Interventions at the laboratory level to reduce laboratory test ordering by family physicians: Systematic review

Retrospective analyses of routine preoperative blood testing in a tertiary eye hospital: could Choosing Wisely work in China?

AIMS

To explore the possibility of implementing Choosing Wisely on ocular patients in China by investigating the prevalence of abnormalities in routine preoperative blood tests (RPBTs) and its turnaround time (TAT).

METHODS

Data from 102 542 ocular patients between January 2016 and December 2018, at Zhongshan Ophthalmic Center, were pooled from the laboratory information system. The test results were divided into normal and abnormal, including critical values. Ocular diseases were stratified into 11 subtypes based on the primary diagnosis. The TAT of 243 350 blood tests from January 2017 to December 2018 was categorised into transportation time and intralaboratory time.

RESULTS

RPBT was grouped into complete blood count (CBC), blood biochemistry (BBC), blood coagulation (BCG) and blood-borne pathogens (BBP), completed for 97.22%, 87.66%, 94.41% and 95.35% of the recruited patients (male, 52 549 (51.25%); median(IQR) age, 54 (29-67) years), respectively. Stratified by the test items, 9.19% (95% CI 9.07% to 9.31%) were abnormal results, and 0.020% (95% CI 0.019% to 0.022%) were critical; most abnormalities were on the CBC, while glucose was the most common critical item. Classified by the patients' primary diagnosis, 76.97% (95% CI 76.71% to 77.23%) had at least one abnormal result, and 0.28% (95% CI 0.25% to 0.32%) were critical; abnormal findings were reported in 45.29% (95% CI 44.98% to 45.60%), 54.97% (95% CI 54.65% to 55.30%), 30.29% (95% CI 30.00% to 30.58%) and 11.32% (95% CI 11.12% to 11.52%) for the CBC, BBC, BCG and BBP tests, respectively. The median transportation time and intralaboratory TAT of the samples were 12 min and 78 min respectively.

CONCLUSION

Blood abnormalities are common in ocular patients. With acceptable timelines, RPBT is still indispensable in China for patient safety.

A meta-analysis on first-trimester blood count parameters-is the neutrophil-to-lymphocyte ratio a potentially novel method for first-trimester preeclampsia screening?

Objective

Meta-analysis focusing on the role of first-trimester neutrophil-to-lymphocyte ratio (NLR) in the prediction of preeclampsia.

Data sources

PubMed, Scopus, Web of Science, Cochrane Library, and Embase databases were queried from inception up to December 31, 2022.

Study eligibility criteria

The study included all types of original research that was conducted in humans and values of NLR were measured during the first trimester, among patients who later developed preeclampsia, compared to the values of control groups.

Study appraisal and synthesis methods

Two reviewers independently performed data abstraction and quality appraisal, and disagreements were resolved by consensus and, if necessary, by the opinion of a third reviewer. During the analysis, PRISMA and MOOSE guidelines were followed. All statistical analyses were made with R.

Results

For the research on the predictive role of NLR values in the first trimester for preeclampsia, a total of 6 studies were selected for analysis, covering 2,469 patients. The meta-analysis revealed a 95% confidence interval (CI) for the effect size of 0.641 to 1.523, with a prediction interval of 0.027 to 2.137.

Conclusion

Based on the analysis, NLR is a promising biochemical marker for future pieces of research that try to find new screening methods for first-trimester preeclampsia. We encourage other researchers to examine NLR's predictive value combined with other markers in preeclampsia screening, this way being able to find new and affordable protocols for first-trimester preeclampsia screening.

Systematic review registration

identifier CRD42023392663.

Interventions to improve appropriateness of laboratory testing in the intensive care unit: a narrative review

Healthcare expenses are increasing, as is the utilization of laboratory resources. Despite this, between 20% and 40% of requested tests are deemed inappropriate. Improper use of laboratory resources leads to unwanted consequences such as hospital-acquired anemia, infections, increased costs, staff workload and patient stress and discomfort. The most unfavorable consequences result from unnecessary follow-up tests and treatments (overuse) and missed or delayed diagnoses (underuse). In this context, several interventions have been carried out to improve the appropriateness of laboratory testing. To date, there have been few published assessments of interventions specific to the intensive care unit. We reviewed the literature for interventions implemented in the ICU to improve the appropriateness of laboratory testing. We searched literature from 2008 to 2023 in PubMed, Embase, Scopus, and Google Scholar databases between April and June 2023. Five intervention categories were identified: education and guidance (E&G), audit and feedback, gatekeeping, computerized physician order entry (including reshaping of ordering panels), and multifaceted interventions (MFI). We included a sixth category exploring the potential role of artificial intelligence and machine learning (AI/ML)-based assisting tools in such interventions. E&G-based interventions and MFI are the most frequently used approaches. MFI is the most effective type of intervention, and shows the strongest persistence of effect over time. AI/ML-based tools may offer valuable assistance to the improvement of appropriate laboratory testing in the near future. Patient safety outcomes are not impaired by interventions to reduce inappropriate testing. The literature focuses mainly on reducing overuse of laboratory tests, with only one intervention mentioning underuse. We highlight an overall poor quality of methodological design and reporting and argue for standardization of intervention methods. Collaboration between clinicians and laboratory staff is key to improve appropriate laboratory utilization. This article offers practical guidance for optimizing the effectiveness of an intervention protocol designed to limit inappropriate use of laboratory resources.

Choosing which in-hospital laboratory tests to target for intervention: a scoping review

INTRODUCTION

Some laboratory testing practices may be of low value, leading to wasted resources and potential patient harm. Our scoping review investigated factors and processes that developers report using to inform decisions about what tests to target for practice improvement.

METHODS

We searched Medline on May 30th, 2019 and June 28th, 2021 and included guidelines, recommendation statements, or empirical studies related to test ordering practices. Studies were included if they were conducted in a tertiary care setting, reported making a choice about a specific test requiring intervention, and reported at least one factor informing that choice. We extracted descriptive details, tests chosen, processes used to make the choice, and factors guiding test choice.

RESULTS

From 114 eligible studies, we identified 30 factors related to test choice including clinical value, cost, prevalence of test, quality of test, and actionability of test results. We identified nine different processes used to inform decisions regarding where to spend intervention resources.

CONCLUSIONS

Intervention developers face difficult choices when deciding where to put scarce resources intended to improve test utilization. Factors and processes identified here can be used to inform a framework to help intervention developers make choices relevant to improving testing practices.

Changing healthcare professionals' non-reflective processes to improve the quality of care

RATIONALE

Translating research evidence into clinical practice to improve care involves healthcare professionals adopting new behaviours and changing or stopping their existing behaviours. However, changing healthcare professional behaviour can be difficult, particularly when it involves changing repetitive, ingrained ways of providing care. There is an increasing focus on understanding healthcare professional behaviour in terms of non-reflective processes, such as habits and routines, in addition to the more often studied deliberative processes. Theories of habit and routine provide two complementary lenses for understanding healthcare professional behaviour, although to date, each perspective has only been applied in isolation.

OBJECTIVES

To combine theories of habit and routine to generate a broader understanding of healthcare professional behaviour and how it might be changed.

METHODS

Sixteen experts met for a two-day multidisciplinary workshop on how to advance implementation science by developing greater understanding of non-reflective processes.

RESULTS

From a psychological perspective 'habit' is understood as a process that maintains ingrained behaviour through a learned link between contextual cues and behaviours that have become associated with those cues. Theories of habit are useful for understanding the individual's role in developing and maintaining specific ways of working. Theories of routine add to this perspective by describing how clinical practices are formed, adapted, reinforced and discontinued in and through interactions with colleagues, systems and organisational procedures. We suggest a selection of theory-based strategies to advance understanding of healthcare professionals' habits and routines and how to change them.

CONCLUSION

Combining theories of habit and routines has the potential to advance implementation science by providing a fuller understanding of the range of factors, operating at multiple levels of analysis, which can impact on the behaviours of healthcare professionals, and so quality of care provision.

Specific test panels for patients with heart failure: implementation and use in the Spanish National Health System

Objectives

The use of specific test panels (STP) for heart failure (HF) could help improve the management of this condition. The purpose of this study is to gain an insight into the level of implementation of STPs in the management of HF in Spain and gather the opinions of experts, with a special focus on parameters related to iron metabolism.

Methods

The opinions of experts in HF were gathered in three stages STAGE 1 as follows: level of implementation of STPs (n=40). STAGE 2: advantages and disadvantages of STPs (n=12). STAGE 3: level of agreement with the composition of three specific STPs for HF: initial evaluation panel, monitoring panel, and de novo panel (n=16).

Results

In total, 62.5% of hospitals used STPs for the clinical management of HF, with no association found between the use of STPs and the level of health care (p=0.132) and location of the center (p=0.486) or the availability of a Heart Failure Unit in the center (p=0.737). According to experts, the use of STPs in clinical practice has more advantages than disadvantages (8 vs. 3), with a notable positive impact on diagnostics. Experts gave three motivations and found three limitations to the implementation of STPs. The composition of the three specific STPs for HF was viewed positively by experts.

Conclusions

Although the experts interviewed advocate the use of diagnostic and monitoring STPs for HF, efforts are still necessary to achieve the standardization and homogenization of test panels for HF in Spanish hospitals.

Current state of laboratory test utilization practices in the clinical laboratory

Appropriate laboratory test utilization is of growing interest in the face of rising healthcare costs and documented evidence of over- and under-utilization. Building from published literature, laboratory organizations have recently published guidelines for establishing laboratory utilization management programs. However, systematic reviews and meta-analyses have consistently struggled to define rigorous evidence-based best practice recommendations due to the paucity of published data or the heterogeneity of available data. We sought to gain information about utilization practices and programs currently in use and which factors contribute to their success by distributing a survey among laboratory professionals. The survey received seventy-four eligible respondents. We observed a wide range in the duration of laboratory utilization programs and the number of stewardship initiatives. In addition, there was great variety in the utilization practices used and the tests or processes targeted by programs. There was similarity in how initiatives are evaluated and who is involved with utilization programs. Finally, respondents often credited a multidisciplinary committee, support from leadership, and strong IT support/data access as important factors for their program's perceived success. Many of these factors agree with previously published literature.

Efficiency over thoroughness in laboratory testing decision making in primary care: findings from a realist review

Background

Existing research demonstrates significant variation in test-ordering practice, and growth in the use of laboratory tests in primary care. Reviews of interventions designed to change test-ordering practice report heterogeneity in design and effectiveness. Improving understanding of clinicians’ decision making in relation to laboratory testing is an important means of understanding practice patterns and developing theory-informed interventions.

Aim

To develop explanations for the underlying causes of patterns of variation and increasing use of laboratory tests in primary care, and make recommendations for future research and intervention design.

Design & setting

Realist review of secondary data from primary care.

Method

Diverse evidence, including data from qualitative and quantitative studies, was gathered via systematic and iterative searching processes. Data were synthesised according to realist principles to develop explanations accounting for clinicians’ decision making in relation to laboratory tests.

Results

A total of 145 documents contributed data to the synthesis. Laboratory test ordering can fulfil many roles in primary care. Decisions about tests are incorporated into practice heuristics and tests are deployed as a tool to manage patient interactions. Ordering tests may be easier than not ordering tests in existing systems. Alongside high workloads and limited time to devote to decision making, there is a common perception that laboratory tests are relatively inconsequential interventions. Clinicians prioritise efficiency over thoroughness in decision making about laboratory tests.

Conclusion

Interventions to change test-ordering practice can be understood as aiming to preserve efficiency or encourage thoroughness in decision making. Intervention designs and evaluations should consider how testing decisions are made in real-world clinical practice.

Investigation of polycystic ovarian syndrome: variation in practice and impact on the speed of diagnosis

Objective

Accurate diagnosis of polycystic ovarian syndrome (PCOS) enables clinical interventions/cardiometabolic risk factor management. Diagnosis can take over 2 years and multiple clinician contacts. We examined patterns of PCOS-associated biochemical investigations following initial consultation prior to pelvic ultrasound scan (USS).

Methods

We determined in 206 women (i) the range of different biochemical test panels used in the diagnosis of PCOS in primary/secondary care prior to USS relative to national guidance in the UK and (ii) the relation between testing patterns and time to USS to highlight potential delays introduced by inappropriate testing.

Results

In these 206 women, 47 different test combinations were requested at initial venepuncture; only 7 (3%) had the test panel suggested in UK guidance (follicle-stimulating hormone/luteinizing hormone/testosterone/sex hormone-binding globulin/prolactin). The number of tests performed prior to USS varied from one test to all seven tests. There was an inverse relation between the number of biochemistry tests requested at initial venepuncture episode and 'time to scan'. Those who had <3 tests had a significantly longer time from first request to USS (median 70 days) than those with 3-7 tests (median 40 days; P = 0.002). One venepuncture episode prior to USS was associated with shorter 'time to scan' (median 29 days) than those with 2-4 episodes (median 255 days; P < 0.001).

Conclusion

There was no identifiable pattern to biochemical investigations requested as part of the initial diagnostic evaluation in women with suspected PCOS. We recommend standardization of the initial biochemical panel of analytes for PCOS workup, with incorporation into hospital/general practice ordering software systems.

The impact of interventions applied in primary care to optimize the use of laboratory tests: a systematic review

Laboratory tests are important tools in primary care, but their use is sometimes inappropriate. The aim of this review is to give an overview of interventions applied in primary care to optimize the use of laboratory tests. A search for studies was made in the MEDLINE and EMBASE databases. We also extracted studies from two previous reviews published in 2015. Studies were included if they described application of an intervention aiming to optimize the use of laboratory tests. We also evaluated the overall risk of bias of the studies. We included 24 studies. The interventions were categorized as: education, feedback reports and computerized physician order entry (CPOE) strategies. Most of the studies were classified as medium or high risk of bias while only three studies were evaluated as low risk of bias. The majority of the studies aimed at reducing the number of tests, while four studies investigated interventions aiming to increase the use of specific tests. Despite the studies being heterogeneous, we made results comparable by transforming the results into weighted relative changes in number of tests when necessary. Education changed the number of tests consistently, and these results were supported by the low risk of bias of the papers. Feedback reports have mainly been applied in combination with education, while when used alone the effect was minimal. The use of CPOE strategies seem to produce a marked change in the number of test requests, however the studies were of medium or high risk of bias.

A compulsory pop-up form reduces the number of vitamin D requests from general practitioners by 25 percent

OBJECTIVE

Healthcare costs, including costs for laboratory tests, are increasing worldwide. One example is the measurement of vitamin D. General practitioners in the Capital Region of Denmark include a vitamin D status in approximately 20% of all laboratory requisitions. This study intended to examine the effect of a compulsory pop-up form in the electronic request system on the number of vitamin D tests and to monitor the indications.

DESIGN

From 1 January 2017, we introduced a compulsory pop-up form in which the general practitioners had to state the indication for measuring vitamin D, choosing from a predefined set of indications. Intervention practitioners were compared with control practitioners before and after the intervention.

SETTING

General practices in the Capital Region of Denmark.

SUBJECTS

In total, 572 general practitioners and 383,964 patients were included in the period from 1 January 2016 to 31 December 2018.

MAIN OUTCOME MEASURES

Number of vitamin D tests and distribution of indications.

RESULTS

We observed a drop in number of vitamin D requisitions to 70% (in 2017) and 75% (in 2018) relative to 2016. During the same period, the number of requisitions increased by 33% in a non-intervention group of practitioners. The indication 'Monitoring of treatment with vitamin D' was the most frequently used indication, recorded in 121,475 patients.

CONCLUSION

A compulsory pop-up form reduces the number of vitamin D requests from general practitioners by 25%. The implication is that pop-up forms can be used to decrease healthcare costs.

The effect of laboratory requisition modification, audit and feedback with academic detailing or both on utilization of blood urea testing in family practice in Newfoundland, Canada

OBJECTIVES

Measuring blood urea at the same time as serum creatinine in stable ambulatory patients in family practice is largely unnecessary. The objective was to assess the relative impact of changing the laboratory requisition versus audit and feedback and academic detailing on the volume of orders for blood urea.

DESIGN AND METHODS

A natural experiment was observed over the period April 2015 to March 2018 in the Canadian province of Newfoundland where three health regions had different approaches to trying to reduce such urea testing. The Eastern and Western regions removed urea from the standard laboratory requisition but the test could still be ordered by writing it on the requisition. Central region requisitions continued to list urea. Audit and feedback was undertaken with family doctors in Eastern region after the requisition change and that was followed by academic detailing. A nephrologist gave presentations to groups of family doctors on one occasion in Central region.

RESULTS

The volume of serum creatinine testing was largely unchanged over time in each region. The volume of urea testing reduced by 73%, 48% and 28% in Eastern, Western and central regions. Interrupted time series analysis showed significant changes in test volume after requisition change in Eastern and Western regions as well as after audit and feedback in Eastern and the presentations in Central region. The incremental impact of academic detailing was not statistically significant.

CONCLUSION

We conclude that removing urea from standard test order menus was the most effective in reducing test volumes, but combination with audit and feedback augmented the impact.

Essential role of laboratory physicians in transformation of laboratory practice and management to a value-based patient-centric model

The laboratory is a vital part of the continuum of patient care. In fact, there are few programs in the healthcare system that do not rely on ready access and availability of complex diagnostic laboratory services. The existing transactional model of laboratory "medical practice" will not be able to meet the needs of the healthcare system as it rapidly shifts toward value-based care and precision medicine, which demands that practice be based on total system indicators, clinical effectiveness, and patient outcomes. Laboratory "value" will no longer be focused primarily on internal testing quality and efficiencies but rather on the relative cost of diagnostic testing compared to direct improvement in clinical and system outcomes. The medical laboratory as a "business" focused on operational efficiency and cost-controls must transform to become an essential clinical service that is a tightly integrated equal partner in direct patient care. We would argue that this paradigm shift would not be necessary if laboratory services had remained a "patient-centric" medical practice throughout the last few decades. This review is focused on the essential role of laboratory physicians in transforming laboratory practice and management to a value-based patient-centric model. Value-based practice is necessary not only to meet the challenges of the new precision medicine world order but also to bring about sustainable healthcare service delivery.

Interactive whiteboard use in clinical reasoning sessions to teach diagnostic test ordering and interpretation to undergraduate medical students

BACKGROUND

Over-testing of patients is a significant problem in clinical medicine that can be tackled by education. Clinical reasoning learning (CRL) is a potentially relevant method for teaching test ordering and interpretation. The feasibility might be improved by using an interactive whiteboard (IWB) during the CRL sessions to enhance student perceptions and behaviours around diagnostic tests. Overall, IWB/CRL could improve their skills.

METHODS

Third-year undergraduate medical students enrolled in a vertically integrated curriculum were randomized into two groups before clinical placement in either a respiratory disease or respiratory physiology unit: IWB-based CRL plus clinical mentoring (IWB/CRL + CM: n = 40) or clinical mentoring only (CM-only: n = 40). Feasibility and learning outcomes were assessed. In addition, feedback via questionnaire of the IWB students and their classmates (n = 233) was compared.

RESULTS

Analyses of the IWB/CRL sessions (n = 40, 27 paperboards) revealed that they met validated learning objectives. Students perceived IWB as useful and easy to use. After the IWB/CRL + CM sessions, students mentioned more hypothesis-based indications in a test ordering file (p <  0.001) and looked for more nonclinical signs directly on raw data tests (p <  0.01) compared with students in the CM-only group. Last, among students who attended pre- and post-assessments (n = 23), the number of diagnostic tests ordered did not change in the IWB/CRL + CM group (+ 7%; p = N.S), whereas it increased among CM-only students (+ 30%; p <  0.001). Test interpretability increased significantly in the IWB/CRL + CM group (from 4.7 to 37.2%; p <  0.01) but not significantly in the CM-only group (from 2.4 to 9.8%; p = 0.36).

CONCLUSIONS

Integrating IWB into CRL sessions is feasible to teach test ordering and interpretation to undergraduate students. Moreover, student feedback and prospective assessment suggested a positive impact of IWB/CRL sessions on students' learning.

Implementation of an educational province-wide intervention to reduce redundant vitamin B12 testing: A cross-sectional study

INTRODUCTION

We describe the implementation of an Alberta-wide intervention aimed at educating clinicians about redundant vitamin B₁₂ testing. We hypothesized that the introduction of an educational comment outlining recommended vitamin B₁₂ test intervals would reduce the annual number of vitamin B₁₂ tests performed.

MATERIALS AND METHODS

We performed a cross-sectional observational study that included all vitamin B₁₂ tests ordered in Alberta between May 1, 2017 and April 30, 2018. An educational comment was appended to all vitamin B₁₂ test results in Alberta beginning May 2, 2017. Using a simple seasonal model, we compared predicted versus observed vitamin B₁₂ test volumes for the 12-month period following the introduction of the educational comment. The sole outcome measured was the monthly change in volume of vitamin B₁₂ testing. A cost-analysis of the effects of the intervention on test volumes was also performed.

RESULTS

Over the sum of the first 12 months of the intervention, 18,000 more vitamin B₁₂ tests were ordered compared to the predicted value in Alberta. With an estimated cost of $7 per test, this resulted in a $126,000 increase in costs for vitamin B₁₂ testing provincially.

CONCLUSIONS

An educational intervention aimed at limiting inappropriate vitamin B₁₂ testing in Alberta did not alter testing as desired. Multiple utilization management strategies and a longer observation period may be needed to reduce redundant vitamin B₁₂ testing.

Going beyond audit and feedback: towards behaviour-based interventions to change physician laboratory test ordering behaviour

Studies indicate there are a variety of contributing factors affecting physician test ordering behaviour. Identifying these behaviours allows development of behaviour-based interventions. Methods Through a pilot study, the list of contributing factors in laboratory tests ordering, and the most ordered tests, were identified, and given to 50 medical students, interns, residents and paediatricians in questionnaire form. The results showed routine tests and peer or supervisor pressure as the most influential factors affecting physician ordering behaviour. An audit and feedback mechanism was selected as an appropriate intervention to improve physician ordering behaviour. The intervention was carried out at two intervals over a three-month period. Findings There was a large reduction in the number of laboratory tests ordered; from 908 before intervention to 389 and 361 after first and second intervention, respectively. There was a significant relationship between audit and feedback and the meaningful reduction of 7 out of 15 laboratory tests including complete blood count (p = 0.002), erythrocyte sedimentation rate (p = 0.01), C-reactive protein (p = 0.01), venous blood gas (p = 0.016), urine analysis (p = 0.005), blood culture (p = 0.045) and stool examination (p = 0.001). Conclusion The audit and feedback intervention, even in short duration, affects physician ordering behaviour. It should be designed in terms of behaviour-based intervention and diagnosis of the contributing factors in physicians' behaviour. Further studies are required to substantiate the effectiveness of such behaviour-based intervention strategies in changing physician behaviour.

Evaluating practice variance among family physicians to identify targets for laboratory utilization management

BACKGROUND

There is widespread variation in testing practice among practitioners, however there has been no objective way to pinpoint target tests for utilization management. We propose to take advantage of inter-physician variance in clinical practice as a quantitative measure to generate lists of potentially misutilized tests.

METHODS

Testing frequencies from a database of clinical testing volumes for outpatients in Calgary, Canada, were obtained for the study period of 2016. For each chemistry, microbiology or hematology test, an arithmetic coefficient of variation (CV) was calculated from family physicians' ordering frequencies.

RESULTS

The mean CV for all 358 tests considered was 219% (95% CI 206-231%) with a range of 52-729%. The highest variance was observed for human T-lymphotropic virus antibody testing and several tests for heavy metal levels (mercury, copper, zinc and chromium). Among the 100 most commonly run tests, high variance was found for several endocrinology tests including cortisol.

CONCLUSIONS

The utility of ranking clinical tests by ordering variance presents a practical approach to evaluate relative variation in physician practice strategy and to identify potential areas of misutilization.

Optimising laboratory monitoring of chronic conditions in primary care: a quality improvement framework

Monitoring of chronic conditions accounts for a significant proportion of blood testing in UK primary care; not all of this is based on evidence or guidelines. National benchmarking shows significant variation in testing rates for common blood tests. This project set out to standardise the blood tests used for monitoring of chronic conditions in primary care across North Devon, and to measure and reduce the harms of unwarranted testing. Chronic disease test groups were developed in line with current guidelines and implemented using one-click electronic test ordering systems. The main difference from previous general practitioner practice algorithms was removing the requirement for full blood count and liver function test monitoring for many conditions. Baseline harms of testing were measured and included significant costs, workload and patient anxiety. By defining the scale of the problem, we were able to leverage change across several cycles of quality improvement, using a pathology optimisation forum for peer-led improvement, and developing a framework focusing on what matters to patients. Overall primary care testing rates in North Devon fell by 14% for full blood count testing and 22% for liver function tests, but without a reduction in the number of tests showing possible significant pathology. We estimate that this has reduced testing costs by £200 000 across a population of around 180 000 people and has reduced downstream referral costs by a similar amount. Introduction of simple chronic disease test groups into primary care electronic ordering systems, when used alongside engagement with clinicians, leads to both quality improvement and reduction in system costs.

A Systematic Review of Studies of the STOPP/START 2015 and American Geriatric Society Beers 2015 Criteria in Patients ≥ 65 Years

BACKGROUND

Polypharmacy remains problematic for individuals ≥65.

OBJECTIVE

To summarise the percentages of patients meeting 2015 STOPP criteria for Potentially Inappropriate Prescriptions (PIPs), 2015 Beers criteria for Potentially Inappropriate Medications (PIMs), and START criteria Potential Prescribing Omissions (PPOs).

METHODS

Searches conducted on 2 January 2019 in Medline, Embase, and PubMed identified 562 studies and 62 studies were retained for review. Data were abstracted independently.

RESULTS

62 studies (n=1,854,698) included two RCTs and 60 non-randomised studies. For thirty STOPP/START studies (n=1,245,974) average percentages for ≥1 PIP weighted by study size were 42.8% for 1,242,010 community patients and 51.8% for 3,964 hospitalised patients. For nineteen Beers studies (n = 595,811) the average percentages for ≥1 PIM were 58% for 593,389 community patients and 55.5% for 2,422 hospitalised patients. For thirteen studies (n=12,913) assessing both STOPP/START and Beers criteria the average percentages for ≥1 STOPP PIP were 33.9% and Beers PIMs 46.8% for 8,238 community patients, and for ≥ 1 STOPP PIP were 42.4% and for ≥1 Beers PIM 60.5% for 4,675 hospitalised patients. Only ten studies assessed changes over time and eight found positive changes.

CONCLUSION

PIP/PIM/PPO rates are high in community and hospitalised patients in many countries. RCTs are needed for interventions to: reduce new/existing PIPs/PIMs/PPO prescriptions, reduce prescriptions causing adverse effects, and enable regulatory authorities to monitor and reduce inappropriate prescriptions in real time. Substantial differences between Beers and STOPP/START assessments need to be investigated whether they are due to the criteria, differential medication availability between countries, or data availability to assess the criteria.

Explaining variations in test ordering in primary care: protocol for a realist review

INTRODUCTION

Studies have demonstrated the existence of significant variation in test-ordering patterns in both primary and secondary care, for a wide variety of tests and across many health systems. Inconsistent practice could be explained by differing degrees of underuse and overuse of tests for diagnosis or monitoring. Underuse of appropriate tests may result in delayed or missed diagnoses; overuse may be an early step that can trigger a cascade of unnecessary intervention, as well as being a source of harm in itself.

METHODS AND ANALYSIS

This realist review will seek to improve our understanding of how and why variation in laboratory test ordering comes about. A realist review is a theory-driven systematic review informed by a realist philosophy of science, seeking to produce useful theory that explains observed outcomes, in terms of relationships between important contexts and generative mechanisms.An initial explanatory theory will be developed in consultation with a stakeholder group and this 'programme theory' will be tested and refined against available secondary evidence, gathered via an iterative and purposive search process. This data will be analysed and synthesised according to realist principles, to produce a refined 'programme theory', explaining the contexts in which primary care doctors fail to order 'necessary' tests and/or order 'unnecessary' tests, and the mechanisms underlying these decisions.

ETHICS AND DISSEMINATION

Ethical approval is not required for this review. A complete and transparent report will be produced in line with the RAMESES standards. The theory developed will be used to inform recommendations for the development of interventions designed to minimise 'inappropriate' testing. Our dissemination strategy will be informed by our stakeholders. A variety of outputs will be tailored to ensure relevance to policy-makers, primary care and pathology practitioners, and patients.

PROSPERO REGISTRATION NUMBER

CRD42018091986.

What do tests do for doctors? A qualitative study of blood testing in UK primary care

BACKGROUND

Rates of blood testing are rising with significant geographical variability. Most research into diagnostic testing focuses on the role of tests in diagnostic decision-making.

OBJECTIVE

The aim of this study was to explore the non-medical motives for blood testing by considering what tests do for doctors, through qualitative interviews with general practitioners (GPs).

METHODS

We undertook 23 in-depth semi-structured interviews with UK GPs. Reasons for performing recent inflammatory marker blood tests were explored by reviewing GPs pathology inboxes to ground discussions in real-life clinical practice. Interviews were transcribed verbatim and analysed using a grounded theory approach.

RESULTS

Blood tests offer doctors a tool to manage uncertainty; within a context of increased litigation, risk aversion and reduced continuity of care. Tests can also be offered as a 'gift' for patients, a way to be seen to be 'doing something'; in the social context of time pressures and perceived patient pressures. There was a tension however. On the one hand, doctors talked about using tests for reassurance and as a 'gift' offering 'truth'. Yet paradoxically, they also discussed the challenges of uncertainty and anxiety from inconclusive test results.

CONCLUSION

Our study emphasises that defining 'unnecessary' blood testing may not be as simple as determining medical criteria for testing; psychosocial reasons may be equally valid and interlinked. Further research is needed to help GPs manage uncertainty within the context of a risk averse society, and to explore the congruence and dissonance between doctors' and patients' perceptions of testing.

Use of the Mean Abnormal Result Rate (MARR) to Gauge Changes in Family Physicians' Selectivity of Laboratory Test Ordering, 2010-2015

OBJECTIVES

The mean abnormal result rate (MARR) has recently been advanced as a metric of laboratory test appropriateness. We used the MARR metric to examine patterns of change in family physician test requisitions over time.

METHODS

We accessed the Laboratory Information System of Calgary Laboratory Services for family physician-ordered testing on outpatients to gather aggregate test and abnormal result counts from 2010 to 2015.

RESULTS

Over the 6 years, there was an annual average of 3,401,553 tests for 411,295 distinct patients on their first test requisition for the year. The MARR increased from 8.1% to 9.0% through this period.

CONCLUSIONS

The MARR for Calgary and surrounding area gives tentative evidence of a gradual increase in physician test selectivity in recent years. Further data from other catchment areas are needed before making assertions about broader trends in physician awareness of laboratory resource use.

Implementation of an intervention to reduce population-based screening for vitamin D deficiency: a cross-sectional study

BACKGROUND

We describe the implementation of an intervention in Alberta in support of the Choosing Wisely Canada recommendation against population screening for vitamin D deficiency (as determined by serum total 25-hydroxyvitamin D testing). We hypothesized that the introduction of a specialized requisition for vitamin D testing would reduce the annual number of vitamin D tests performed.

METHODS

We performed a cross-sectional observational study that included all vitamin D tests ordered in Alberta between Apr. 1, 2015, and Mar. 31, 2016. There were no exclusion criteria. A special requisition for ordering vitamin D tests in Alberta was introduced on Apr. 1, 2015. Using an interrupted time series model, we compared predicted versus observed vitamin D test volumes for the 12-month period following the introduction of the new requisition. The sole outcome measure was the monthly change in volume of vitamin D testing. In addition, we calculated any cost savings as a result of reduced testing.

RESULTS

Over the first 12 months of the intervention, there was a reduction in the number of tests ordered from a predicted 342 477 tests to 29 525 tests (91.4% reduction). This decrease represented a direct spending decrease of Can$938 856-$1 564 760 per year in Alberta.

INTERPRETATION

A provincially led implementation of a Choosing Wisely Canada recommendation resulted in a large and sustained reduction in serum total 25-hydroxyvitamin D testing in Alberta. This study shows that provincially led interventions based on Choosing Wisely Canada recommendations can result in substantial reductions in laboratory tests.

Opportunities to Enhance Laboratory Professionals' Role On the Diagnostic Team

BACKGROUND

The 2015 Institue of Medicine report Improving Diagnosis in Health Care highlighted that diagnostic errors cause patient harm and that improvement in the diagnostic process requires better collaboration among physicians and laboratory professionals. The purpose of this study is to understand why physicians do not contact laboratory professionals when facing diagnostic challenges and identify opportunities for laboratory professionals to become more recognized members of the clinical care team.

METHODS

A random sample of 31,689 physicians from the American Medical Association Masterfile were surveyed about diagnostic challenges in laboratory test ordering and results interpretation, solutions to these challenges, and interactions with laboratory professionals.

RESULTS

We received responses from 1768 physicians (5.6%). When faced with diagnostic challenges, they reported using electronic resources because they find it difficult and time-consuming to contact the laboratory. Only 20% had an effective way to access laboratory professionals, mostly seeking help for logistical but less for clinical issues. Continuing medical education, professional articles, and updates from the laboratory were helpful.

CONCLUSIONS

Laboratory professionals have an opportunity to play a greater role in the diagnostic process by becoming active members of the clinical care team, beyond providing results. This study provides strategies to increase laboratory professionals' role in the diagnostic process.

Clinical Action Curves: Measuring the Magnitude of Physician Response to Abnormal Laboratory Results

OBJECTIVES

While reference limits are foundational to interpreting clinical laboratory tests, they may not correspond to the actual values triggering clinical response. We propose to measure this using clinical action curves, which plot test values against an indicator of clinical action.

METHODS

We selected repeat test ordering as a quantifiable, objective, useful measure that is readily calculable using available laboratory data. Using all results in Calgary in 2010-2011 for eight analytes, clinical action curves for each analyte were plotted as the relationship between index test value and retesting hazard, modeled using Cox proportional hazards with restricted cubic splines. Clinical action limits were defined where retesting hazard rose 38% above baseline (25%-50% considered).

RESULTS

In general, clinical action increased before the reference limits, and clinical action limits were narrower than reference limits. However, some reference limits showed no increased clinical action and may thus be ignored in practice.

CONCLUSIONS

Clinical action curves and limits provide practical, objective tools for describing physician responses to test values. Results suggest that many normal results are treated as abnormal and vice versa; such discrepancies require further scrutiny and ultimately reconciliation via altered reference ranges or altered practice patterns.