When children’s hospital laboratorians receive a specimen for testing, they are acutely aware that “there’s a child tied to that sample, and it took an invasive procedure to get it,” said Tony Smith, BSHCM, MLT(ASCP)^CM, CLSSBB, a senior healthcare consultant with ARUP Healthcare Advisory Services.

“It’s not just a tube of blood. It’s a baby’s tube of blood,” he said.

The weight of that responsibility is one reason children’s hospitals were early pioneers in laboratory stewardship, according to Smith. Clinicians and laboratorians alike want to ensure that pediatric patients receive the right testing at the right time to avoid unnecessary testing and the harm that can result.

Now, financial pressures are driving a renewed push for laboratory stewardship in pediatric settings. A mean of 47.2% of children’s hospital discharges are paid for by Medicaid, according to RAND, a nonprofit, nonpartisan research group. However, Medicaid reimbursement rates are not keeping up with hospital costs. An American Hospital Association survey found that Medicaid reimbursements only cover 83% of hospital costs.

These financial challenges are expected to worsen for children’s hospitals in the wake of H.R.1, legislation that reduces federal Medicaid spending by about $900 billion over a decade. The Children’s Hospital Association reported that, collectively, children’s hospitals will lose billions of dollars of revenue once the legislation is fully implemented.

Laboratory stewardship is not just about cost savings—it’s mostly about doing what’s best for the patient. “Knowing that reimbursement was already tight and is getting tighter in the face of recent policy changes, we want to make sure that every test that’s ordered for a child is backed by evidence and empathy—and stewardship is how you honor both of those things,” Smith said.

Unique Patients, Unique Challenges

When it comes to laboratory stewardship, children’s hospitals face some unique challenges compared with adult healthcare facilities. For example, many pediatric illnesses are rare and require esoteric testing not performed by in-house laboratories, which leads to the use of numerous specialty reference laboratories. Before Boston Children’s Hospital began its stewardship efforts, it had relationships with more than 250 reference laboratories, said Mark Kellogg, PhD, associate director of Chemistry and director of the Quality and Regulatory Program at Boston Children’s.

Another challenge is that pediatric hospitals have fewer clinical pathways—models that outline recommended diagnostic approaches for patients with specific symptoms or conditions. Clinicians in adult settings follow clinical pathways for chest pain, suspected stroke, and sepsis, among many other conditions.

“These sorts of pathways don’t exist as much in a pediatric hospital because there are not a lot of common presentations to build these pathways around,” said Dennis Dietzen, PhD, division chief of Pathology and Laboratory Medicine at Phoenix Children’s Hospital. “You’re making it up as you go, so laying a blanket of stewardship on that is really hard.”

Laboratory stewardship efforts first began to take shape in the 1990s. One example is ARUP’s Analyzing Test Ordering Patterns™ (ATOP^®) program, which launched in the ‘90s to help laboratories identify opportunities for improvement. In the mid-2000s, innovations in genetic testing caused laboratory budgets to balloon, and children’s hospitals started to focus on laboratory stewardship more intently.

“If anyone knows the importance of lab stewardship, it’s pediatric institutions,” said Smith, who was instrumental in the development of Children’s Hospital Colorado’s stewardship program beginning in the mid-2000s.

Smith and other clinical laboratory leaders who are seasoned in building and improving laboratory stewardship programs within pediatric settings offer the following advice.

Build a Committee That Carries Authority

It’s important to ensure that the hospital stewardship committee wields real power and is not just an advisory committee, said Dietzen, who served at St. Louis Children’s Hospital for 23 years before joining Phoenix Children’s. Dietzen helped St. Louis Children’s launch its stewardship program about 15 years ago and is now spearheading Phoenix Children’s first stewardship committee.

“I’ve spent the past several months figuring out where in the hospital hierarchy this committee needs to live so that it has proper authority to enforce the protocols it deems necessary,” he said. “You need an administrative champion, someone within the hierarchy of the hospital who will support what you’re doing no matter what.”

At Children’s Colorado, the stewardship program was tied to hospitalwide quality improvement initiatives, which helped to “put some weight behind it at the executive level,” Smith said. “We had to reach all the way up to the C-suite.”

Get Clinicians Involved

Sandy Richman, MBA, C(ASCP), vice president, ARUP Healthcare Advisory Services, said it’s important to a stewardship effort to “get the right people in the room so that it’s not lab driven—it’s more lab supported. But it has the involvement of clinicians who can help make those clinical decisions and also be a voice for the committee and take information back to their colleagues.”

Clinician participation helps secure organizational support from other clinicians. At Boston Children’s, the stewardship committee membership must transition every two years. “In the years when we couldn’t get clinical volunteers and it became lab heavy, that’s when we saw the biggest pushback,” Kellogg said.

Gather Data

Successful stewardship interventions depend on quality data sources. “You have to have data dashboards and analytics, and that’s something that we can help our clients with,” Smith said. “It’s really the backbone of stewardship.”

Data are essential for helping stakeholders “understand why the process you want to implement is in the best interest of the patients and the physicians who are taking care of those patients,” Dietzen said. “Data from multiple institutions, from peer-reviewed studies, and your own internal data are absolutely essential to convince people.”

Unfortunately, internal data can be difficult to access. When Boston Children’s began to focus on stewardship, it had two staff members who were primarily dedicated to retrieving data. “That’s all they did because it was so intense,” Kellogg said. “We’re now down to one data analyst, and maybe 30% of her job is pulling data for the stewardship group. But it took her years to develop the databases.”

Build a Test Formulary

Developing a test formulary is one way to manage test options and reduce misutilization. “Oftentimes, test formulary creation can be met with resistance because providers feel that the lab is telling them which tests they can order and which they can’t,” Richman said. “A better way to position that is, ‘We’re making it easier for you to order the correct test.’ So, rather than giving them multiple options, remove some of those tests that are commonly misordered, and direct them to the tests they should be ordering.”

Dietzen noted that a test formulary makes it possible to create a tiered permission system. “Within that formulary, have tests that everybody can order, and then another tier of tests that can be ordered by specialists only, and then another tier of tests where it takes an act of Congress to order that test. You have to have those guardrails in place,” he said.

Establish Approval Pathways

Some tests may require, if not an act of Congress, at least some form of oversight and approval. Boston Children’s created a subcommittee that reviewed all requests for genetic tests. Over time, the committee established guidelines and a pathway that clinicians could follow to order genetic tests without previous approval. “Now, only a handful of requests don’t meet the criteria and need to go to the committee for review,” Kellogg said.

Some hospitals require approval when clinicians want to order testing from a new specialty reference laboratory or when the test cost meets a certain threshold. Part of that approval process may include helping the patient’s family understand the expected expense for them and gaining their acknowledgement and consent before moving forward.

Narrow the Pool of Reference Labs

“Children’s hospitals serve a unique population and provide a lot of specialized care. Most pediatric hospitals use more than 50 reference labs, so there’s a financial opportunity in consolidating those labs,” Richman said.

If the same test is being ordered from multiple reference labs, hospitals can remove duplicate testing from the formulary to ensure clinicians are ordering the most cost-effective option. Consolidating labs also makes it easier to negotiate volume-based discounts and monitor quality metrics.

When Children’s Colorado began to focus on stewardship, it ordered from a pool of 155 reference labs. At Boston Children’s, clinicians were ordering from more than 250 different reference labs. Over time, both of those hospitals were able to reduce the number of reference labs to about 50.

To achieve this reduction, Boston Children’s assembled a test selection committee to identify which tests should be on its formulary and to choose the appropriate reference laboratories to perform sendout testing. “It was the first time we ever did true RFIs [requests for information] to identify the right lab partners. We developed a robust program for gathering data about labs, evaluating tests, and making recommendations to the lab director and medical staff,” Kellogg said.

Take Advantage of Information Technology Solutions

“Fully utilizing IT [information technology] infrastructure is a great way to help improve efficiencies and guide appropriate utilization,” Smith said. “At Children’s Colorado, we worked with Epic and our analysts in the lab to develop utilization management workflows that placed ordering guardrails around tests that were under stewardship management.”

These guardrails can range from mild notifications to test-access restrictions. “You can hide the orders. You can make it so that a certain subset of clinicians can’t even see that order. That’s a little drastic,” Dietzen said. “The gentlest action is a suggestion: ‘This might not be the best test. Have you considered X test?’ Make them provide information about the patient and check the appropriate boxes. Finally, the most stringent control is making it so they cannot order the test without approval.”

Keep the Focus on Patients

For laboratorians working in pediatric settings, it’s impossible to forget that each test is linked to a child and that clinicians and anxious parents are waiting for answers. “Disconnecting from that emotion is hard,” Smith said. “Whether it’s an adult or a pediatric patient, it doesn’t change the need to do what’s right for the patient. Stewardship creates pathways to better diagnostic care for patients.”