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Reducing Patient Charges by Eliminating Amylase from Lab Panelsby Jeff rey Wisw ell, David Nestler and Ronna Campbell | 4:39 PM November 22, 2013

My colleagues and I were interested in reducing the cost of frequently ordered laboratory panels (groupings of

blood tests) ordered by the emergency department (ED). After evaluating the evidence, we removed amylase from

the lab panels for abdominal pain and for medical clearance of psychiatric patients who need to be transferred to a

psychiatric facility. Both actions resulted in an overall subs tantial decrease in patient charges.

The Problem

In EDs across the country, patients are asses sed by their chief complaints (headache, abdominal pain, chest pain,

shortness of breath, etc.). Due to the need for timely and effective diagnos is of high volumes of potentially ill

patients within minutes, most tests are ordered at the onset of an encounter. A common way to do this is to use

panel-based blood tests, or lab panels . These panels can be expensive and increase health care costs. In

patients presenting with abdominal pain, both amylase and lipase have been historically ordered to assess for

pancreatitis. This practice has been questioned becaus e lipase has been s cientifically proven to be moresensitive and specific than amylase in the evaluation of this disease process.

The Solution

After reviewing a previous study (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2967686/) on cost savings achieved

by educating providers on the minimal utility of amylase and the subsequent removal of amylase from an

abdominal pain lab panel, we sought to assess the generalizability of those results at our site. Support among ED

providers (em ergency medicine attendings, residents, and advanced practice providers) was obtained by e-mail

and in-person interviews. We subs equently removed amylase from the abdominal pain panel in our electronic-

medical-record ordering system. Although amylase was no longer on the panel, providers were still able to order it

individually if desired.

The Financial Background

At our ED, the abdominal pain panel cons isted of a complete blood count with differential, electrolyte panel, point-

of-care glucose, lactate, aspartate aminotransferase (AST), alkaline phos phatase, total bilirubin, direct bilirubin,

lipase, and amylase. The total patient charge for the panel was $593 without amylase and $649 with it. Patients

were charged $56 for amylase and $71 for lipase.

The Results

Pre-intervention, amylase was ordered on average 498 times per month for the preceding year (325 times per

month through the abdominal pain panel and 173 times per month individually or within another panel). Post-

intervention, it was ordered 119 times per month (0 times per month through the abdominal pain panel and 119times per month individually or within another lab panel). Based on $56 per amylase test, monthly charges

decreased from an average of $27,860 to $6,664 an annual decrease of $254,352.

After realizing significant cost savings by removing amylase from the abdominal pain panel, we investigated the

other reasons it continued to be ordered. We subsequently found it was part of a routine lab panel used for

medical clearance of psychiatric patients who needed to be transferred to a ps ychiatric facility. With approval from

the department of psychiatry, we further decreased the ordering of this non-specific test from 119 times per month

to 24 times per month resulting in an additional savings of $63,616 dollars per year.

Between both panels , we reduced patient charges by $317,968 per year, a 95% reduction from the previous total

attributed to this s ingle lab test. Although we were concerned that consulting services would request amylase, we

are not aware of any formal requests to have it returned to the panels.

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8/13/2019 Reducing Patient Charges by Eliminating Amylase From Lab Panels - Jeffrey Wiswell, David Nestler , And Ronna C

2/2

11/23/13 Reducing Patient Charges by Eliminating Amylase from Lab Panels - Jeffrey Wiswell, David Nestler , and Ronna Campbell - Harvard Business Review

blogs.hbr.org/2013/11/reducing-patient-charges-by-eliminating-amylase-from-lab-panels/ 2/2

When M&A Is Not the Best Option for Hos pitals (http://blogs.hbr.org/2013/11/when-ma-is-not-the-best-option-for-

hospitals/)

The Big Barrier to High-Value Health Care: Des tructive Self-Interest (http://blogs.hbr.org/2013/11/the-big-barrier-

to-high-value-health-care-destructive-self-interest/)

A Framework for Reducing Suffering in Health Care (http://blogs.hbr.org/2013/11/a-framework-for-reducing-

suffering-in-health-care/)

Fix the Handful of U.S. Hospitals Responsible for OutofControl Costs (http://blogs.hbr.org/2013/11/fix-the-

handful-of-u-s-hospitals-responsible-for-out-of-control-costs/)

(http://hbr.org/special-collections/insight/leading-health-care-

innovation?desktop=true)

Leading Health Care Innovation

From the Editors of Harvard Business Reviewand the New England

Journal of Medicine

http://hbr.org/special-collections/insight/leading-health-care-innovation?desktop=truehttp://blogs.hbr.org/2013/11/fix-the-handful-of-u-s-hospitals-responsible-for-out-of-control-costs/http://blogs.hbr.org/2013/11/a-framework-for-reducing-suffering-in-health-care/http://blogs.hbr.org/2013/11/the-big-barrier-to-high-value-health-care-destructive-self-interest/http://blogs.hbr.org/2013/11/when-ma-is-not-the-best-option-for-hospitals/