The Cost of Not Having Clinical Information
V Parkash, B Arcarese, L Hao, P Cohen, M Pinto. Yale University School of Medicine, New Haven, CT
Background: Inadequate clinical data (ICD) on requisition forms ranges up to 20% depending on the institution. Well-recognized negative consequences of ICD include delays in signout and substantial changes in diagnoses. Cases with malignant diagnoses and tissues from certain anatomic areas are more prone to incur a diagnostic change due to ICD. ICD also creates additional cost due to potentially unnecessary testing of tissues in order to arrive at a definitive diagnosis. This cost has not been estimated to date.
Design: A retrospective search over a 6 month period (Jan 08- July 08) revealed 14 cases coded as endobronchial or liver needle biopsy for tumor. Liver and lung biopsies were chosen because these are the two most likely sites of metastatic disease, and therefore most likely to generate a broad differential. Of these, 10 cases did not have an adequate clinical history. These cases were circulated amongst four pathologists to determine the number of immunohistochemical stains (IHC) that each would order to evaluate the case in the absence of additional information. History was then obtained on these patients, in the forms of radiology reports, chart review or phone call to the clinician. The slides were re-circulated, and the pathologists listed the IHC stains they would order with knowledge of the new clinical data. A cost difference between the two scenarios was calculated based on Medicare reimbursement rates for IHC.
Results: When these 10 cases were reviewed with ICD, the number of stains per pathologist ranged from 36 to 64. The pathologist who ordered 36 stains would have ordered additional panels depending on the outcome of staining with the first panel. On average the number of stains per case was 5.6 (range 3-14). When the cases were reviewed with additional detailed history, the number of stains ranged from 24 to 53, with an average of 2.8 stains per case. In three cases, at least two pathologists felt that no stains were necessary. At a global medicare reimbursement of $109 per stain, this resulted in a reduction of $305 per case. At a professional reimbursement of $44 per stain, $123 was saved. Two pathologists, each for one case, would have exceeded the maximum billable stains for a local insurance company in the absence of adequate clinical data.
Conclusions: Inadequate clinical history imposes a cost on the health care system in the form of dollars spent by pathologists to perform additional studies on tissue biopsies.
Category: Quality Assurance
Tuesday, March 10, 2009 8:30 AM
Platform Session: Section F 1, Tuesday Morning