Improving Molecular Genetic Test Utilization through Order Restriction, Test Review, and Guidance

Abstract

The ordering of molecular genetic tests by health providers not well trained in genetics may have a variety of untoward effects. These include the selection of inappropriate tests, the ordering of panels when the assessment of individual or fewer genes would be more appropriate, inaccurate result interpretation and inappropriate patient guidance, and significant unwarranted cost expenditure. We sought to improve the utilization of molecular genetic tests by requiring providers without specialty training in genetics to use genetic counselors and molecular genetic pathologists to assist in test selection. We used a genetic and genomic test review process wherein the laboratory-based genetic counselor performed the preanalytic assessment of test orders and test triage. Test indication and clinical findings were evaluated against the test panel composition, methods, and test limitations under the supervision of the molecular genetic pathologist. These test utilization management efforts resulted in a decrease in genetic test ordering and a gross cost savings of $1,531,913 since the inception of these programs in September 2011 through December 2013. The combination of limiting the availability of complex genetic tests and providing guidance regarding appropriate test strategies is an effective way to improve genetic tests, contributing to judicious use of limited health care resources.

Figure 1

Volume reductions and cost savings associated with clinical decision support tools, calculated from a monthly report of restricted test order attempts and their associated institutional costs.

Figure 2

Impact of clinical decision support tools (CDST) initiative (July to December 2012). A: Ambulatory test orders (n = 52). B: Inpatient test orders (n = 20). Nondeemed user reorder indicates that the user ordered the test (usually as a miscellaneous order, for which a CDST cannot be used) without using the recommended strategies of either referring the patient to clinical genetics or consulting with another deemed user who could place the order. No further orders represent cases where no additional attempts to order genetic testing and no referrals to clinical genetics were identified during that episode of care.

Figure 3

Orders modified and cost savings associated with genetic and genomic test review, September 2011 to December 2013, on the basis of institutional cost of canceled tests or the difference in cost between the original and the modified test order. The dramatic increase in both orders modified and cost savings from August 2012 coincides with the implementation of a more comprehensive and consistent review process using daily pending logs.

Figure 4

Outcome of 2013 genetic and genomic test review cases (n = 152). A: Type of order alteration. B: Associated cost savings. Cancel represents cases where no genetic testing was ordered. Change includes modifications in gene tested, method, or testing laboratory. Reflex specifically represents a change from multiple concurrent tests or a multigene panel to a strategy of reflexed testing.

Figure 5

Impact of genetic test utilization management initiatives on multigene test panel orders from 2007 to 2013. GGTR, genetic and genomic test review.