Brandy Gunsolus, DCLS, MLS(ASCP)CM

Medical laboratories are continuously faced with more obstacles. However, the theme is inherently the same: do more with less. I have seen laboratories pinch pennies in an effort to make budget when supplies, shipping costs, and labor costs continue to increase. Some of the more creative efforts include utilizing a sterilization service for instrument sample cups instead of paying full price for new ones, and two labs combining their orders to obtain discount pricing they would not be able to have alone.

While trying to reduce our laboratory spending, we naturally look at what is commonly perceived as easy targets: reduce overtime, lean processes, and reduce wastage. However, with current labor shortages, overtime is one of those things that will happen, and most labs have already leaned their processes and reduced their wastage. While we have traditionally focused on these items as being the only ones perceived to be within our control, there is an area that laboratories can target to obtain savings for both the patient and the laboratory: send-out testing.

Physicians often order esoteric send-out testing because a journal article mentions a test that they perceive may have benefit for their current patient.1 They often do not understand when a test still has not had its clinical utility proven; in essence, does the result of the test actually affect patient management, which would then improve the patient outcome?2 With the ease of online searches, they may also acquire a false understanding of the true usefulness of a test.3

“Beginning to review your specimen referral testing, and the appropriateness of the testing, is a great way to make significant dents in your laboratory expenses.”

Establish a Laboratory Test Formulary
So how do laboratories face these challenges? One option is to establish a facility laboratory test formulary. Much like the drug formularies of our pharmacy colleagues, a laboratory test formulary is a listing of testing that has been vetted and approved by the laboratory. Utilization of any test not included on the laboratory test formulary would require special laboratory medical director permission and justification from the ordering provider. Medical laboratory personnel can lay the initial groundwork for this list, but the laboratory medical director would need to provide formal approval.

While establishing a laboratory test formulary may seem like a massive undertaking, it is easiest when written as an exclusionary list. Here, all laboratory testing is considered to be formularyapproved testing except a listing of the tests that are not approved and, thus, excluded from the formulary. This exclusionary listing also provides the opportunity to list why the exclusion from the approved laboratory test formulary and cite evidence supporting the exclusion of the test.

Communicate Why a Test is Excluded
So now you have a test that is excluded from the laboratory test formulary and a physician tries to order the test. What do you do? These are best handled by succinctly telling the physician the test is no longer on the laboratory test formulary due to whatever the reason the test was excluded. This could be lack of adequate validation of the test, the test is available as research use only, clinical utility of the test has not been adequately proven, or the test is only offered by a non-CLIA certified laboratory, such as those overseas. In my experience most physicians are understanding of formularies and rarely question these types of messages. Should you have any that do, those questions should certainly be handed over to your laboratory’s DCLS or medical director to be addressed.

Beginning to review your specimen referral testing, and the appropriateness of the testing, is a great way to make significant dents in your laboratory expenses. You may find easy wins—such as duplicate genetic testing—that you should easily be able to make a policy to cancel or an electronic medical record solution to prevent the initial order. You are also likely to find many test orders that should never be ordered and be restricted by a laboratory test formulary. By eliminating this type of unnecessary testing, you will reduce your laboratory reference laboratory invoices and reduce patient costs by not having to cover deductibles or costs of noncovered testing. You will never know what the potential for savings are until you look.


  1. Greenblatt MB, Nowak JA, Quade CC, et al. Impact of a prospective review program for reference laboratory testing requests. Am J Clin Pathol. 2015; 143:627–634.
  2. Astion M. How to say no to sendouts–strategies for coping with tests that aren’t ready for clinical use. Clinical Laboratory News. 2019. 45(10).
  3. Astion M. The Google factor: are the worried well making healthcare sick. Clinical Laboratory News. 2014. 40(1).

Brandy Gunsolus is doctor of clinical laboratory science at Augusta University Medical Center in Augusta, Georgia.

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