The Buck Stops Here: Rational Oversight for Hematologic Testing

Complex hematological tests aid in establishing hematologic diagnoses, but can be quite costly. We hypothesized that certain diagnostic tests (specifically JAK2 at $175/test, BCR-ABL at $163/test, and flow cytometry at $275/test) that were being ordered without input from a hematologist were generally not indicated and expensive. We reviewed all of these tests sent between September 2013 and September 2015. 20/55 or 36% of JAK2 mutations, 19/37 or 51% of BCR-ABL mutations, and 47/74 or 63% of flow cytometry were completed without hematology input, primarily via primary care (72/86 or 84%). Tests that were ordered or recommended by hematology were excluded from the subsequent cost analysis. In total $19,500 was spent (without hematology input). One hematologist then reviewed the charts on every test that had been ordered not by hematology to determine if the test was clinically appropriate. 12/20 or 60% of JAK2 mutations, 19/19 or 100% of BCR mutations, and 44/47 or 94% of flow cytometry evaluations were felt to be unnecessary. Thus $17,300 of the $19,500 could have been saved had there been hematology input at the outset. This would have amounted to 86 e-consults over 2 years, which would be 1.2 extra consults/week; these consults generally take under 10 minutes, so less than 2 minutes/day. This all translates to ~$1,075 over 2 years of a hematologist’s salary, clearly more cost-effective than permitting everyone to be able to order these tests. We should consider recommending hematology input prior to allowing these tests (and perhaps other costly unusual hematology investigations) to be sent out, perhaps via a pop-up suggestion for a hematology e-consult when ordered; the e-consult would also be a tool to educate other providers on the appropriate use of these tests and may ultimately lead to a decrease in the ordering of these e-consults.