ASCP Honors 2023 Choosing Wisely Champions for Leadership in Reducing Unnecessary Laboratory Testing

Choosing Wisely Champions Recognized for Driving Innovation in Health Care

ASCP's Choosing Wisely Champions program is recognizing four individual clinicians, as well as pathologists, laboratory professionals, and clinical teams for their commitment effective test utilization and laboratory stewardship. All four champions were selected to present their work virtually on October 10, as part of the 2023 ASCP Annual Meeting Path to Long Beach.

The Choosing Wisely Champions program recognizes clinicians who are leading efforts to reduce overuse and waste in medicine. The program acknowledges the work of those who provide appropriate care and encourages others to follow their lead.

“Identifying Champions and sharing their successes allows all of us to learn from their efforts to improve healthcare delivery,” said Lee H. Hilborne, MD, MPH, FASCP, DLM(ASCP)^CM, Chair of the ASCP Effective Test Utilization Steering Committee.

Below are the honorees and a synopsis of their achievements.

Grace Mahowald, MD, PhD
Medical Director, Massachusetts General Hospital Core Laboratory

Dr. Grace Mahowald, medical director of the Massachusetts General Hospital Core Laboratory, Boston, has focused her efforts in addressing utilization challenges in a range of disciplines including toxicology, chemistry, and immunology. Her latest work was initiated during the COVID-19 pandemic, a time of unprecedented staffing and fiscal challenges. Dr. Mahowald identified two common clinical lab workflows, laboratory add on requests and complete blood count (CBC) / differentials, as areas requiring a high investment of time from the laboratory with often minimal clinical benefit. Dr. Mahowald, having trained in internal medicine as well as pathology, was familiar with the overuse of these tests and sought to bridge the gap in understanding.

To address these challenges, Dr. Mahowald created and implemented electronic health record (EHR) clinical decision support tools to alert providers to situations where the requested add-on order or CBC with differential order may not be appropriate. These alerts were designed and implemented after extensive discussions with clinical teams from internal medicine, oncology, and emergency medicine.

The add on alert for adult inpatients was implemented in March 2022, resulting in a 62-percent decrease in inpatient add on orders in 2022 compared to the same period in the previous year. Decreases occurred immediately after alert implementation and have been sustained over time. The CBC and differential alert significantly decreased the overall volume of orders for CBC / differential by thousands of tests per month, and importantly decreased the number of labor-intensive manual differentials performed by the lab. This resulted in a highly impactful improvement in turnaround time of over 20 minutes for all manual differentials, with no negative impacts to patient care. Dr. Mahowald’s innovative and collaborative problem-solving approaches have successfully improved the long-term efficiency and quality of the laboratory and have permitted laboratory staff to be deployed optimally to sustain high quality care. 

ARUP Healthcare Advisory Services
- Sandy Richman, MBA, C(ASCP), Director, Healthcare Advisory Services
- Dave Shiembob, MBA, C(ASCP)^CM, Manager, Healthcare Advisory Services
- Jennifer Tincher, MBA, Senior Healthcare Consultant

ARUP’s Healthcare Advisory Services team collaborates with health systems across the United States to better implement Choosing Wisely guidelines that optimize both reference and in-house laboratory test utilization. The team continues to develop and deploy data analytics tools that are meaningful for clients such as the new AnalyticsDx^TM Comprehensive Dashboard and Utilization Analysis reports. 

The team has helped clients identify key opportunities to eliminate gaps in their test use that do not adhere to Choosing Wisely guidelines, as well as opportunities to reduce inappropriate tests, thereby reducing costs and improving patient safety. AnalyticsDx^TM Comprehensive Dashboard and Utilization Analysis reports use pre-built topics to help guide clinical decision support, including troponin retest intervals, clinical utility of CK-MB and procalcitonin testing, misutilization of Clostridium difficile, among other topics. Currently, the team has deployed more than a dozen AnalyticsDx^TM Comprehensive Dashboards in healthcare systems nationwide and is scaling the tool to meet growing customer demand.

The team is actively involved with patient-centered Laboratory Utilization Guidance Services (PLUGS) and has presented multiple stewardship-focused presentations at the PLUGS Summit. In 2022, the team presented “The Importance of Good Governance in Lab Stewardship: Setting your program up for success,” and in 2023 presented on “How to Lead with Data-Driven Laboratory Stewardship.”

Hackensack Meridian Health Laboratory Stewardship Committee
Team Lead:
William Fleischman, MD, MHS, Vice President, Regional Chief Quality Officer  

Team Members:
- Barbara Burch, MHA, MLS(ASCP), Vice President, Network Laboratory Services  - Alexander Ewing, MD, Professor and Chair, Department of Pathology, JFK University Medical Center 
- Albert Rojtman, MD, MLS(ASCP), Chief Clinical Microbiology & Molecular Diagnostics, Jersey Shore University Medical Center 
- Zahra F. Ebrahim, DCLS, MLS(ASCP)^CM, Manager, Hospital Laboratory Stewardship, Quest Diagnostics 
- Karen Feeney, MPA, MLS(ASCP)DLM, Manager, Hospital & Lab Services, Bayshore Medical Center 
- Adam McMullen, MHA, MLS(ASCP)^CM, Administrative Director, Laboratory Services, Jersey Shore University Medical Center 

In 2021, Hackensack Meridian Health (HMH), a health system with 18 hospitals, partnered with Quest Diagnostics for clinical laboratory management. To reduce costs, standardize care, and optimize test ordering, HMH and Quest formed a laboratory stewardship program. The program has three key elements: engaged stakeholders from HMH, ongoing advisory services from Quest, and use of Quest Laboratory Stewardship Enterprise (QLS), an electronic business intelligence and reporting platform developed by health technology leader hc1.

Hackensack Meridian Health’s Laboratory Stewardship Committee (LSC) includes network executive leadership, clinicians, nursing leaders, laboratorians, clinical informaticists, and IT specialists. The LSC analyzed test utilization data from QLS and based on the findings and clinical feedback, initiated dozens of projects to improve appropriate lab utilization.

The Choosing Wisely recommendations have been a valuable guide for HMH LSC projects.

●  Inspired by Choosing Wisely recommendation #30, the LSC added a question to the broad respiratory pathogen panel (RPP) order to help ensure that RPP is ordered for certain defined indications. RPP orders subsequently decreased by approximately 70 percent, from an average of 4,700 tests per month to about 1,470 tests per month.

●  Consistent with recommendation #10, the LSC added TSH with reflex to Free T4 to facility order lists and provided system-wide restraining. This intervention has to-date prevented approximately 26,500 unnecessary Free T4 from being ordered. The average rate of Free T4 per 1,000 patients decreased from 25.0 to 22.1.

●  Based on recommendation #13, the LSC removed amylase from GI order sets for acute pancreatitis, decreasing concurrent ordering of amylase with lipase by about 40 percent.

With these successes, the LSC hopes to continue promoting stewardship of laboratory resources through initiatives such as utilizing electronic clinical decision support to reduce unnecessary duplicative testing, reducing use of limited utility tests, and adopting evidence-based testing algorithms.

Parkview Health System Laboratory Stewardship Committee
Representatives:
- Lisa Daniel, MLS(ASCP)BB, Corporate Director, Laboratory Services
- Nicole Shankster, MLS(ASCP), Laboratory Specialist, Referral Testing and Accreditation
- R. Craig McBride, MD, Pathologist and Laboratory Medical Director, Parkview Health - Laboratories
Trent Miller, MBA, CPA, Senior Vice President, Specialty Service Line & Ancillary Services

Parkview Health serves northeast Indiana and northwest Ohio and is committed to evidence-based care.  For this reason, Parkview has been at the forefront of implementing Choosing Wisely laboratory initiatives via a multi-disciplinary laboratory utilization committee.  As director of Corporate Laboratory Services, Lisa Daniel and Dr. Craig McBride led the committee starting initiatives based on Choosing Wisely recommendations addressing CBC/BMP, CK-MB, amylase, and RBC folate testing.

Don’t order diagnostic tests at regular intervals (such as every day).
Before September 2020, inpatient electronic order sets didn’t limit the number of sequential daily BMPs or CBCs. In response, the committee modified all order sets by adding endpoints for daily tests (72-hours initially and then 48-hour limits). Inpatient volumes for BMPs and CBC were reduced 65 percent over the following year.

Don’t test for amylase in cases of suspected acute pancreatitis & don’t test for CK-MB in the diagnosis of acute myocardial infarction.
Before early 2020, amylase and/or CK-MB testing were present on various inpatient order-sets. Based on Choosing Wisely recommendations the committee removed amylase and/or CK-MB from all inpatient order sets. Combined Amylase and CK-MB inpatient volumes decreased 82 percent over the next year.

Do not order RBC folate levels at all.
In 2023, the committee unbundled RBC folate, serum folate and B12 testing and eliminated inpatient RBC folate testing. Approximately 5880 RBC folate tests have been eliminated per year.

The committee is now pursuing additional initiatives focusing on unnecessary thyroid testing, serum folate and B12 testing, vitamin D testing, test intervals, and best practice laboratory testing for coagulation disorders and catheter associated urinary tract infections. 

“ASCP would like to commend these honorees for their leadership and innovation,” says Edna Garcia, MPH, director of scientific engagement and research. “While the Choosing Wisely campaign has now officially ended, ASCP will continue in our efforts to promote effective test utilization and laboratory stewardship.”

Learn more about ASCP's Choosing Wisely initiative at ascp.org/choosingwisely.

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