11/23/13

Reducing Patient Charges by Eliminating Amylase from Lab Panels - Jeffrey Wiswell, David Nestler , and Ronna Campbell - Harvard Business Review

HBR Blog Network

Reducing Patient Charges by Eliminating Amylase from Lab Panels
by Jeffrey Wisw ell, David Nestler and Ronna Campbell | 4:39 PM November 22, 2013

My colleagues and I were interested in reducing the cost of frequently ordered laboratory panels (groupings of blood tests) ordered by the emergency department (ED). After evaluating the evidence, we removed amylase from the lab panels for abdominal pain and for medical clearance of psychiatric patients who need to be transferred to a psychiatric facility. Both actions resulted in an overall substantial decrease in patient charges. The Problem In EDs across the country, patients are assessed by their chief complaints (headache, abdominal pain, chest pain, shortness of breath, etc.). Due to the need for timely and effective diagnosis of high volumes of potentially ill patients within minutes, most tests are ordered at the onset of an encounter. A common way to do this is to use panel-based blood tests, or lab panels. These panels can be expensive and increase health care costs. In patients presenting with abdominal pain, both amylase and lipase have been historically ordered to assess for pancreatitis. This practice has been questioned because lipase has been scientifically proven to be more sensitive and specific than amylase in the evaluation of this disease process. The Solution After reviewing a previous study (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2967686/) on cost savings achieved by educating providers on the minimal utility of amylase and the subsequent removal of amylase from an abdominal pain lab panel, we sought to assess the generalizability of those results at our site. Support among ED providers (emergency medicine attendings, residents, and advanced practice providers) was obtained by e-mail and in-person interviews. We subsequently removed amylase from the abdominal pain panel in our electronicmedical-record ordering system. Although amylase was no longer on the panel, providers were still able to order it individually if desired. The Financial Background At our ED, the abdominal pain panel consisted of a complete blood count with differential, electrolyte panel, pointof-care glucose, lactate, aspartate aminotransferase (AST), alkaline phosphatase, total bilirubin, direct bilirubin, lipase, and amylase. The total patient charge for the panel was $593 without amylase and $649 with it. Patients were charged $56 for amylase and $71 for lipase. The Results Pre-intervention, amylase was ordered on average 498 times per month for the preceding year (325 times per month through the abdominal pain panel and 173 times per month individually or within another panel). Postintervention, it was ordered 119 times per month (0 times per month through the abdominal pain panel and 119 times per month individually or within another lab panel). Based on $56 per amylase test, monthly charges decreased from an average of $27,860 to $6,664 an annual decrease of $254,352. After realizing significant cost savings by removing amylase from the abdominal pain panel, we investigated the other reasons it continued to be ordered. We subsequently found it was part of a routine lab panel used for medical clearance of psychiatric patients who needed to be transferred to a psychiatric facility. With approval from the department of psychiatry, we further decreased the ordering of this non-specific test from 119 times per month to 24 times per month resulting in an additional savings of $63,616 dollars per year. Between both panels, we reduced patient charges by $317,968 per year, a 95% reduction from the previous total attributed to this single lab test. Although we were concerned that consulting services would request amylase, we are not aware of any formal requests to have it returned to the panels. Follow the Leading Health Care Innovation insight center on Twitter @HBRhealth (https://twitter.com/HBRhealth) . E-mail us at healtheditors@hb r.org (mailto:healtheditors@hb r.org) , and sign up to receive updates here. (http://vovici.com/wsb .dll/s/1549g543ed?wsb 2=IS)
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11/23/13

Reducing Patient Charges by Eliminating Amylase from Lab Panels - Jeffrey Wiswell, David Nestler , and Ronna Campbell - Harvard Business Review

Leading Health Care Innovation

From the Editors of Harvard Business Review and the New England Journal of Medicine

(http://hbr.org/special-collections/insight/leading-health-careinnovation?desktop=true)

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