Over the past 2 years, COVID-19 profoundly strained hospital labs. Volume increases for some tests related to COVID-19 diagnosis and management increased as much as 26,000%, despite overall testing volumes declining significantly (1). Throughout the pandemic, health systems struggled to monitor unpredictable patterns while juggling laboratory management, staffing issues, and supply gaps.

As they emerge from the worst of the COVID-19 pandemic, hospitals and health systems face significant financial challenges. The American Hospital Association estimates that the effects of COVID-19 hospitalizations, combined with cancelled and forgone services, may represent an average financial impact of $50.7 billion in monthly losses for American hospitals (2). These financial challenges put pressure on labs to lower costs and increase efficiency.

Reference Labs as a Source of Help in Lab Stewardship

One source of potential help for hospital labs is their reference laboratory, whether the reference lab is a commercial lab or one within their own integrated health system. Reference lab relationships are complex, requiring thoughtful management to align the needs of the smaller hospital lab with the larger reference lab.

In a successful relationship, a smaller lab uses the more abundant clinical, management, and IT resources of the reference lab to innovate. Specifically, reference labs often can increase efficiency and clinical care by improving a hospital lab’s stewardship program.

Lab stewardship helps ensure that valuable but limited resources are used wisely (3). Its main goal is providing the right test for the right patient in the right care setting for the right price. In addition to helping health systems use lab services efficiently, lab stewardship helps prevent misdiagnosis and unnecessary costly procedures. When done well, stewardship leads to better patient care and enhanced recognition of the lab by health system leadership (4). Reference labs may help hospital labs with lab stewardship by:

  • Determining whether it is more valuable to perform testing in-house or in the reference lab
  • Providing evidence-based testing algorithms
  • Instituting IT solutions that help physicians choose the correct test
  • Instituting IT solutions to properly sequence reflex testing to avoid overuse of confirmatory testing
  • Instituting IT solutions that better measure test utilization that fuel quality improvement by identifying and monitoring misutilization, including duplicates, less useful tests, and the overuse of large tests panels
  • Providing continuing education, tools, and other resources that improve the administration of a lab stewardship program

Specific examples of stewardship improvement through a collaboration between reference lab and hospital lab are listed in Table 1. The examples are derived from our experience and that of PLUGS members who collaborate with a variety of commercial and in-system reference labs.

How Hospital and Reference Labs Collaborate on Stewardship

Tips for Aligning a Hospital Lab and a Reference Lab

Reference labs and hospital labs have overlapping goals, but they do not have the exact same goals. The foundation of a good relationship is identifying shared goals and choosing projects—like those in Table 1—in which three parties benefit: the hospital lab, the reference lab, and patients. That benefit should then be communicated to hospital leadership to enhance the reputation of the hospital lab and the reference lab in the integrated health system. 

Selecting the initial stewardship projects depends on the depth of the relationship between the hospital lab and reference lab, as well as the resources each can bring to the table. If the relationship between the reference lab and hospital is new or uncertain, it is prudent to start with an easier project such as the reduction of duplicate testing. If the relationship is more mature, then it is logical to pursue a more significant project, such as tackling a pattern of overuse of large testing panels.

Overall, the most important elements for a successful stewardship collaboration include a cross-functional lab stewardship committee, easy access to test order and result data, and a plan of action that matches the current state of the reference laboratory relationship.

A Powerful Partnership

Investing in a relationship with a reference laboratory can create a powerful partnership that helps hospital labs tackle common lab stewardship challenges. These include testing issues related to staffing shortages, declining or expanding testing volumes, and under and overutilization of tests. Proper selection of projects increases the likelihood of success now and into the future.  

Michael L. Astion, is the medical director in the department of laboratories at Seattle Children’s Hospital and a professor at the University of Washington department of laboratory medicine and pathology. +Email: [email protected]

Donna D. Cooper, MS, MBA, is the senior director of product solutions in the health systems division of Quest Diagnostics. +Email: [email protected]


1. Durant TJS, Peaper DR, Ferguson D, et al. Impact of COVID-19 pandemic on laboratory utilization. J Appl Lab Med 2020 Nov 1; doi: 10.1093/jalm/jfaa121.

2. American Hospital Association. Hospitals and Health Systems Face Unprecedented Financial Pressures Due to COVID-19. www.aha.org/guidesreports/2020-05-05-hospitals-and-health-systems-face-unprecedented-financial-pressures-due (Accessed March 9, 2023).

3. Dickerson JA, Fletcher AH, Procop GW, et al. Transforming laboratory utilization review into laboratory stewardship: Guidelines by the PLUGS national committee for laboratory stewardship. J Appl Lab Med 2017; doi: 10.1373/jalm.2017.023606.

4. Procop, GW. Developing and managing a medical laboratory (test) utilization management program. Wayne, PA. Clinical and Laboratory Standards Institute; 2017.