Appropriate test ordering by clinicians is a key aspect of clinical laboratory management. It can save time and money. One of the most obvious goals of this approach is to cull out duplicate test orders when the patient in question is clinically stable and the additional results are useless. The number of test cycles to arrive at a diagnosis can also often be reduced by immediately ordering a more specific test rather than repetitive groups of less-specific tests. The more specific test may be more expensive than the others but the total cost of testing may be less. In general, clinicians often require the most advice when ordering molecular and genetic tests. They tend to be the most expensive, most complicated, and require the most interpretive skill. ARUP Laboratories has published a white paper on the value of genetic counselors (GCs) emaployed by the lab to assist clients in genetic test ordering (see: Value of Genetic Counselors in the Laboratory), Below is an excerpt from it:
Genetic counselors (GCs) employed by diagnostic laboratories may write medical papers, coordinate research, create and maintain genetic databases, educate clients and health care providers, and review test orders. Of these duties, the one that most directly benefits patients, medical institutions, and insurers is the rigorous reviewing of genetic test orders. GCs at ARUP Laboratories, a national reference laboratory, collectively save ordering institutions more than $30,000 per month by modifying test orders to improve utilization. Seven GCs at ARUP Laboratories performed a review of all genetic test modifications over an 11-month period, reviewing clinical information that accompanied test orders for complex genetic tests (i.e., sequencing, large duplication/deletion analysis, or arraybased technologies) before testing was performed. The GCs considered the clinical utility and cost-effectiveness of the ordered tests and contacted the ordering institution and/or health care provider to collect additional clinical information, confirm testing, or suggest alternative testing based on the provided clinical information or family history. The GCs identified and cancelled or changed inappropriately ordered genetic tests for an average cost savings of $36,500 per month, representing approximately 30 percent of all complex genetic tests ordered [and assisted in an average of 107 test modifications per month]. Among frequently misordered tests were requests for fullgene sequencing when a familial mutation was known or when a screening panel would have been more appropriate (e.g., cystic fibrosis testing in expectant individuals with no family history). Erroneously ordered genetic testing delays medical decision-making and increases diagnostic costs.
I have occasionally encountered superiors during my career who have discouraged my interest in studying lab overutilization. These individuals have been motivated by the fact that the performance of clinical labs is frequently judged by the volume of tests performed and therefore attempts to reduce this test volume should be avoided. This brings up the very interesting question of why ARUP, a commercial reference lab, would hire GCs whose major role should be to discourage test-ordering or, better stated, encourage appropriate test ordering. Here is a repeat quote from the article above in case you missed it:
The GCs identified and cancelled or changed inappropriately ordered genetic tests for an average cost savings of $36,500 per month, representing approximately 30 percent of all complex genetic tests ordered [and assisted in an average of 107 test modifications per month].
I believe that, in the long-run, the effective use of lab services will always be the best business model. ARUP clearly believe in such a policy, I would also suggest that its customers understand this as well. In the competitive commercial lab sector, this policy may help to differentiate it from competing labs and bring it more business.