Hematologic Malignancies: Impact of an Integrated Pathology Process and Decision Support Tool on Diagnosis and Follow-up Health Care Costs

Background: The process of integrating and interpreting information from multiple diagnostic tests, which may have been provided by multiple laboratories, can result in inaccurate diagnoses and treatment delays for patients with hematologic malignancies. A diagnostic process and decision support tool that integrates laboratory results and guides clinical diagnosis may improve diagnostic accuracy and targeted treatment. This study compares the completeness and actionability of bone marrow biopsy work-up results as well as follow-up health care costs for patients with suspected hematologic cancers whose diagnostic tests were managed by specialty hematology and other types of laboratories.

Methods: Adult patients who had undergone a bone marrow biopsy (BMB) and had been diagnosed with a hematologic condition between January 2007 and March 2012 were identified from a large US commercial health insurance database affiliated with Optum. Patient cohorts were identified based upon laboratories performing marrow morphologic assessment/directing testing sequence: Genoptix (GX, a specialty hematology-testing laboratory) and large commercial laboratories and other laboratories such as community hospital laboratories (OL); academic labs were not included. Cohorts identified for medical chart review were matched for age, sex, geographic region, primary diagnosis on the bone marrow biopsy index date, comorbidity score, and all-cause health care costs. Medical charts were obtained from the BMB-referring physician. Independent oncologists and hematologists reviewed patients’ medical charts to determine the impact of BMB pathology reports on diagnosis and disease management. GX and OL reports were compared for completeness (diagnostic work-up in accordance with guidelines and no additional tests recommended) and actionability (enough information provided to make or rule out a diagnosis and to generate treatment recommendations). Administrative claims health care costs per patient per month (PPPM) for the period 30 days post-biopsy through 12 months were examined. Logistic regression assessed differences between cohorts for completeness, actionability and definitive diagnosis adjusted for age, gender, comorbidity and initial diagnosis on the index date. Generalized linear models assessed costs, adjusting for demographics, baseline clinical characteristics, initial diagnosis on the BMB date, definitive diagnosis, completeness and actionability on the BMB work-up report.

Results: This analysis included 499 subjects with BMB results from GX (n=249) or OL (n=250). Overall, average age of patients was 52 (SD 12) with baseline Quan-Charlson score of 1.2 (SD 1.5). The majority of patients had a non-cancer hematological condition diagnosis on the index date (GX 64% and OL 56%) rather than a specific hematological cancer diagnosis. The GX BMB work-up reports were more likely to be complete (OR 2.2; p=0.001) and provide a definitive diagnosis (OR 2.1; p< 0.001) than the OL BMB work-up reports. The odds for GX reports to be actionable compared to OL reports for actionability were greater (OR 1.3) although not statistically significant. Follow-up PPPM overall health care costs for GX patients were 32% (p=0.04) lower than for the OL patients.

Conclusions: Comprehensive integrated reports of complete bone marrow biopsy work-up results provide advantages over traditional lab reports by highlighting critical information and ensuring testing is completed according to both guidelines and clinical need.