More cost-effective urinalysis testing.
Faced with prospective payment regulations, increased laboratory utilization, and decreases in personnel, lab directors and supervisors must device innovative methods to cope. For the last three years, the department of laboratory medicine at our 379-bed university-affiliated teaching hospital has worked closely with the division of renal medicine to establish policies for urinalysis testing that both meet clinical requirements for good patient care and eliminate unnecessary testing.
Our hematology laboratory annually performs more than 20,000 urinalysis examinations. Since prospective payment, we have taken a number of steps aimed at performing urinalysis in the simplest and most cost-effective manner while at the same time maintaining high standards of analytical performance.
First we adopted the chemical screening algorithm developed by Statland and Ng in 1983 for use in conjunction with the Chemstrip 6L dipsticks for urinalysis. We performed microscopic examinations only if 1) the dipstick was positive for erythrocytes or leukocytes, 2) the dispstick indicated greater than 1 + protein, or 3) a microscopic examination was specifically requested by a physician. Statland and Ng estimated this policy would eliminate 50 per cent of microscopic examinations.
The literature reports that between 30 and 60 per cent of all urine specimens submitted are negative on both the dipstick and microscopic examination. Our own data confirmed this.
In 1984, we developed a method of standardizing urine microscopic findings. Employing the ICL Kova system, we used the following ranges to report cells: 0-2, 3-5, 6-10, 11-20, 21-100, and greater than 100/HPF.
In another move, our laboratory acquired the Yellow IRIS automated urinalysis instrument after a thorough evaluation. We were looking for ways to standardize further the performance of urinalysis, to reduce the labor involved, to decrease the cost per test, and to provide a method that could more effectively screen urine specimens for the presence of significant microscopic findings. We found that the Yellow IRIS reduced the variability between technologists encountered in conventional manual methods of centrifugation, decantation, and preparation and examination of the sediment.
The instrument combines a low-power examination of urine for cells, crystals, and casts with a chemical dipstick analysis. It then uses decision rules to determine if a high-power examination is required.
Testing time for a routine urinalysis has been reduced from six to less than two minutes. The cost of using the instrument is about 50 per cent less than our modified manual method--$1.10 versus $2.18 per test. In addition to these savings, precision and automatic consolidation and reporting of results were important factors in our decision to use the instrument in our laboratory for all urinalysis testing.
Two and a half years ago, we took another major step. Laboratory medicine physicians working with nephrologists in our hospital developed a policy designed to eliminate clinically unnecessary testing and to transfer a larger percentage of routine urinalysis to the day shift, which by virtue of its larger staff has greater flexibility in handling increased work volume.
In the past, all requests for urinalysis were honored. That changed with our urinalysis utilization policy (see Table I), which allows processing of only one specimen per day for each patient. If a physician wants more than one specimen tested and the request does not meet the criteria for nonroutine testing, he or she must discuss the case with the laboratory physician.
Routine urinalysis tests are performed between 8 a.m. and 4 p.m., Monday through Friday. Nonroutine urine specimens are processed whenever ordered; the physician writes the reason for the order on the test request form. Five categories of patients are preapproved for nonroutine handling, either off-hours or for more than one urinalysis per day: emergency room cases, admissions after 4 p.m., patients of the surgery schedule for the next day, diabetics, and febrile patients.
We studied how these requirements affected the number of urinalysis tests ordered by physicians on each of the three daily shifts. The study periods were 17 days before and 17 days after the new testing policy. Figure I shows how many urine specimens were received and analyzed in two-hour intervals over the three shifts. In all but three of the intervals, fewer tests were ordered after the policy change. In two of the three intervals with a higher number of test orders, 4 to 6 p.m. and 6 to 8 p.m., tests actually performed fell below prepolicy figures. Only during the 8-to-10 a.m. period did the number of tests performed rise under the new policy. The increase reflected a transfer of routine testing from the third shift to the day shift.
Figure II presents the same data in the form of totals for the three shifts. On the third shift, the number of tests decreased from 91 to 23, or from 9.6 to 3.3 per cent of daily urinalyses. On the day shift, the number of urinalyses dropped from 581 to 474. The day shift's share of total urinalysis work increased from 61.7 to 68 per cent, however, because of the policy's requirement that routine testing be performed between 8 a.m. and 4 p.m.
The number of urine tests performed on the evening shift decreased from 270 to 200, but the proportion of total workload performed on this shift remained unchanged at 28.7 per cent.
Comparing the two 17-day periods, we were able to influence physicians to decrease urinalysis requests by 19 per cent, from 942 to 760. The additional decision rules led to an overall workload reduction of 26 per cent, to 697.
Technologists can apply the testing guidelines to well-defined cases without checking with the laboratory physician. For example, a technologist presented with a request that indicates "new fever spike" can immediately perform the urinalysis even if the test is the second one for that patient that day.
All other exceptions to the urinalysis utilization policy are handled in direct discussion between the laboratory physician and clinician. For medical students and new house staff, we find that a brief telephone conversaion about the policy at the beginning of rotations helps eliminate unnecessary and repetitive test ordering.
We believe that our urinalysis test utilization policy has been a successful response to cost constraints. We continue to review our methods and instrumentation to insure that we are providing the most accurate results in a timely and cost-effective manner.
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|Title Annotation:||development of policy eliminating unnecessary urine testing|
|Author:||Daigneault, Robert W.; Carlson, Desiree A.|
|Publication:||Medical Laboratory Observer|
|Date:||Mar 1, 1987|
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