Laboratory Review of Genetic Test Orders Cuts Errors, Costs

Three percent of genetic test orders are cancelled or modified due to an order error found during a utilization management (UM) review of higher risk orders, according to a study published in the August issue of the American Journal of Clinical Pathology. Furthermore, clinicians without specialty training in genetics make genetic test order errors at a significantly higher rate than geneticists. Ensuring the laboratory is actively involved in the diagnostic workup through UM review is important to minimize diagnostic errors and unnecessary costs to patients.

Previous studies identified diagnostic errors tied to mistakes in test selection and ordering. Additionally, send-out test orders, particularly, for genetic tests remain a costly issue for laboratories. However, results show that lab UM programs can address both of these issues—effectively decreasing send-out testing costs and minimizing errors associated with genetic test orders.

The researchers retrospectively analyzed a UM case database at a pediatric, tertiary care medical center consisting of 1,393 genetic test orders (September 2012 to February 2015). Reviewers categorized order modifications and cancellations, quantified positive results and order errors, and compared errors by provider (genetics with nongenetics) for both inpatient and outpatient orders. Cancellations were characterized as resulting from cost, redundancy, inappropriateness, lack of insurance preauthorization, deferral of testing (e.g., waiting for other testing results), or new information making the test no longer necessary.

The UM system required reviews by doctoral-level faculty or genetic counselors for laboratory orders with costs (to the laboratory) above a defined threshold (lowered from $1,000 to $700 during the course of this study), multiple genetic tests on one order, orders requested to be sent to a non-preferred or international laboratory, orders requested for send outs for tests performed in-house, and orders for tests associated with predefined conditions known to be associated with errors or other ordering problems (e.g., familial mutation testing).

The researchers found that overall 67 percent of test orders were approved (n=936), while the UM affected one-third of all genetic test orders. Specifically, the review led to 15 percent of orders being performed sequentially (n=205), 9.4 percent were modified (n=131), and 8.6 percent were cancelled (n=121). The most common reason for modifications was high cost, while problems with preauthorization were the most common reasons for cancellation. The overall error rate (derived from incorrect orders that were corrected during review or cancelled because they were deemed inappropriate) was 3.0 percent.

“Of the orders with errors, we found that approximately one-fourth (or about 1 percent of all orders) could have had diagnostic implications for the patient if the order was not corrected, demonstrating that the UM program not only decreases waste but also helps prevent diagnostic errors,” write the authors led by Patrick C. Mathias, M.D., Ph.D., from University of Washington, Seattle. Additionally, the authors say “more than half of modifications or cancellations decreased costs by selection of an alternate reference laboratory or were prompted by the institution’s insurance preauthorization policies (which were instituted to prevent patients from receiving unexpected large bills due to rejection of claims by insurance carriers).”

Errors, Cancellations by Provider Type
The cancellation rate for nongenetics providers was three times the rate for geneticists, although rates of abnormal results were similar between the two groups. However, the authors suspect the influence of the UM program on test cancellation may have contributed to the similar positive result rates between the groups. Geneticists were more likely to order sequential testing than nongeneticists.

Approval rates and abnormal result rates were similar for inpatient and outpatient orders. Tests ordered or recommended by nongeneticists had error rates near 5 percent in both inpatient and outpatient settings. However, order error rates reached approximately 8 percent among tests recommended by genetics providers in the inpatient setting, which the authors say, “reflects the fact that inpatient orders are entered by residents who have less experience ordering genetic tests.”

“The findings of this study reinforce past work suggesting that send-out testing presents a high risk for order entry error,” writes Mathias and colleagues. “These findings emphasize that developing system solutions to handle the total genetic testing process should be a priority for laboratories and health systems. … Even orders from genetics providers had an error rate of nearly 2 percent, which emphasizes the utility of a structured UM program that relies on expert review by laboratory professionals.”

Takeaway: UM review of higher risk genetic test orders can cut costs for laboratories and patients, as well as catch order errors that potentially hold diagnostic implications for patients.