A-206 Instilling Diagnostic Stewardship through Pathology Resident Triage of Referral Testing

Background Formal laboratory directorship education varies amongst institutions. Typically lecture-based curriculum highlights core competencies including: scientific knowledge, management and leadership skills, quality assurance and regulatory compliance, ethics, safety, and budgeting and financial management. Our institution has implemented clinical pathology call (“Keeper of the Beeper” or “KOB call”) to prepare pathology residents to investigate transfusion reactions, positive meningitis panels, critical lab values, as well as referral testing triage. The referral testing triage emphasizes the budgeting and financial management competency by learning how to manage lab resources and help ensure that the lab continues to operate within their financial means while maintaining a high level of patient care and providing direct experiences in clinical consultation to other medical services. Methods Referral tests, which cost greater than $1000, are evaluated to assess the utility and medical necessity. This evaluation process includes review of the patient’s chart to find the clinical indication for the test ordered, and in some cases, discussion with the clinical team and ordering physician if the indication was not clear from initial chart review. Information regarding the patient’s status of inpatient or outpatient was documented. After complete evaluation, the test was either approved, rejected, and/or provision of alternate testing options were provided. Tests greater than $1000 and on the Department of Pathology referral testing formulary are eliminated from evaluation and automatically approved. Results Over an 8-month period, 8 tests were rejected for send out referral testing through our triaging protocol. The reasons for rejections included: redundancy (n=2), incorrect order (n=1), non-contributory (n=2), deviation from standard of care (n=2), or research purposes (n=1). Of note, 5 of the 8 rejected tests were ordered in the inpatient setting, for which institutional billing of these non-indicated tests would have directly affected our department budget. The rejected tests resulted in total direct savings of $21,175. Conclusion Lab triage of send out tests is a crucial aspect of laboratory management to ensure both efficiency and diagnostic stewardship in providing patient care. While our data are somewhat limited, we are observing trends in a positive direction that demonstrates the value that Pathology Residents are able to provide while gaining firsthand exposure to the roles of a laboratory director. The implementation of this protocol has yielded valuable insight into frequently ordered tests, allowing us to expand the pre-approved list in our formulary. These data also serve as a critical resource should the decision be made to bring these tests in-house. We believe this is a model that could be easily replicated at other academic medical centers and should be considered as a tool for teaching aspects of diagnostic stewardship in Pathology Residency programs.