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Seattle Children's Laboratory Stewardship Program

Important Note

Tools for SCH Providers

The following tools are intended to help Seattle Children's providers and other staff navigate the preauthorization process, including appeals for denied requests, in the most efficient and effective manner. Additional tools for all providers can be found below.

Program Description

Seattle Children's Hospital Laboratory Stewardship Program was formally established in 2012 to support providers and patients by ensuring the right test at the right time.  Laboratory testing is complex and we seek to partner with clinical experts to support test identification, assessment of test and reference laboratory quality, and logistical coordination support, including insurance preauthorization for genetic tests. Tests that meet defined criteria – such as miscellaneous tests and all genetic tests - are reviewed by our rotating team consisting of lab genetic counselors and doctoral-level consultants.  Review occurs in a 2-step process: 1) at the time of preauthorization of genetic tests, and 2) at the time of the order.  

Since 2012, >20,000 cases were reviewed (25% miscellaneous non-genetic orders, and the remainder were genetic orders/preauths). The majority of requests (70% of cases) reviewed were approved without modification and often without the provider's awareness.  Approximately 2% of all requests were ordered incorrectly and could have resulted in diagnostic errors. Overall, orders are modified or canceled 30% of the time, resulting in more appropriate orders and cost avoidance for patients/families/insititution (> $3 million to date).

Tools for Providers

The following tools are intended to help providers, laboratory administration staff, and others navigate the preauthorization process at their institutions while adhering to payer policies and utilizing available resources. The tools were created by a working group within the PLUGS Insurance Alignment Committee.

Laboratory Stewardship Program Policies & Procedures

Links to relevant hospital policies and laboratory procedures were created to ensure transparency in the laboratory stewardship program. Please note that these policies are only visible within the Seattle Children's intranet.

Guidance for Addressing Patient-Directed Lab Requests

  • Share our values.  “Seattle Children’s Hospital supports patient-centered, evidence-based care.”
  • Address the distinction between analytical validity and clinical utility. “Even though a test may have analytical validity (it can measure what it says), it is often harder to understand the test’s clinical utility: will we do something different based on the results of the test? And, will that make you better?”
  • Refer to the Seattle Children’s hospital lab stewardship program & review process. “I am not sure if we can coordinate this request, and I will check with our laboratory stewardship team to learn more. This team reviews new labs/tests before they can be offered to our patients. ”
  • Defer sample collection. 
  • Resources: More people are seeking options outside of clinical labs to obtain health related genetic information. As access to direct-to-consumer genetic testing increases, demand for clinicians to provide genetic literacy to the public also increases. It’s important that all healthcare providers understand benefits and limitations of DTC testing. Additional information regarding DTC genetic testing can be found here.

Frequently Asked Questions

What is the purpose of laboratory test case review?

The purpose of the laboratory test case review is to improve patient care and safety by ensuring clinical necessity and accuracy. The Reference Laboratory Consultant is the faculty member of the lab stewardship team that reviews cases. The Laboratory Genetic Counselors review genetic test requests.

 

Which laboratory tests are included as part of the case review process?

The following requests require consultation with a Reference Laboratory Consultant or Laboratory Genetic Counselor before testing is initiated:

  • All genetic tests.
  • All miscellaneous send-out tests, including but not limited to:
    • All requests for tests using an alternate methodology than is offered in-house, including repeat testing.
    • All requests for tests to be sent to an alternate reference lab other than the preferred lab.
    • All requests for tests to be sent to an international laboratory, which are not already approved.
  • All requests that include one order exceeding $700. This includes defined tests which are designated with "UM" in the name.
  • Any testing deemed by the Laboratory Stewardship team to be needing review before sending.

 

What questions are considered during the case review process?

The Reference Laboratory Consultant or Laboratory Genetic Counselor will consider the following questions when reviewing each case. Any modifications or recommendations for cancellation must be discussed and agreed upon by the ordering provider. If a provider is non-responsive within 5 business days, the consultant will use their discretion to ensure appropriate care for the patient, while considering sample stability. Ultimately, any order modifications or cancellations are at the discretion of the ordering provider, with the exception of test or disease specific policies.

  • Was the correct test ordered?
  • Is the test medically necessary? See Preauthorization Policy in Child.
  • Can sequential testing be considered?
  • Is there a test or disease specific policy that should be followed?
  • Are there alternate tests that are more appropriate?
  • Has the optimal test & reference laboratory been selected?
  • Is insurance pre-authorization required?
  • Has this test been ordered before? If not, refer to the New Laboratory Test Request Form.

 

What is the difference between patient-centered and patient-directed test requests?

Seattle Children's Lab Stewardship program is focused on patient-centered laboratory testing. Our approach is to enhance quality, delivery, and cost for appropriate and medically necessary tests. Providers have reported an increase in patient-directed testing requests, which may be due to increasing accessibility of direct-to-consumer laboratory testing and other societal influences (e.g. 23andme, wellness kits, IgG allergy panels, broad naturopathic work-ups).

 

How do I connect with the laboratory stewardship team? 

The Seattle Children's Lab Stewardship program is suppored by genetic counselors, doctoral-level consultants, pathologists, and other laboratorians. We welcome participation in our weekly Laboratory Stewardship meeting on Tuesdays at 10:00 AM. 

 

You may direct questions to 206-987-5400 or LabGC@seattlechildrens.org and we can connect you with the approrpriate team member.

References

  1. Dickerson JA, Cole B, Conta J, Wellner M, Wallace SE, Jack R, Rutledge, J, and ML Astion. Improving the value of costly genetic reference laboratory testing with active utilization management. Archives of Pathology and Laboratory Medicine 2014;138(1):110–113. doi: 10.5858/arpa.2012-0726-OA.

  2. Mathias PC, Conta JH, Konnick EQ, Sternen DL, Stasi SM, Cole BL, Astion ML, and JA Dickerson. Preventing genetic testing order errors with a laboratory utilization management program. American Journal of Clinical Pathology 2016;146(2):21–226. doi: 10.1093/ajcp/aqw105.

  3. Wittowski CL, Clowes Candadai S, Perrone ME, Gallego DF, Conta JH, Dickerson JA. Evaluation of Exome Sequencing Criteria for Hospital Stewardship and Insurance Authorization at a Pediatric Hospital. Arch Pathol Lab Med. 2021 Apr 9. doi: 10.5858/arpa.2020-0572-OA.

Last Updated

This document was last reviewed by the Lab Stewardship Committee on Feb 1, 2022.

Department

Send Outs/Genetic