Data-Driven Iterative Refinement of Bone Marrow Ancillary Testing Guidelines Improves Test Utilization and Decreases Costs
Adam C Seegmiller, Annette S Kim, Claudio A Mosse, Mary Ann Thompson, Shaoying Li, Aaron C Shaver, Mary M Zutter. Vanderbilt University School of Medicine, Nashville, TN
Background: The Hematopathology Diagnostic Management Team (DMT) is a group of hematologists, hematopathologists, and bioinformaticians that develops guidelines and systems to promote appropriate test utilization for hematologic malignancies. This group created standard ordering protocols (SOPs) that significantly reduced unnecessary utilization of bone marrow cytogenetic and molecular tests. However, there was often insufficient published evidence to guide testing decisions. To address this deficiency, we collected testing data before and after SOP implementation and used it as evidence to revise SOPs. We hypothesized that this data-driven iterative SOP refinement would further decrease unnecessary testing and reduce costs.
Design: Testing data was collected on 2,586 adult bone marrows performed at Vanderbilt University between August 2010 and February 2012, consisting of disease category and clinical setting; total number of tests performed, including tests concordant or discordant with SOP guidelines; omitted tests; and test results. The original SOPs were revised to eliminate test recommendations in settings where positive test rates were close to zero. Additional data was collected for four months after implementation of the revised SOPs (668 bone marrows) and compared to that of the preceding six months (909 bone marrows).
Results: The average number of tests performed per bone marrow was significantly lower after implementation of the revised SOPs (3.15 before vs. 2.94 after; P=0.003). This was due to a 10% decrease in SOP-recommended (concordant) tests (2.68 vs. 2.41; P<0.001). There was no significant change in discordant or omitted tests. Reductions in test utilization were most apparent in cases of acute lymphoblastic leukemia (13% decrease), bone marrow failure (52% decrease), and myeloproliferative neoplasms (22% decrease). These changes resulted in a 10% decrease in testing costs to payers ($195 decrease per marrow; P<0.001). Taken together, the successive SOP implementations have reduced total tests by 21% and costs by 27% compared with original pre-implementation values.
Conclusions: Application of SOPs not only decreased unnecessary tests initially, but also facilitated collection of data that was used to refine the SOPs. Application of revised guidelines led to further reductions in tests and additional cost savings. Thus, the DMT functions as a rapid learning system, in which testing data is continuously collected and analyzed to iteratively improve this complex decision-making process.
Tuesday, March 5, 2013 9:30 AM
Poster Session III # 183, Tuesday Morning