertently repeated. (4, 5) These tests have little or no impact on the hospital course of the patient, save the cost of the test. However, unnecessary laboratory investigations can trigger expensive and/or invasive diagnostic work-ups or therapies.

In the inpatient setting, reference testing represents a direct upfront cost to the laboratory. When billed as part of a diagnosis-related group, it is difficult to recover a significant portion of these costs. A common cost-containment strategy at some academic institutions is the pathologist-conducted review of reference laboratory tests. (6) This approach is traditionally thought of as time-consuming and most applicable to teaching hospitals, where the task of vetting send-out tests is delegated to the clinical pathology resident. There are scant data with regard to what types of tests are most often being screened by pathology house staff and the clinical rationale behind order modifications. We therefore employed an interdisciplinary approach to screening microbiologic send-out tests in order to assess cost impact and clinical rationale.


The George Washington University Hospital is a 370-bed tertiary care hospital located in downtown Washington, DC. For the last 15 years, we have routinely employed a resident or house staff-based approach to screening reference laboratory testing. Using this approach, the client services division of the core laboratory requires that all microbiologic send-out tests be reviewed by the clinical pathology house staff prior to being sent to the reference laboratory, regardless of test type or cost. In the last year we adopted a more interdisciplinary approach to screening send-out test requests. Key clinicians were identified who could facilitate communication with ordering physicians. These individuals were identified using service-based test-ordering totals and the likelihood that they would be caring for any one patient for whom microbiologic send-out tests were ordered. Using those criteria we approached the Department of Medicine's Divisions of Hospital Medicine and Infectious Diseases. In discussing the laboratory's role in the usage management of send-out tests, we asked that these individuals facilitate communication with ordering clinical services. This was accomplished in a number of ways, including but not limited to: introduction of pathology faculty and house staff to clinical teams, provision of clinical round times and locations, and facilitation of pathology faculty and house staff participation in patient rounds.

As client services staff receive orders for send-out microbiologic tests, they are held in the laboratory and delivered to the clinical pathology house staff once or twice daily, with a range of 0 to 12 requisitions daily. The test requisitions are then used to review patients' electronic medical records for pertinent history and laboratory data. Finally, rather than attempt to call or page the ordering physician, test requisitions are taken directly to the wards and emergency department for discussion. (7, 8)

In addition, for those test requisitions not addressed by the method described above, clinical house staff members are engaged as part of microbiology-specific rounds that are held 5 times a week in the microbiology laboratory. These rounds are attended by medicine and infectious diseases house staff and occasionally attending physicians, and are led by the clinical pathology house staff and attending microbiologist.

As a result of these face-to-face discussions and laboratory rounds, tests are approved, modified, or canceled. All send-out test requisitions for calendar year 2012 were archived, and data regarding order date, ordering service, the indication for order modification, and the ultimate dispensation of the test were recorded. Cost analyses were performed using the price per test as negotiated by The George Washington University Hospital with an extramural reference laboratory. These prices represent direct billing charges to The George Washington University Hospital by the extramural reference laboratory. All of the data presented herein represent orders placed for inpatient services only. No tests were canceled without prior discussion with a treating physician. All study methods were approved by the Institutional Review Board at The George Washington University. Data and statistical analyses were performed using Microsoft Excel software (Microsoft Corporation, Redmond, Washington).


Summary of Reviewed Send-Out Tests and Cost Savings Analysis

During the course of 1 year, the clinical pathology house staff reviewed a total of 1207 microbiologic send-out test requisitions (Table 1). Canceled tests represented a total savings of $53,719. (13) in direct cost to the laboratory. All of the data in Table 1 exclude the cost of in-house labor and supplies. The average unit cost per canceled reference test was $117 per test. A survey of all clinical pathology house staff found the average amount of time needed to review send-out test requisitions and meet with clinical staff to be 71 ([+ or -] 29) minutes per day (n = 15 residents), including rounds held in the microbiology laboratory.

A detailed analysis of nucleic acid test requisitions demonstrated that most nucleic acid tests were ordered for the detection of viral pathogens (93%, or 740 tests). The remaining nucleic acid tests were ordered for the detection of bacterial pathogens (7%, or 57 tests). Hepatitis C virus (225 tests) and herpes simplex virus (138 tests) represented the largest proportion of total nucleic acid tests ordered and reviewed (Table 2). The hepatitis C virus test requisitions were further analyzed to reveal that 30% of all of the hepatitis C virus nucleic acid tests were ordered with either a negative antibody screening test or concomitantly with an antibody screening test that was ultimately negative. Of all the hepatitis C virus nucleic acid tests ordered, 31% did not require modification prior to final dispensation. The herpes simplex virus test requisitions were further analyzed to reveal that 76% of all of the herpes simplex virus nucleic acid tests were ordered on cerebrospinal fluid specimens. Of those cerebrospinal fluid specimens, 72% had normal white blood cell counts, and 46% had normal white blood cell counts, glucose concentration, and total protein concentration, as defined by our laboratory's reference intervals.

A detailed analysis of serology and culture test requisitions demonstrated that most tests were ordered for the detection of viral pathogens (51%, or 210 tests) and bacterial pathogens (27%, or 112 tests). The remaining tests were ordered for the detection of fungal (12%, or 49 tests), protozoal (7%, or 29 tests), and parasitic pathogens (3%, or 10 tests). Epstein-Barr virus immunoglobulins (51 tests) and a bacterial meningitis antigen agglutination panel (47 tests) represented the largest proportion of total serology and culture tests ordered and reviewed (Table 3).

Stratification of Ordered and Canceled Tests by Ordering Department and Consultation Status

An analysis of the total number of send-out microbiologic tests ordered by individual departments demonstrated that most time spent in consultation by the pathology house staff was focused on a handful of clinical departments (Figure, A and B). Further analysis revealed that if the Division of Infectious Diseases had been consulted on patients for whom a test request was being reviewed, the dispensation was more likely to be canceled (P < .001, [chi square] test; Figure, C and D).

Rationale for Test Cancellation

All canceled requisitions were determined to have been canceled for preanalytic reasons. (9) The requisitions were further categorized based on the fundamental rationale behind canceling the order. Three categories were used: "clinical indication," "order entry error," and "follow-up." The "clinical indication" category represented 65% of canceled tests and included such reasons as: a confirmation test ordered in the absence of a screening test order, a confirmation test ordered with a negative screening test result, and a change in clinical status and/or clinical history. The "order entry error" category represented 35% of canceled tests and included such reasons as: mistaken orders, duplicate orders, incorrectly inputted test orders, and insufficient specimen quantity. The "follow-up" category represented rare insistences, 0.2% of canceled tests, when patients were discharged prior to a test being screened by the pathology house staff and the ordering physician determined that the test be followed up in the outpatient setting.


Previous studies have estimated the average cost of reference tests to be $26 to $46; however, our data suggest an average cost per microbiologic reference test to be $117. (10, 11) The rapid emergence of molecular diagnostic reference testing portends an even greater relative contribution to overall health care cost. There are limited published data from which to assert that our cancellation rate or service ordering trends for microbiologic send-out tests are consistent with those of other United States or international institutions. (10, 12) However, in a recent workgroup publication the American College of Physicians highlighted microbiologic screening tests in a list of clinical situations in which testing does not reflect high-value care. (7)

It has been demonstrated that the formation of formal oversight committees can effectively reduce laboratory send-out test expenditures when there is active involvement by medical staff. (13, 14) We demonstrate that simple face-to-face interdisciplinary communication between pathology and either infectious diseases or hospitalist medical staff is a cost-effective method in itself for ensuring high-value send-out test use, and that pathologists can engage with clinicians regularly enough to actively influence diagnostic testing and patient management decisions. Furthermore, the benefits of such an approach to clinical pathology house staff and medical staff were tangible. There was no resistance to test review on the part of the ordering clinicians, given that this has been standard practice in the microbiology department for the greater part of two decades. In addition to the educational benefits reaped by pathology house staff with regard to testing methods and interpretation, medical staff were equally engaged in active learning. Similarly, we believe such an approach helps to prepare clinical house staff to constructively deal with future questions they may face as attending physicians regarding their send-out test requisitions. Furthermore, data shown in Figure 1 suggest that when pathology house staff could use key clinical services, such as infectious diseases and hospitalists, as a portal to the clinical staff treating the patient, the likelihood was higher that a send-out test order would ultimately be modified or reconsidered.

Our estimated time commitment per test screened (approximately 15 minutes) is longer than was estimated in a recent, more administrative-based intervention. (12) The advantage with our approach is that the review of send-out tests happens essentially in real time. This avoids the perception on the part of the clinical staff that such a review is delaying patient care, and allows the pathology house staff to get the most up-to-date patient information. Similarly, face-to-face interaction makes for fruitful and collegial discussion. Our data demonstrate that although order entry errors make up a significant fraction of canceled send-out tests, most send-out tests were canceled following interdisciplinary discussion of the patient's clinical findings. This type of discussion is challenging to have by impersonal electronic or telephone communication.

The general applicability of the current study is somewhat limited to the inpatient setting. The fee-for-service reimbursements sought in the outpatient setting are not relevant to the per diem reimbursements sought for the inpatient services examined herein. Therefore, the cost savings estimated by this study are thought to represent direct savings through avoidable and unnecessary charges to the hospital from extramural reference laboratories. Similarly, the practice of screening reference laboratory tests need not apply only to the academic hospital with resident house staff. This type of consultation represents a leadership role for pathologists to take in the era of more sophisticated and costly molecular testing. Because most clinicians do not currently have the time to provide such a service, it is unlikely that in the future they will find the necessary time or knowledge base to do so on their own. Furthermore, in anticipation of bundled payments for care, prevention of avoidable or unnecessary testing represents a modality wherein the pathologist can effectively demonstrate his or her value to patient care.

Pathologists can proactively reach beyond the laboratory to help manage the appropriate use of testing and drive appropriate postanalytic interpretation of test results and clinical decision making, but they must do so in conjunction and collaboration with clinicians in order to ensure the most appropriate cost-effective patient care.


(1.) Smith M, Saunders R, Stuckhardt L, McGinnis JM, eds.; National Research Council. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Washington, DC: National Academies Press; 2013.

(2.) Weinberger SE. Providing high-value, cost-conscious care: a critical seventh general competency for physicians. Ann Intern Med. 2011; 155(6):386-388.

(3.) Tilburt JC, Wynia MK, Sheeler RD, et al. Views of US physicians about controlling health care costs. JAMA. 2013; 310(4):380-388.

(4.) van Walraven C, Raymond M. Population-based study of repeat laboratory testing. Clin Chem. 2003; 49(12):1997-2005.

(5.) Bates DW, Boyle DL, Rittenberg E, et al. What proportion of common diagnostic tests appear redundant? Am J Med. 1998; 104(4):361-368.

(6.) Carter E, Bennett BD. Reference test review by pathology house staff: a cost-containment strategy for the clinical laboratory. Clin Leadersh Manag Rev. 2002; 16(1):3-6.

(7.) Qaseem A, Alguire P, Dallas P, et al. Appropriate use of screening and diagnostic tests to foster high-value, cost-conscious care. Ann Intern Med. 2012; 156(2):147-149.

(8.) Laine C. High-value testing begins with a few simple questions. Ann Intern Med. 2012; 156(2):162-163.

(9.) Hawkins R. Managing the pre- and post-analytical phases of the total testing process. Ann Lab Med. 2012; 32(1):5-16.

(10.) MacMillan D, Lewandrowski E, Lewandrowski K. An analysis of reference laboratory (send out) testing: an 8-year experience in a large academic medical center. Clin Leadersh Manag Rev. 2004; 18(4):216-219.

(11.) Valenstein PN, Praestgaard AH, Lepoff RB. Six-year trends in productivity and utilization of 73 clinical laboratories: a College of American Pathologists laboratory management index program study. Arch Pathol Lab Med. 2001; 125(9): 1153-1161.

(12.) Liu Z, Abdullah A, Baskin L, Lewis G, Kelter G, Naugler C. An intervention to reduce laboratory utilization of referred-out tests. Lab Med. 2012; 43(5):164-167.

(13.) Zhao JJ, Liberman A. Pathologists' roles in clinical utilization management: a financing model for managed care. Am J Clin Pathol. 2000; 113(3):336-342.

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Scott W. Aesif, MD, PhD; David M. Parenti, MD; Linda Lesky, MD; John F. Keiser; MD, PhD

Accepted for publication March 19, 2014.

Published as an Early Online Release April 23, 2014.

From the Department of Pathology (Drs Aesif and Keiser), and the Divisions of Infectious Diseases (Dr Parenti) and Hospital Medicine (Dr Lesky), Department of Medicine, The George Washington University, Washington, DC.

The authors have no relevant financial interest in the products or companies described in this article.

Presented in poster format at the 2012 annual meeting of the American Society for Clinical Pathology; November 2, 2013; Boston, Massachusetts.

Reprints: John F. Keiser, MD, PhD, Department of Pathology, The George Washington University, 2100W Pennsylvania Ave NW, Ste 5027, Washington, DC 20037 (e-mail:
Table 1. A Summary of All Send-Out Test Requisitions Screened by
Pathology House Staff and Faculty in 2012, Categorized by Test Type
and With Associated Cancellation Percentages and Cost Savings

Test Type              Total     Total     Percent    Cost Saved
                       Orders   Canceled   Canceled

Nucleic acid tests      797       323         41      $48,231.63
Serology and culture    410       136         33      $5,487.50
Total                   1207      459         38      $53,719.13

Test Type              Percent of
                       Cost Saved

Nucleic acid tests         90
Serology and culture       10

Table 2. Detailed List of Screened
Nucleic Acid Tests (a)

                                 Total     Total     Percent
Test Name                        Orders   Canceled   Canceled

Borrelia spp, DNA,
  qualitative                      57        37         65
Cytomegalovirus virus,
DNA, qualitative                   92        30         33
Epstein-Barr virus, DNA,
  qualitative                      65        29         45
Epstein-Barr virus, DNA,
  quantitative                      7         2         29
Enterovirus, RNA, qualitative      16         5         31
HIV-1, genotype                    33         7         21
HIV-1, DNA, qualitative            27        19         70
HIV-1, RNA, quantitative           29         6         21
Hepatitis B virus, DNA,
  qualitative                      19        16         84
Hepatitis B virus, DNA,
  quantitative                     18         9         50
Hepatitis C virus, genotype        34        10         29
Hepatitis C virus, RNA,
  qualitative                      85        51         60
Hepatitis C virus, RNA,
  quantitative                    106        31         29
HSV 1 and 2, DNA,
  qualitative                     138        48         35
JC virus, DNA, qualitative         16         3         19
Varicella zoster virus, DNA,
  qualitative                      31        13         42
West Nile virus, RNA,
  qualitative                      10         9         90
Other (<5 total annual
  orders)                          14         1          7

Abbreviations: HIV, human immunodeficiency virus; HSV, her
herpes simplex virus.

(a) A detailed summary of all nucleic acid send-out test requisitions
screened by pathology house staff and faculty in 2012 is given; the
tests are listed by name with associated cancellation percentages.
The "other" category of nucleic acid send-out tests included: BK
virus, dengue fever virus, parvovirus, and Pneumocystis jirovecii
amplifica-tion assays.

Table 3. Detailed List of Screened Serologic Tests
and Cultures (a)

                            Total     Total     Percent
Test Name                   Orders   Canceled   Canceled

Adenosine deaminase            8         0          0
Aspergillus spp, antigen       6         0          0
Bacterial meningitis,
  antigen panel               47        47        100
Bartonella spp, Ig             5         1         20
Cytomegalovirus, Ig           41         5         12
Coxsackie virus, Ig           21         5         24
Dengue fever virus, Ig         7         2         29
Epstein-Barr virus, Ig        51        13         25
Hepatitis B virus, e
  antigen                     14         8         57
Histoplasma spp, antigen      35         4         11
Herpes simplex virus,
culture                       15        12         80
Borrelia spp, Ig and WB       36         4         11
  pneumoniae, Ig               5         1         20
Parvovirus B19, Ig            17         3         18
Toxoplasma gondii, Ig         26         6         23
West Nile virus, Ig           30        11         37
Other (<5 total annual
  orders)                     46        14         30

Abbreviations: Ig, immunoglobulin, including IgG, IgM, and/or total;
WB, Western blot analysis.

(a) A detailed summary of all serologic and culture send-out test
requisitions screened by pathology house staff and faculty in 2012 is
given; the tests are listed by name with associated cancellation
percentages. The "other" category of serologic and culture send-out
tests included: adenovirus, Bordetella spp, Coccidioides spp,
Coxiella spp, Cryptococcus spp, DNase B, Echinococcus spp, Entamoeba
histolytica, Ehrlichia spp, hepatitis A virus, human T-lymphocyte
virus, Rickettsia spp, rubella virus, Trichinella spp, and Western
equine encephalomyelitis virus Ig assays. Antigen assays included:
beta-D-glucan, Cryptococcus spp, Giardia spp, Legionella spp,
norovirus, and Streptococcus pneumoniae.

All send-out test requisitions screened by
pathology house staff and faculty in 2012,
presented as either total tests ordered (A and
C) or canceled tests (B and D). The tests are
broken down by ordering department (A and
B) and whether the Division of Infectious
Diseases had consulted on the patient for
whom a send-out test had been ordered (C
and D; * P <.001). The "other" department
category included: cardiology, interventional
radiology, neurologic surgery, orthopedic
surgery, general surgery, obstetrics and gynecology,
and nephrology. Abbreviations: ED,
emergency department; ID, Division of Infectious


Total Tests

Other           12%
ED              12%
Neurology       23%
Medicine        53%



Other           10%
ED               9%
Neurology       36%
Medicine        45%


ID Consult      15%
No ID Consult   85%


ID Consult      39%
No ID Consult   61% *

Note: Table made from pie chat.
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Author:Aesif, Scott W.; Parenti, David M.; Lesky, Linda; Keiser, John F.
Publication:Archives of Pathology & Laboratory Medicine
Date:Feb 1, 2015
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