Encouraging Quality Pathology Ordering in Australia S Public Hospitals

Encouraging Quality Pathology Ordering in Australia’s Public Hospitals

Final Report

2011

A project funded under the Australian Government’s Quality Use of Pathology Program and conducted by the National Coalition of Public Pathology Inc.

Contents

1Executive Summary

2Introduction

2.1Background

2.2Purpose

2.3Scope of the Project

2.4Conducting the Project

2.5Consultation with Stakeholders

2.6Information Gathering and Analysis

2.7Roundtable Discussion

2.8Assessing the Evidence

2.9Defining Appropriate/Inappropriate Ordering

2.10Limitations and Boundaries

2.11Structure of Report

3Setting the Context: Australia’s Public Hospitals and Pathology Services

3.1Role and Responsibilities of Australia’s Public Hospitals

3.2Size of Australia’s Public Hospital Sector

3.3Diversity in Australia’s Public Hospitals

3.4Current and Emerging Challenges

3.5Policy Developments

3.6Pathology in the Public Hospital Setting

3.7Organisational Features

3.8Demand and Use of Pathology

3.9Requesting……………………………………………………………………………………………………...15

3.10 Utilisation……………………………………………………………………………………………………….....16

3.11 Pathology Testing Cycle…………………………………………………………………..……………….…16

4The Question of Appropriateness

4.1Why the Interest?

4.2Inappropriate versus Appropriate Use

4.3Why it is Important?

4.4Defining Appropriate Test Use

4.5Modifying Use

4.6Australian Developments

5A Situational Analysis: Current and Planned Activities and Practices

5.1About the Survey

5.2Importance and Problems Addressed

5.3Strategies and Targets

5.4Monitoring Success and Effectiveness

6Interventions – What the Evidence Shows

6.1Approach to Analysis of Interventions

6.2Education, Audit and Feedback

6.3Rules and Agreements to Restrict Test Requests

6.4Re-Design of the Request Form

6.5Computerised Physician Order Entry Systems

6.6Reimbursement and Funding Models

6.7Summary

7Conclusions – Lessons Learned and Future Directions

7.1A Heterogeneous Evidence Base

7.2Types of Interventions or Demand Management Strategies– Effectiveness and Sustainability

7.3Success Factors7

7.5Australian Efforts

7.6Identified Gaps and Opportunities for Improvement

7.7Recommended Actions

7.8Concluding Remarks

Abbreviations and Acronyms

Appendices

1Project Steering Committee and Project Team

2List of Participating Organisations and Individuals

3Literature Search Strategy

4Current and Planned Practices Survey Instrument

5Roundtable Discussion

References

1Executive Summary

This project has sought to explore, document and review the efforts undertaken in Australia’s public hospitals to better manage demand for and appropriate use of pathology testing in patient care.

Project Context

Public hospitals are a vital part of Australia’s hospital sector and health system. They are diverse in terms of size, location and types of services provided. They are also an area of public scrutiny in terms of access and quality. Government efforts are focused on improving efficiency, accountability and quality in the face of increasing demand, community expectations and budgetary pressures. It is against this policy context that this project on improving quality pathology ordering is being undertaken. (Section 2)

The Evidence Base Assembled

The picture of efforts to improve appropriate pathology ordering and utilisation has been assembled in three parts:

Understanding the different approaches taken to considering appropriate and inappropriate pathology ordering in the hospital setting(Section 4);
Establishing a snapshot of current and planned strategies in place in public pathology services across Australia (Section 5); and
Examining the evidence available on the types of interventions or demand management strategies implemented in Australia and overseas and their impact on test requesting patterns of clinicians (Section 6).

The evidence assembled is heterogeneous,spanning the spectrum from peer reviewed published articles and systematic reviews through to anecdotal reports from key informants, and variable in quality.

Some recurring themes have emerged that enable broad conclusions to be made about the effectiveness and sustainability of interventions and strategies targeting clinicians’ requesting behavior as well as gaps in the evidence base that require addressing.

The Question of Appropriateness

One of the fundamental questions that underpins the project is defining appropriate pathology ordering. There has been much debate but limited science around appropriateness of pathology requesting with very little in the way of robust research methodology and with various stakeholders bringing different perspectives to the issue (Section 3).

Although the logic of definitions of inappropriate pathology requesting, such as “… performed at the wrong time or too frequently to be of value in diagnosis, prognosis, or ongoing clinical management”, is compelling, applying them retrospectively, in the absence of the clinical contextual detail present at the time a request was made, is often hazardous and contributes limited information of real value.

Appropriateness is a complex multifaceted concept and managing it requires an understanding of which diverse factors are relevant in any local setting. It is also important to remember that the approach to ordering pathology can significantly affect patient flow in busy hospital settings as well as individual patient clinical outcomes. These matters need to be considered in any health economic analysis.

Pathology is not an end unto itself. It is a critical input to the clinical management of most patients and its benefit or otherwise must be considered in the context of the clinical and cost outcome of the episode of care in which it is used, and not in isolation. Information from pathology investigations also informs public health surveillance and serves an important health protection function within our communities. This also has significant economic implications.

Types of Interventions and Demand Management Strategies

Our review has found that there are many strategies that will change pathology ordering frequency, particularly when used in combination, but sustainability is a major challenge.Strategies identified fall into five broad categories:

Education, audit and feedback – e.g. education programs, guideline dissemination, pre and post analytical feedback on test appropriateness, feedback on test predictive value and feedback on test cost.
Rules and agreements to restrict test requests– e.g.re-engineering and implementation of clinical guidelines/pathways, implementation of minimum re-test interval schedules and linking requesting authority to clinical staff seniority (“traffic lights”).
Re-design of the request form to provide guidance to requesters– e.g.providing a list of approved tests that they may circle, tick or order, listing test costs to send a price signal, aligning request forms to modified clinical practice guidelines for test ordering and unbundling/banning use of test panels on request forms.
Computerised Physician Order Entry (CPOE) systems–includes real time decision support.
Reimbursement and funding models– e.g. budget holding by the laboratory, budget holding by requester, activity based funding (e.g. diagnosis related group (DRG) based funding) and budget holding by regulator.

Their Effectiveness and Sustainability

While the quantum and quality of the evidence across these five broad categories of strategies are variable, the following broad conclusions may be made about their effectiveness and sustainability:

Education, audit and feedbackis an effective demand management strategy, however, the effect gradually declined during the period after the intervention.
For rules and agreements to restrict test requests, minimum re-test intervals are successful in effecting and maintaining a reduction in unnecessary repeat test requests by clinicians, as evident by the sustainability of the interventions. Traffic lights systems have been an effective intervention in targeting the test requesting behaviour of junior doctors in the emergency department setting, improving quality of requesting, and reducing unnecessary testing including repeat testing. In each of the three states and territory where it has been implemented, the effect has been sustained between 4 and 11 years. Where clinical guidelines are implemented, senior clinicians are likely to request fewer tests when they have a more direct involvement in planning clinical pathways, and in the early stages of the patient’s management.
Strategies involving re-design of the request form are effective in reducing the use of pathology tests irrespective of the purpose, approach to the re-design process or the format of the re-designed request form. As an overall strategy, re-design of request forms appears to be an effective mechanism for supporting good clinical practice, particularly among inexperienced junior doctors. Questions, however, remain about the impact of price signals (e.g. display of tests costs on the request form) on test requesting.
CPOE systems are not a panacea but they have been shown to be an effective tool to bring real time evidence based decision support to requesting physicians, thereby assisting efforts to manage demand for pathology. To be successful in this role, CPOE technology needs to be developed to a level of utility and efficiency acceptable to users. Until stakeholders accept the investment requirement, need to adopt coordinated implementation plans including impact assessment and better research design, its take up will be slow.Information technology offers potential to assist in managing the use of this valuable resource, particularly by providing tools to give clinicians real-time assistance at the time requests for pathology investigations are made, but design and deployment of such tools is sadly still in its infancy.
The role of reimbursement and funding models in managing demand for pathology testing does not appear to have been examined to any great degree with only one study found. It dealt with the transfer of hospital laboratory budgets to requesters. Experience in several Dutch hospitals where such a system has been in place for a number of years indicates that, although it functions well with a decrease in test ordering observed, demand returned to its former pattern after a few years.

While all strategies appear to have the capability to deliver success, there is no consensus on a sustainable model(s) for broader adoption long term and sustainability remains a challenge.

Success Factors

Our review indicates that there is no single or easy pathway to achieving sustained improvement in appropriate pathology ordering and utilisation in the public hospital setting. Success appears to be associated with the interplay of a number of critical factors:

Targeting multiple behavioural factors.
Basing models on proven and robust behavioural science principles using a multi-faceted approach.
Clinical engagement and ownership at a senior level.
Clinical champions or lead clinicians to drive the approach.
Using strategies that are simple and easily integrated into everyday practice.
Adapting strategies to meet local needs and circumstances.

The cultural behaviour determinants of pathology requesting are often underestimated and most likely hold the key to long term success. (Sections 6 and 7)

Future Directions

Our reviewhas shown clearly that there is a lot that can be done to sanitise our thinking around appropriate use of pathology and also establish some useful baseline data to help better tackle this issue in the future. It has also shown that considerable efforts have been taken to achieve improvement in appropriate pathology ordering and utilisation in Australian public hospitals. Our survey of current and planned practices found that most public pathology services (75% of respondents) are doing something in this area in the public hospitals they serve, mostly they are driven by pathology and strategies used follow those found in the literature.

NCOPP has made some constructive suggestions about where to start and our members are keen to assist in taking this forward (Section 7).

Our first recommendation focuses on the development of a standard national definition of appropriate pathology test ordering. A fundamental problem the project has grappled with is the lack of a consistent definition of appropriate versus inappropriate pathology test ordering. To address this gap, the project has developed a matrix that encapsulates a uniform national definition that could be applied to the assessment of whether a request for any/every pathology test was appropriate. The matrix recognises that, within the hospital and entire healthcare system, there are many different settings and indications where ordering of pathology investigations is appropriate.

The matrix is presented below. Essentially, it combines the different purposes of pathology testing with broad clinical indications for use.

If none of the boxes in the matrix can be ticked, the test should be regarded as inappropriate.
Similarly, if there is an indication, according to the matrix, for a test to be done and it is not ordered, this would indicate inappropriate ordering of pathology via omission to order an indicated test.

Appropriate Pathology Test Ordering Matrix

Purpose of Pathology Testing / Clinical Indications for Use
Indicated for Acute/ Immediate Patient Care / Indicated as part of a Clinical Pathway/ Standard Care for patients with that condition / Indicated for Public Health Objective / Indicated to assist good Patient Flow
For Diagnosis
For Treatment
For Monitoring – disease or therapy
For Assessment of Possible Adverse Event or Side-effect
For Exclusion of a Possible Diagnosis
Required to Assess or Manage a Comorbidity
(separate to main diagnosis)
Screening*

*NOTE: This covers the use of tests for purposes of ‘disease screening’. Formal population based screening programs are recognised indicators for pathology tests, but generally they are not undertaken as part of usual patient management in the public hospital setting. However, patients in public hospitals may have pathology tests as part of a comprehensive assessment of factors potentially contributing to a problem or as part of a health check strategy.

The matrix should be used for all future research and audits in Australia to review and assess pathology test ordering and in the evaluation of interventions on this topic. Also, it may be useful as an educational tool in an intervention strategy and/or national guidelines.

Other recommendations deal with:

Development of standard data sets on pathology utilisation in Australia’s public hospitals for data collection and benchmarking purposes with initial efforts focused on assessing on the top 10 to 15 DRGsfor admitted patient services for public hospitals nationally and the top 10 to 15 pathology tests used in public hospitals.
Monitoring and participating in electronic health record systems and CPOE systems developments.

NCOPP thanks the Department of Health and Ageing for funding this project under the Quality Use of Pathology Program (QUPP).

We also thank the many organisations and individuals who have contributed information and insights to the project.

2Introduction

The National Coalition of Public Pathology (NCOPP) was awarded a grant in 2010 by the Department of Health and Ageing (DOHA) under the Australian Government’s Quality Use of Pathology Program (QUPP) to undertake a project on Encouraging Quality Pathology Ordering in Australia’s Public Hospitals. NCOPP is the organisation that represents the publicly owned and operated pathology services in each state and territory. They provide the vast majority of pathology services to support the needs of patients of Australia’s public hospitals.

2.1Background

Finding ways to better manage demand for and improve quality use of pathology testing in Australian public hospitals has been a growing area of interest. It has been driven by several factors: rising demand for public hospital services and pathology testing; budgetary constraints and pressures to ensure best use of scarce resources; continuing questions about the clinical appropriateness and value of current ordering patterns; and government efforts to improve hospital performance, patient safety and quality. A range of interventions has been trialled and/or developed in various jurisdictionsbut there has not been any attempt to look at them collectively. Little is known about the overall effort undertaken in public hospitals to improve the quality use of pathology services in patient care in Australia’s public hospitals, or of its effectiveness and sustainability.

2.2Purpose

This project seeks to address that gap by providing an initial exploration of the area. Itaims to:

document, pool and review the knowledge and experience in Australian public hospitals to better manage demand for and appropriate use of pathology testing in patient care;
consider lessons learned; and
establish future directions for achieving sustainable change.

The project addresses one of QUPPs priority areas – improving the quality of pathology ordering. NCOPP expects that the project’s results will provide a useful resource to inform and guide the promotion of evidence based pathology practices.

2.3Scope of the Project

The project focused on the Australian public hospital setting and pathology ordering by doctors and other clinicians for admitted and non admitted patients. Public hospitals are the main early training ground for clinicians and initiatives that support quality ordering early in their professional careers may have benefits downstream and over time. The current project complements those that have focused on pathology ordering in the community and other settings.

2.4Conducting the Project

The project was conducted over the period late September 2010 to the end of May 2011. A Steering Committee was formed to guide and oversee the project. A list of members and the project team is at Appendix 1. In broad terms, the project involved:

information gathering and analysis;
consulting with stakeholders;
synthesising and evaluating information from a variety of sources using a common assessment approach;
examining lessons learnt;
considering and assessing future directions for national uptake and adoption; and
developing a set of findings, conclusions and recommendations.

2.5Consultation with Stakeholders

A variety of organisations and individuals were approached to advise them of the project, seek their help in identifying relevant information and studies and enlist their participation in the project. Organisations included public pathology services, pathology professional bodies, national healthcare safety and quality bodies as well as clinicians, researchers and academics in the field. A list of participating organisations and individuals is at Appendix 2.

2.6Information Gathering and Analysis

Information about studies, initiativesand current practices aimed at reducing unnecessary pathology testing and improving appropriate use was gathered from a variety of sources and in four ways:

a limited review of the published literature;
a review of projects funded under the QUPP relevant to this project;
a survey of demand management practices of public pathology services; and
from stakeholders and through other research.

The literature review was targeted to Australia and a selection of countries with comparable health systems in order to give an international perspective. The initial pass covered the period 1995 to the present and focused on hospital pathology services. Additional references were found by following up references cited. Studies focused on general practice or family settings were, in general, excluded. Details of the literature search strategy are provided at Appendix 3.