Monitoring the use of expensive gastrointestinal pathogen panel (GIPP) diagnostic testing -- and intervening when such tests are not indicated -- saves money and reduces inappropriate use in hospitals, according to a study published April 23 in Infection Control & Hospital Epidemiology.
Researchers used an electronic health record (EHR) system with clinical decision-support (CDS) tools to educate clinicians and block questionable GIPP orders for patients hospitalized with diarrhea at the University of Nebraska Medical Center. This approach cut the rate of inappropriate testing by 46%, with estimated savings of $168,000 over 15 months, lead author Dr. Jasmine Marcelin and colleagues wrote.
The intervention evaluated in the study included educational alerts about best practices based on antimicrobial stewardship program (ASP) recommendations for diagnostics usage, as well as a "hard stop" in the EHR to prevent inappropriate orders.
Prior to the hard stop, 21.5% of orders were deemed to be inappropriate, compared with 4.9% afterward, the researchers reported.
"We demonstrated that restriction of GIPP testing is feasible and safe, and resulted in significant cost savings," they wrote.
"Benefits of diagnostic stewardship include improved patient satisfaction, reduction of irrelevant or false-positive test results and their nonbeneficial treatment, and significant cost savings," they noted. "Interventions that combine clinician education, audit/feedback, and real-time EHR ordering restrictions are more likely to successfully reduce unnecessary laboratory testing."
GIPP panels effective but pricey
Many companies that make in vitro diagnostics promote panel tests for their effectiveness in catching syndromes (a variety of symptoms and signs that can signal a disease) and reducing false-negative results associated with single pathogen tests, commented Bruce Carlson, publisher of Kalorama Information, a sister company of LabPulse.com.
However, panel tests involve ruling out conditions and add to the overall diagnostic costs, so they are a target for budget cutters, Carlson added.
In the case of GIPP, the introduction of polymerase chain reaction (PCR)-based panels for gastrointestinal pathogens has allowed for the rapid identification of more organisms and has "shifted the paradigm of evaluation of diarrheal illnesses away from labor-intensive and insensitive direct stool examination and culture methods," Marcelin and colleagues noted.
Marcelin et al evaluated the appropriateness and costs associated with GIPP testing following the implementation of the FilmArray gastrointestinal panel (BioFire) at their center in Nebraska in 2015.
The test panel is fast and sensitive for the detection of 22 common disease-causing organisms. However, it is expensive and often not needed for patients later in their hospital stay or when repeated on the same patient, the researchers explained.
"Consistent with published literature, we found that stool testing in patients hospitalized for >72 hours or those who have previously been tested is unlikely to be clinically relevant, which suggests that restricting repeat GIPP testing in the inpatient setting is reasonable," they wrote. "Reduction of unnecessary (either inappropriate or repetitive) laboratory testing is an attractive goal for quality initiatives, clinical microbiology laboratories, and ASPs."
The center had determined that the cost of about $30,000 for implementing multiplex panel testing would be offset by much larger savings reaped from the reduction of inpatient isolation time. And it has found that turnaround time for test results has been reduced from 55.5 hours with traditional stool cultures to 3.9 hours with GIPP.
However, outside of Clostridium difficile and norovirus, the organisms detected by the panel are uncommon, the authors noted.
Looking at tests ordered and the associated costs between 2016 and 2018, the researchers measured the impact of a diagnostic stewardship intervention involving best practice advisory alerts and the hard-stop blocking GIPP testing in inpatients after 72 hours.
At the Nebraska center, EHR alerts must be clearly justified and pass through rigorous committee review, researchers noted.
Referring clinicians could override the EHR block on GIPP by requesting approval through the microbiology lab manager, which was typically granted.
"Strong operational support of an override workflow by the microbiology laboratory directors was critical to the successful implementation of a hard-stop alert in the EHR," the authors wrote. "We chose a 'hard stop' alert that prevents the clinician from ordering the test if appropriateness criteria are not fulfilled. A CDS of this type is very effective at changing practice, but it must be carefully deployed to prevent patient harm and clinician dissatisfaction."
The best practice advisory alert data allowed the researchers to measure the number of times an order panel was opened but not completed and estimate savings accordingly.
Marcelin and colleagues also included the costs of alternative tests when the GIPP panel was avoided.
Significant reduction in test orders reported
The number of GIPP tests ordered dropped from 1,587 before the intervention to 1,165 after it, they reported, a statistically significant reduction (p < 0.001).
Estimated cost savings of $168,000 included $67,000 from orders blocked by the hard stop in the EHR and estimated savings related to best practice alerts.
The microbiology lab director approved 57 test orders that had been rejected by the EHR and challenged by clinicians, of which five (8%) were positive, the researchers reported. The only pathogens detected through the override option were Cryptosporidium and norovirus, and none of these cases resulted in a change of management.
"Thus, the restriction as implemented is likely safe and further restriction of even these approved results may be appropriate," the group wrote.
Limitations of the study included the retrospective single-center design; the use of an EHR with robust clinical decision support, which is not available in all centers; and the use of one particular test when others are also available.
"However, restriction of inappropriate testing is not dependent on the type of panel used; therefore, our results are likely generalizable to other institutions," the researchers added.
Marcelin and colleagues also did not evaluate specific clinical outcomes, such as the length of stay or use of antibiotics.
The researchers concluded that given the high cost of testing, institutions should consider ways to ensure appropriate testing by engaging with their microbiology laboratory and antimicrobial stewardship teams.
"Incorporating diagnostic stewardship into the [antimicrobial stewardship program] can ensure that the costs do not outweigh the benefits of the test," they wrote. "Considering the degree of savings that a simple intervention can create, there is also a compelling argument for the value of an ASP, as $168,000 could potentially cover a large majority of a stewardship full-time equivalent (FTE)."
The results were published in conjunction with a white paper by the Society for Healthcare Epidemiology of America (SHEA) in the same journal explaining the role of the EHR and CDS systems in enhancing antimicrobial stewardship programs. The white paper includes advice on improving the oversight of drugs and diagnostics amid increased scrutiny of use by regulatory and accreditation agencies, as well as payors.