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Ropers FG, Rietveld S, Rings EHHM, Bossuyt PMM, van Bodegom-Vos L, Hillen MA. Diagnostic testing in children: A qualitative study of pediatricians' considerations. J Eval Clin Pract 2023; 29:1326-1337. [PMID: 37221991 DOI: 10.1111/jep.13867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/02/2023] [Accepted: 05/04/2023] [Indexed: 05/25/2023]
Abstract
AIMS AND OBJECTIVES Studies in adult medicine have shown that physicians base testing decisions on the patient's clinical condition but also consider other factors, including local practice or patient expectations. In pediatrics, physicians and parents jointly decide on behalf of a (young) child. This might demand more explicit and more complex deliberations, with sometimes conflicting interests. We explored pediatricians' considerations in diagnostic test ordering and the factors that influence their deliberation. METHOD We performed in-depth, semistructured interviews with a purposively selected heterogeneous sample of 20 Dutch pediatricians. We analyzed transcribed interviews inductively using a constant comparative approach, and clustered data across interviews to derive common themes. RESULTS Pediatricians perceived test-related burden in children higher compared with adults, and reported that avoiding an unjustified burden causes them to be more restrictive and deliberate in test ordering. They felt conflicted when parents desired testing or when guidelines recommended diagnostic tests pediatricians perceived as unnecessary. When parents demanded testing, they would explore parental concern, educate parents about harms and alternative explanations of symptoms, and advocate watchful waiting. Yet they reported sometimes performing tests to appease parents or to comply with guidelines, because of feared personal consequences in the case of adverse outcomes. CONCLUSION We obtained an overview of the considerations that are weighed in pediatric test decisions. The comparatively strong focus on prevention of harm motivates pediatricians to critically appraise the added value of testing and drivers of low-value testing. Pediatricians' relatively restrictive approach to testing could provide an example for other disciplines. Improved guidelines and physician and patient education could help to withstand the perceived pressure to test.
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Affiliation(s)
- Fabienne G Ropers
- Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Sophie Rietveld
- Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Edmond H H M Rings
- Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
- Department of Pediatrics, Sophia Children's Hospital, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Patrick M M Bossuyt
- Amsterdam University Medical Centers, University of Amsterdam, Epidemiology & Data Science, Amsterdam, The Netherlands
- Amsterdam Public Health, Methodology, Amsterdam, The Netherlands
| | - Leti van Bodegom-Vos
- Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Marij A Hillen
- Amsterdam University Medical Centers, location AMC, Amsterdam Public Health, Medical Psychology, Amsterdam, The Netherlands
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2
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Early-stage lung cancer associated with higher frequency of chest x-ray up to three years prior to diagnosis. Prim Health Care Res Dev 2022; 23:e66. [PMID: 36321523 PMCID: PMC9641667 DOI: 10.1017/s1463423622000573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVES Symptom awareness campaigns have contributed to improved early detection of lung cancer. Previous research suggests that this may have been achieved partly by diagnosing lung cancer in those who were not experiencing symptoms of their cancer. This study aimed to explore the relationship between frequency of chest x-ray in the three years prior to diagnosis and stage at diagnosis. SETTINGS Lung cancer service in a UK teaching hospital. PARTICIPANTS Patients diagnosed with lung cancer between 2010 and 2013 were identified. The number of chest x-rays for each patient in the three years prior to diagnosis was recorded. Statistical analysis of chest x-ray frequency comparing patients with early- and late-stage disease was performed. RESULTS One-thousand seven-hundred fifty patients were included - 589 (33.7%) with stage I/II and 1,161 (66.3%) with stage III/IV disease. All patients had at least one chest x-ray in the six months prior to diagnosis. Those with early-stage disease had more chest x-rays in this period (1.32 vs 1.15 radiographs per patient, P = 0.009). In the period 36 months to six months prior to lung cancer diagnosis, this disparity was even greater (1.70 vs 0.92, radiographs per patient, P < 0.001). CONCLUSIONS Increased rates of chest x-ray are likely to contribute to earlier detection. Given the known symptom lead time many patients diagnosed through chest x-ray may not have been experiencing symptoms caused by their cancer. The number of chest x-rays performed could reflect patient and/or clinician behaviours in response to symptoms.
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de Bekker PJGM, de Weerdt V, Vink MDH, van der Kolk AB, Donker MH, van der Hijden EJE. 'Give me something meaningful': GPs perspectives on how to improve an audit and feedback report provided by health insurers - an exploratory qualitative study. BMJ Open Qual 2022; 11:bmjoq-2022-002006. [PMID: 36375859 PMCID: PMC9664288 DOI: 10.1136/bmjoq-2022-002006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 10/24/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Audit and feedback (A&F) is a valuable quality improvement strategy, which can contribute to de-implementation of low-value care. In the Netherlands, all health insurers collaboratively provide A&F to general practitioners (GPs), the 'Primary Care Practice Report' (PCPR). Unfortunately, the use of this report by GPs is limited. This study examined the thoughts of GPs on the usability of the PCPR and GPs recommendations for improving the PCPR. METHOD We used an interpretative qualitative design, with think-aloud tasks to uncover thoughts of GPs on the usability of the PCPR and semistructured interview questions to ask GPs' recommendations for improvement of the PCPR. Interviews were audiorecorded and transcribed ad verbatim. Data were analysed using thematic content analysis. RESULTS We identified two main themes: 'poor usability of the PCPR', and 'minimal motivation to change based on the PCPR'. The GPs found the usability of the PCPR poor due to the feedback not being clinically meaningful, the data not being recent, individual and reliable, the performance comparators offer insufficient guidance to assess clinical performance, the results are not discussed with peers and the definitions and visuals are unclear. The GPs recommended improving these issues. The GPs motivation to change based on the PCPR was minimal. CONCLUSIONS The GPs evaluated the PCPR as poorly usable and were minimally motivated to change. The PCPR seems developed from the perspective of the reports' commissioners, health insurers, and does not meet known criteria for effective A&F design and user-centred design. Importantly, the GPs did state that well-designed feedback could contribute to their motivation to improve clinical performance.Furthermore, the GPs stated that they receive a multitude of A&F reports, which they hardly use. Thus, we see a need for policy makers to invest in less, but more usable A&F reports.
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Affiliation(s)
- P J G M de Bekker
- Department of Health Economics & Talma Institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands .,Zorgvuldig Advies, Utrecht, Netherlands
| | - V de Weerdt
- Department of Health Economics & Talma Institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands.,Amsterdam University Medical Centres, Holendrecht, Netherlands
| | - M D H Vink
- Department of Health Economics & Talma Institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands.,Gynaecology, Amsterdam Universitair Medische Centra, Duivendrecht, Netherlands
| | - A B van der Kolk
- Talma Institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - M H Donker
- Department of Health Sciences, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - E J E van der Hijden
- Department of Health Economics & Talma Institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands.,Zilveren Kruis Health Insurance, Zeist, Netherlands
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4
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Lapointe A, Royer Moreau N, Simonyan D, Rousseau F, Mallette V, Préfontaine-Racine F, Paquette C, Mallet M, St-Pierre A, Berthelot S. Identification of Predictors of Abnormal Calcium, Magnesium and Phosphorus Blood Levels in the Emergency Department: A Retrospective Cohort Study. Open Access Emerg Med 2021; 13:13-21. [PMID: 33500669 PMCID: PMC7823096 DOI: 10.2147/oaem.s289748] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 12/22/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose With rising healthcare costs limiting access to care, the judicious use of diagnostic tests has become a critical issue for many jurisdictions. Calcium, magnesium and phosphorus serum levels are regularly performed tests in the emergency department, but their clinical relevance have come into question. Authors sought to determine risk factors that could predict abnormal calcium, magnesium and phosphorus serum levels, as well as identify patients who may need corrective interventions. Methods A retrospective cohort study was conducted in two academic hospitals in Québec City. Demographic and clinical characteristics of 1008 patients who had serum calcium and/or magnesium and/or phosphorus levels drawn by an emergency physician were collected. Multivariate logistic regression models were fitted to obtain adjusted odds ratios for each risk factor for abnormal calcium or magnesium or phosphorus blood levels, and for a required intervention. Results Among patients for whom calcium, magnesium and phosphorus were tested in the Emergency Department, the most significant risk factors (OR>2) for electrolytic abnormality were as follows: hypocalcemia – respiratory distress, diuretics (excluding loop and thiazide), anti-neoplastic medication, long QTc, chronic kidney disease (CKD); hypercalcemia – bone pain, vitamin D, hallucinations; hypomagnesemia – diabetes, corticosteroids; hypermagnesemia – poor extremity perfusion, CKD, furosemide; hypophosphatemia – seizure; hyperphosphatemia – phosphate-binders, CKD, peripheral vascular atherosclerotic disease. Of all patients tested, 3.4% received a corrective intervention initiated by the emergency physician. Predictors of intervention on an electrolyte abnormality include poor peripheral perfusion, nausea and chronic obstructive pulmonary disease (COPD). Conclusion Emergency physicians can potentially reduce the unnecessary testing of calcium, magnesium and phosphorus blood levels by targeting patients with high-acuity conditions or chronic comorbidities such as CKD, diabetes and COPD.
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Affiliation(s)
- Antoine Lapointe
- Département de médecine familiale et de médecine d'urgence, Université Laval, Québec, Canada
| | - Nikyel Royer Moreau
- Département de médecine familiale et de médecine d'urgence, Université Laval, Québec, Canada
| | - David Simonyan
- Centre de recherche du CHU de Québec - Université Laval, Québec, Canada
| | - François Rousseau
- Centre de recherche du CHU de Québec - Université Laval, Québec, Canada
| | - Viviane Mallette
- Département de médecine familiale et de médecine d'urgence, Université Laval, Québec, Canada
| | | | - Caroline Paquette
- Département de médecine familiale et de médecine d'urgence, Université Laval, Québec, Canada
| | - Myriam Mallet
- Centre de recherche du CHU de Québec - Université Laval, Québec, Canada
| | - Annie St-Pierre
- Département de médecine familiale et de médecine d'urgence, Université Laval, Québec, Canada
| | - Simon Berthelot
- Département de médecine familiale et de médecine d'urgence, Université Laval, Québec, Canada.,Centre de recherche du CHU de Québec - Université Laval, Québec, Canada
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5
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Dogan H, Aydin H. Effect of triage on physicians’ clinical decision: A prospective, observational, single-center and cross-sectional study. JOURNAL OF ACUTE DISEASE 2021. [DOI: 10.4103/2221-6189.330740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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6
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Elwenspoek MMC, Scott LJ, Alsop K, Patel R, Watson JC, Mann E, Whiting P. What methods are being used to create an evidence base on the use of laboratory tests to monitor long-term conditions in primary care? A scoping review. Fam Pract 2020; 37:845-853. [PMID: 32820328 PMCID: PMC7759753 DOI: 10.1093/fampra/cmaa074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Studies have shown unwarranted variation in test ordering among GP practices and regions, which may lead to patient harm and increased health care costs. There is currently no robust evidence base to inform guidelines on monitoring long-term conditions. OBJECTIVES To map the extent and nature of research that provides evidence on the use of laboratory tests to monitor long-term conditions in primary care, and to identify gaps in existing research. METHODS We performed a scoping review-a relatively new approach for mapping research evidence across broad topics-using data abstraction forms and charting data according to a scoping framework. We searched CINAHL, EMBASE and MEDLINE to April 2019. We included studies that aimed to optimize the use of laboratory tests and determine costs, patient harm or variation related to testing in a primary care population with long-term conditions. RESULTS Ninety-four studies were included. Forty percent aimed to describe variation in test ordering and 36% to investigate test performance. Renal function tests (35%), HbA1c (23%) and lipids (17%) were the most studied laboratory tests. Most studies applied a cohort design using routinely collected health care data (49%). We found gaps in research on strategies to optimize test use to improve patient outcomes, optimal testing intervals and patient harms caused by over-testing. CONCLUSIONS Future research needs to address these gaps in evidence. High-level evidence is missing, i.e. randomized controlled trials comparing one monitoring strategy to another or quasi-experimental designs such as interrupted time series analysis if trials are not feasible.
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Affiliation(s)
- Martha M C Elwenspoek
- The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Lauren J Scott
- The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Katharine Alsop
- Nightingale Valley Practice, Bristol, UK
- Brisdoc Healthcare Services, Bristol, UK
| | - Rita Patel
- The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Jessica C Watson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Ed Mann
- Tyntesfield Medical Group, Bristol, UK
| | - Penny Whiting
- The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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7
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Harris M, Brekke M, Dinant GJ, Esteva M, Hoffman R, Marzo-Castillejo M, Murchie P, Neves AL, Smyrnakis E, Vedsted P, Aubin-Auger I, Azuri J, Buczkowski K, Buono N, Foreva G, Babić SG, Jacob E, Koskela T, Petek D, Šter MP, Puia A, Sawicka-Powierza J, Streit S, Thulesius H, Weltermann B, Taylor G. Primary care practitioners' diagnostic action when the patient may have cancer: an exploratory vignette study in 20 European countries. BMJ Open 2020; 10:e035678. [PMID: 33130560 PMCID: PMC7783622 DOI: 10.1136/bmjopen-2019-035678] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 08/04/2020] [Accepted: 08/05/2020] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Cancer survival rates vary widely between European countries, with differences in timeliness of diagnosis thought to be one key reason. There is little evidence on the way in which different healthcare systems influence primary care practitioners' (PCPs) referral decisions in patients who could have cancer.This study aimed to explore PCPs' diagnostic actions (whether or not they perform a key diagnostic test and/or refer to a specialist) in patients with symptoms that could be due to cancer and how they vary across European countries. DESIGN A primary care survey. PCPs were given vignettes describing patients with symptoms that could indicate cancer and asked how they would manage these patients. The likelihood of taking immediate diagnostic action (a diagnostic test and/or referral) in the different participating countries was analysed. Comparisons between the likelihood of taking immediate diagnostic action and physician characteristics were calculated. SETTING Centres in 20 European countries with widely varying cancer survival rates. PARTICIPANTS A total of 2086 PCPs answered the survey question, with a median of 72 PCPs per country. RESULTS PCPs' likelihood of immediate diagnostic action at the first consultation varied from 50% to 82% between countries. PCPs who were more experienced were more likely to take immediate diagnostic action than their peers. CONCLUSION When given vignettes of patients with a low but significant possibility of cancer, more than half of PCPs across Europe would take diagnostic action, most often by ordering diagnostic tests. However, there are substantial between-country variations.
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Affiliation(s)
- Michael Harris
- Department for Health, University of Bath, Bath, Somerset, UK
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Mette Brekke
- Department of General Practice and General Practice Research Unit, University of Oslo, Oslo, Norway
| | - Geert-Jan Dinant
- Department of General Practice, Maastricht University, Maastricht, The Netherlands
| | - Magdalena Esteva
- Balearic Islands Health Research Institute (IdISBa), Palma de Mallorca, Illes Balears, Spain
| | - Robert Hoffman
- Department of Family Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Peter Murchie
- Division of Applied Health Science, University of Aberdeen, Aberdeen, UK
| | - Ana Luísa Neves
- Centre for Health Policy, Imperial College London, London, UK
- Centre for Health Technology and Services Research, Department of Community Medicine, Information and Health Decision Sciences, University of Porto, Porto, Portugal
| | - Emmanouil Smyrnakis
- Laboratory of Primary Health Care, General Practice and Health Services Research, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Peter Vedsted
- Research Unit for General Practice, University of Aarhus, Aarhus, Denmark
| | - Isabelle Aubin-Auger
- Department of General Practice, Université Paris Diderot, Paris, Île-de-France, France
| | - Joseph Azuri
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Krzysztof Buczkowski
- Department of Family Medicine, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Nicola Buono
- Department of Family Medicine, National Society of Medical Education in General Practice (SNaMID), Prata Sannita, Italy
| | | | | | - Eva Jacob
- Primary Health Centre, Centro de Saúde Sarria, Sarria, Lugo, Spain
| | - Tuomas Koskela
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Davorina Petek
- Department of Family Medicine, Univerza v Ljubljani, Ljubljana, Slovenia
| | - Marija Petek Šter
- Department of Family Medicine, Univerza v Ljubljani, Ljubljana, Slovenia
| | - Aida Puia
- Family Medicine Department, Iuliu Hagieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
| | | | - Sven Streit
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Hans Thulesius
- Department of Research and Development, Lund University, Malmö, Sweden
| | - Birgitta Weltermann
- Institut für Hausarztmedizin, University of Bonn, Bonn, Nordrhein-Westfalen, Germany
| | - Gordon Taylor
- College of Medicine and Health, University of Exeter, Exeter, Devon, UK
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8
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Shashar S, Codish S, Ellen M, Davidson E, Novack V. Determinants of Medical Practice Variation Among Primary Care Physicians: Protocol for a Three Phase Study. JMIR Res Protoc 2020; 9:e18673. [PMID: 33079069 PMCID: PMC7609196 DOI: 10.2196/18673] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 06/04/2020] [Accepted: 06/14/2020] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND One of the greatest challenges of modern health systems is the choice and use of resources needed to diagnose and treat patients. Medical practice variation (MPV) is a broad term which entails the differences between health care providers inclusive of both the overuse and underuse. In this paper, we describe a 3-phase research protocol examining MPV in primary care. OBJECTIVE We aim to identify the potential targets for behavioral modification interventions to reduce the variation in practice patterns and thus improve health care, decrease costs, and prevent disparities in care. METHODS The first phase will delineate the variation in primary care practice over a wide range of services and long follow-up period (2003-2017), the second will examine the 3 determinants of variation (ie, patient, physician, and clinic characteristics), and attempt to derive the unexplained variance. In the third phase, we will assess a novel component that might contribute to the previously unexplained variance - the physicians' personal behavioral characteristics (such as risk aversion, fear of malpractice, stress from uncertainty, empathy, and burnout). RESULTS This work was supported by the research grant from Israel National Institute for Health Policy Research (Grant No. 2014/134). Soroka University Medical Center Institutional Ethics Committee has approved the updated version of the study protocol (SOR-14-0063) in February 2019. All relevant data for phases 1 and 2, including patient, physician, and clinic, were collected from the Clalit Health Services data set in 2019 and are currently being analyzed. The evaluation of the individual physician characteristics (eg, risk aversion) by the face-to-face questionnaires was started on 2018 and remains in progress. We intend to publish the results during 2020-2021. CONCLUSIONS Based on the results of our study, we aim to propose a list of potential targets for focused behavioral intervention. Identifying new targets for such an intervention can potentially lead to a decrease in the unwarranted variation in the medical practice. We suggest that such an intervention will result in optimization of the health system, improvement of health outcomes, reduction of disparities in care and savings in cost. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/18673.
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Affiliation(s)
- Sagi Shashar
- Clinical Research Center, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Shlomi Codish
- Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Moriah Ellen
- Department of Health Services Management, Guilford Glazer Faculty of Business and Management, Ben Gurion University, Beer-Sheva, Israel.,Institute of Health Policy Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,McMaster Health Forum, McMaster University, Hamilton, ON, Canada
| | - Ehud Davidson
- General Management, Clalit Health Services, Tel Aviv, Israel
| | - Victor Novack
- Clinical Research Center, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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9
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Meidani Z, Mousavi GA, Kheirkhah D, Benar N, Maleki MR, Sharifi M, Farrokhian A. Going beyond audit and feedback: towards behaviour-based interventions to change physician laboratory test ordering behaviour. J R Coll Physicians Edinb 2019. [PMID: 29537404 DOI: 10.4997/jrcpe.2017.407] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
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.
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Affiliation(s)
- Z Meidani
- D Kheirkhah, Infectious Diseases Research Centre, Kashan University of Medical Sciences, Kashan, Iran.
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10
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Duddy C, Wong G. Explaining variations in test ordering in primary care: protocol for a realist review. BMJ Open 2018; 8:e023117. [PMID: 30209159 PMCID: PMC6144329 DOI: 10.1136/bmjopen-2018-023117] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 06/29/2018] [Accepted: 08/10/2018] [Indexed: 12/24/2022] Open
Abstract
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.
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Affiliation(s)
- Claire Duddy
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, Oxford, UK
| | - Geoffrey Wong
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, Oxford, UK
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11
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van der Pluijm-Schouten HW, Hermens RPMG, van Heteren CF, Schers HJ, Schleedoorn MJ, Arkenbout M, Maassen PW, Kremer JAM, Nelen WLDM. General practitioners' adherence to work-up and referral recommendations in fertility care. Hum Reprod 2018; 32:1249-1257. [PMID: 28369357 DOI: 10.1093/humrep/dex060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 03/12/2017] [Indexed: 11/13/2022] Open
Abstract
STUDY QUESTION What is the current guideline adherence by general practitioners (GPs) for work-up and subsequent referral from primary to secondary care for patients suffering from infertility? SUMMARY ANSWER Guideline adherence by GPs concerning infertility was 9.2% in couples referred. WHAT IS KNOWN ALREADY Adherence to recommendations can decrease unnecessary referral, diagnostics and treatments, and consequently result in lower expenditures. Moreover, patients can be saved from unnecessary hospital visits, emotional burden and out of pocket costs. STUDY DESIGN, SIZE, AND DURATION A retrospective cohort study among 306 patients referred for basic fertility work-up between January 2011 and June 2013 from primary care to a secondary care teaching hospital or a tertiary hospital with IVF facilities. PARTICIPANTS/MATERIALS, SETTING AND METHODS Couples were eligible to participate when there was no previous referral for fertility problems and the duration of the child wish was <2 years. Data to assess guideline adherence were collected from the referral letter and the medical records. A patient questionnaire was used to determine patients' general and fertility-related characteristics. MAIN RESULTS AND THE ROLE OF CHANCE The GP performed a Chlamydia Antibody Titre (CAT) testing and semen analysis as recommended in 15.9% and 42.2% of the referred patients, respectively. According to the guideline, 39% of the couples were under referred (i.e. not immediately referred as recommended), 8.8% were unnecessarily referred and the CAT and semen analysis were unnecessarily repeated in secondary care in 80.0% and 57.1% of cases, respectively. LIMITATIONS REASONS FOR CAUTION We could not include non-referred patients with expectant management in primary care, an unknown number of whom became pregnant in this period. This may have resulted in an underestimation of primary care performance. WIDER IMPLICATIONS OF THE FINDINGS Our findings show that guideline adherence concerning work-up and subsequent referral for fertility problems is low. The influence of patient demands for referral remains largely unknown. Barriers and facilitators for guideline adherence should be determined to develop interventions to improve guideline adherence in the areas of work-up and referral for fertility care and to diminish duplicate tests in secondary care. STUDY FUNDING/COMPETING INTEREST(S) Funded by CZ, a Dutch healthcare insurer (grant number AFVV 11-232). CZ had no role in designing the study, data collection, analysis and interpretation of data or writing of the report. Competing interests: None. TRIAL REGISTRATION NUMBER Not applicable.
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Affiliation(s)
- H W van der Pluijm-Schouten
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - R P M G Hermens
- Scientific Institute for Quality of Healthcare, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - C F van Heteren
- Department of Obstetrics and Gynaecology, Canisius Wilhelmina Hospital, PO Box 9015, 6500 GS, Nijmegen, The Netherlands
| | - H J Schers
- Department of Primary and Community Care, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - M J Schleedoorn
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - M Arkenbout
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - P W Maassen
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - J A M Kremer
- Scientific Institute for Quality of Healthcare, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - W L D M Nelen
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
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Cadogan SL, Browne JP, Bradley CP, Fitzgerald AP, Cahill MR. Physician and practice characteristics associated with immunoglobulin test ordering. Fam Pract 2018; 35:41-46. [PMID: 28968810 DOI: 10.1093/fampra/cmx063] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Primary care test requests for serum immunoglobulins are rising rapidly, with concerns that many requests may be unnecessary. Evidence suggests some characteristics of general practitioners (GPs) and practices are associated with higher test ordering. OBJECTIVE To identify the physician and practice characteristics associated with immunoglobulin test ordering. METHODS Retrospective, cross-sectional study using routine laboratory data on primary care serum immunoglobulin requests. Data were linked with GP patient list size data. The primary outcome measure was the count of test requests per GP. Predictor variables were physician gender, years experience, practice region and type (number of GPs), GP patient list size and composition. Mixed-effects multilevel regression models were used to calculate incidence rate ratios (IRRs) with 95% confidence intervals (CIs) for the associations between physician and practice characteristics and GP requesting. Sensitivity analysis was performed by limiting the model to the more than 70 years age category. RESULTS In total, 5990 immunoglobulin tests were ordered by 481 GPs in the South of Ireland during 2013. The number of tests ordered by individual GPs varied from one to 377. In the final fully adjusted Poisson regression analysis, female gender (IRR: 1.81; 95% CI: 1.45-2.26) and less experience (IRR: 2.27; 95% CI: 1.47-3.51) were associated with higher requesting (P < 0.001). None of the practice factors were associated with test ordering. Sensitivity analysis on the 70 years or more age category found similar results. CONCLUSION Further research is required to explore the potential reasons for higher requesting among GPs with fewer years of experience and also among female GPs.
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Affiliation(s)
- Sharon L Cadogan
- Department of Epidemiology and Public Health, University College Cork, Ireland
| | - John P Browne
- Department of Epidemiology and Public Health, University College Cork, Ireland
| | - Colin P Bradley
- Department of General Practice, University College Cork, Ireland
| | - Anthony P Fitzgerald
- Department of Epidemiology and Public Health, University College Cork, Ireland.,Department of Statistics, University College Cork, Cork, Ireland
| | - Mary R Cahill
- Department of Haematology, Cork University Hospital, Cork, Ireland
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Sá L, Teixeira ASC, Tavares F, Costa-Santos C, Couto L, Costa-Pereira A, Hespanhol AP, Santos P, Martins C. Diagnostic and laboratory test ordering in Northern Portuguese Primary Health Care: a cross-sectional study. BMJ Open 2017; 7:e018509. [PMID: 29146654 PMCID: PMC5695440 DOI: 10.1136/bmjopen-2017-018509] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 09/11/2017] [Accepted: 10/03/2017] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES To characterise the test ordering pattern in Northern Portugal and to investigate the influence of context-related factors, analysing the test ordered at the level of geographical groups of family physicians and at the level of different healthcare organisations. DESIGN Cross-sectional study. SETTING Northern Primary Health Care, Portugal. PARTICIPANTS Records about diagnostic and laboratory tests ordered from 2035 family physicians working at the Northern Regional Health Administration, who served approximately 3.5 million Portuguese patients, in 2014. OUTCOMES To determine the 20 most ordered diagnostic and laboratory tests in the Northern Regional Health Administration; to identify the presence and extent of variations in the 20 most ordered diagnostic and laboratory tests between the Groups of Primary Care Centres and between health units; and to study factors that may explain these variations. RESULTS The 20 most ordered diagnostic and laboratory tests almost entirely comprise laboratory tests and account for 70.9% of the total tests requested. We can trace a major pattern of test ordering for haemogram, glucose, lipid profile, creatinine and urinalysis. There was a significant difference (P<0.001) in test orders for all tests between Groups of Primary Care Centres and for all tests, except glycated haemoglobin (P=0.06), between health units. Generally, the Personalised Healthcare Units ordered more than Family Health Units. CONCLUSIONS The results from this study show that the most commonly ordered tests in Portugal are laboratory tests, that there is a tendency for overtesting and that there is a large variability in diagnostic and laboratory test ordering in different geographical and organisational Portuguese primary care practices, suggesting that there may be considerable potential for the rationalisation of test ordering. The existence of Family Health Units seems to be a strong determinant in decreasing test ordering by Portuguese family physicians. Approaches to ensuring more rational testing are needed.
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Affiliation(s)
- Luísa Sá
- MEDCIDS—Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
- Family Health Unit Nova Via, Porto, Portugal
| | - Andreia Sofia Costa Teixeira
- Centre for Research in Health Technologies and Information Systems (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal
| | - Fernando Tavares
- Department of Studies and Planning, Northern Regional Health Administration, Porto, Portugal
| | - Cristina Costa-Santos
- MEDCIDS—Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
- Centre for Research in Health Technologies and Information Systems (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal
| | - Luciana Couto
- MEDCIDS—Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Altamiro Costa-Pereira
- MEDCIDS—Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
- Centre for Research in Health Technologies and Information Systems (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal
| | - Alberto Pinto Hespanhol
- MEDCIDS—Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
- Centre for Research in Health Technologies and Information Systems (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal
| | - Paulo Santos
- MEDCIDS—Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
- Centre for Research in Health Technologies and Information Systems (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal
| | - Carlos Martins
- MEDCIDS—Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
- Centre for Research in Health Technologies and Information Systems (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal
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Magin PJ, Tapley A, Morgan S, Henderson K, Holliday EG, Davey AR, Ball J, Catzikiris NF, Mulquiney KJ, van Driel ML. Changes in pathology test ordering by early career general practitioners: a longitudinal study. Med J Aust 2017; 207:70-74. [PMID: 28701127 DOI: 10.5694/mja16.01421] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 04/21/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To assess the number of pathology tests ordered by general practice registrars during their first 18-24 months of clinical general practice. DESIGN Longitudinal analysis of ten rounds of data collection (2010-2014) for the Registrar Clinical Encounters in Training (ReCEnT) study, an ongoing, multicentre, cohort study of general practice registrars in Australia. The principal analysis employed negative binomial regression in a generalised estimating equations framework (to account for repeated measures on registrars).Setting, participants: General practice registrars in training posts with five of 17 general practice regional training providers in five Australian states. The registrar participation rate was 96.4%. MAIN OUTCOME MEASURE Number of pathology tests requested per consultation. The time unit for analysis was the registrar training term (the 6-month full-time equivalent component of clinical training); registrars contributed data for up to four training terms. RESULTS 876 registrars contributed data for 114 584 consultations. The number of pathology tests requested increased by 11% (95% CI, 8-15%; P < 0.001) per training term. CONCLUSIONS Contrary to expectations, pathology test ordering by general practice registrars increased significantly during their first 2 years of clinical practice. This causes concerns about overtesting. As established general practitioners order fewer tests than registrars, test ordering may peak during late vocational training and early career practice. Registrars need support during this difficult period in the development of their clinical practice patterns.
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Affiliation(s)
| | | | | | | | | | | | - Jean Ball
- Hunter Medical Research Institute, Newcastle, NSW
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Abstract
OBJECTIVES Physician variation in the use of computed tomography (CT) is concerning due to the risks of ionizing radiation, cost, and downstream effects of unnecessary testing. The objectives of this study were to describe variation in CT-ordering rates among emergency physicians (EPs), to measure correlation between perceived and actual CT-ordering rates, to assess attitudes that influence decisions to order imaging tests, and to identify EP attitudes associated with higher CT utilization. METHODS This study was a retrospective review of imaging and administrative billing records at two emergency department sites of a tertiary care adult teaching hospital. The study also included a cross-sectional survey of EPs at this hospital. We asked physicians about their perceived ordering behaviour, and what factors influenced their decision to order a CT. We examined correlations between perceived and actual CT-ordering rates. We adjusted ordering rates for shift distribution using a logistic regression model and identified outlier physicians whose ordering rate was significantly lower or higher than expected. We used multivariable regression analysis to determine which survey responses predicted higher CT utilization. RESULTS During the study period, 59 EPs saw 45,854 patients, and ordered 6,609 CTs - a mean ordering rate of 14.4% (standard deviation (SD)=4.3%). The ordering rate for individual physicians ranged from 5.9% to 25.9%. Of the 59 EPs, 13 EPs were low-ordering outliers; 12 were high-ordering outliers. Forty-five EPs (76.3%) completed the survey. Mean perceived ordering rate was 12.6%, and was weakly correlated with actual ordering (r=0.19, p=0.21). 42 EPs (93.3%) believed they ordered "about the same" or "fewer" CTs than their peers. Of the 17 EPs in the two highest ordering quintiles, only 3 (18%) knew they were high orderers. In the multivariable analysis, higher ordering was associated with increasing strength of response to the following predictors: medico-legal risk (relative risk [RR]=1.18, 95% CI: 1.03-1.21), risk of contrast (RR=1.14, 95% CI: 1.07-1.22), what colleagues would do (RR=1.09, 95% CI: 0.99-1.19), risk of missing a diagnosis (RR=1.08, 95% CI: 0.98-1.21), and patient wishes (RR=1.07, 95% CI: 0.97-1.17). CONCLUSIONS There is large variation in CT ordering among EPs. Physicians' self-reported ordering rate correlates poorly with actual ordering. High CT orderers were rarely aware that they ordered more than their colleagues. Higher rates of ordering were observed among physicians who reported increased concern with 1) risk of missing a diagnosis, 2) medico-legal risk, 3) risk of contrast, 4) patient wishes, and 5) what colleagues would do.
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Trietsch J, van Steenkiste B, Grol R, Winkens B, Ulenkate H, Metsemakers J, van der Weijden T. Effect of audit and feedback with peer review on general practitioners' prescribing and test ordering performance: a cluster-randomized controlled trial. BMC FAMILY PRACTICE 2017; 18:53. [PMID: 28407754 PMCID: PMC5390393 DOI: 10.1186/s12875-017-0605-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/23/2016] [Accepted: 02/28/2017] [Indexed: 01/25/2023]
Abstract
BACKGROUND Much research worldwide is focussed on cost containment and better adherence to guidelines in healthcare. The research focussing on professional behaviour is often performed in a well-controlled research setting. In this study a large-scale implementation of a peer review strategy was tested on both test ordering and prescribing behaviour in primary care in the normal quality improvement setting. METHODS We planned a cluster-RCT in existing local quality improvement collaboratives (LQICs) in primary care. The study ran from January 2008 to January 2011. LQICs were randomly assigned to one of two trial arms, with each arm receiving the same intervention of audit and feedback combined with peer review. Both arms were offered five different clinical topics and acted as blind controls for the other arm. The differences in test ordering rates and prescribing rates between both arms were analysed in an intention-to-treat pre-post analysis and a per-protocol analysis. RESULTS Twenty-one LQIC groups, including 197 GPs working in 88 practices, entered the trial. The intention-to-treat analysis did not show a difference in the changes in test ordering or prescribing performance between intervention and control groups. The per-protocol analysis showed positive results for half of the clinical topics. The increase in total tests ordered was 3% in the intervention arm and 15% in the control arm. For prescribing the increase in prescriptions was 20% in the intervention arm and 66% in the control group. It was observed that the groups with the highest baseline test ordering and prescription volumes showed the largest improvements. CONCLUSIONS Our study shows that the results from earlier work could not be confirmed by our attempt to implement the strategy in the field. We did not see a decrease in the volumes of tests ordered or of the drugs prescribed but were able to show a lesser increase instead. Implementing the peer review with audit and feedback proved to be not feasible in primary care in the Netherlands. TRIAL REGISTRATION This trial was registered at the Dutch trial register under number ISRCTN40008171 on August 7th 2007.
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Affiliation(s)
- J Trietsch
- School for Public Health and Primary Care (CAPHRI), Department of Family Medicine, Maastricht University, PO Box 616, , 6200 MD, Maastricht, The Netherlands.
| | - B van Steenkiste
- School for Public Health and Primary Care (CAPHRI), Department of Family Medicine, Maastricht University, PO Box 616, , 6200 MD, Maastricht, The Netherlands
| | - R Grol
- IQ Healthcare, Radboud University Nijmegen, PO Box 9101 (144), , 6500HB, Nijmegen, The Netherlands
| | - B Winkens
- School for Public Health and Primary Care (CAPHRI), Department of Methodology and Statistics, Maastricht University, PO Box 616, , 6200 MD, Maastricht, The Netherlands
| | - H Ulenkate
- Department of Clinical Chemistry, ZorgSaam Hospital, Wielingenlaan 2, 4535 PA, Terneuzen, The Netherlands
| | - J Metsemakers
- School for Public Health and Primary Care (CAPHRI), Department of Family Medicine, Maastricht University, PO Box 616, , 6200 MD, Maastricht, The Netherlands
| | - T van der Weijden
- School for Public Health and Primary Care (CAPHRI), Department of Family Medicine, Maastricht University, PO Box 616, , 6200 MD, Maastricht, The Netherlands
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The effect of a test ordering software intervention on the prescription of unnecessary laboratory tests - a randomized controlled trial. BMC Med Inform Decis Mak 2017; 17:20. [PMID: 28219437 PMCID: PMC5319139 DOI: 10.1186/s12911-017-0416-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 02/09/2017] [Indexed: 11/25/2022] Open
Abstract
Background The way software for electronic health records and laboratory tests ordering systems are designed may influence physicians’ prescription. A randomised controlled trial was performed to measure the impact of a diagnostic and laboratory tests ordering system software modification. Methods Participants were family physicians working and prescribing diagnostic and laboratory tests. The intervention group had a modified software with a basic shortcut menu changes, where some tests were withdrawn or added, and with the implementation of an evidence-based decision support based on United States Preventive Services Task Force (USPSTF) recommendations. This intervention group was compared with usual software (control group). The outcomes were the number of tests prescribed from those: withdrawn from the basic menu; added to the basic menu; marked with green dots (USPSTF’s grade A and B); and marked with red dots (USPSTF’s grade D). Results Comparing the monthly average number of tests prescribed before and after the software modification, from those tests that were withdrawn from the basic menu, the control group prescribed 33.8 tests per 100 consultations before and 30.8 after (p = 0075); the intervention group prescribed 31.3 before and 13.9 after (p < 0001). Comparing the tests prescribed between both groups during the intervention, from those tests that were withdrawn from the basic menu, the intervention group prescribed a monthly average of 14.0 vs. 29.3 tests per 100 consultations in the control group (p < 0.001). From those tests that are USPSTF’s grade A and B, intervention group prescribed 66.8 vs. 74.1 tests per 100 consultations in the control group (p = 0.070). From those tests categorised as USPSTF grade D, the intervention group prescribed an average of 9.8 vs. 11.8 tests per 100 consultations in the control group (p = 0.003). Conclusions Removing unnecessary tests from a quick shortcut menu of the diagnosis and laboratory tests ordering system had a significant impact and reduced unnecessary prescription of tests. The fact that it was not possible to perform the randomization at the family physicians’ level, but only of the computer servers is a limitation of our study. Future research should assess the impact of different tests ordering systems during longer periods. Trial registration ISRCTN45427977, May 1st 2014 (retrospectively registered).
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van der Horst A, van de Wijngaart DJ, Scherrenburg J, van Dijk N, Janssens PM. Practical motives are prominent in test-ordering in the Emergency Department. ACTA ACUST UNITED AC 2017; 55:1523-1529. [DOI: 10.1515/cclm-2016-1092] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 01/05/2017] [Indexed: 11/15/2022]
Abstract
AbstractBackground:Laboratory test ordering under time pressure may impact test-ordering behavior.Methods:To investigate the test-ordering behavior of doctors working under such pressure, we designed a questionnaire for trainees and staff in the Emergency Department (ED). This questionnaire addressed topics such as necessity of requested tests, time spent on ordering, costs and availability of tests, and the time of the day. We hypothesized that ordering behavior would be guided predominantly by the medical need of tests and aimed at identifying practical motives that also have an effect.Results:Remarkably, two-third of the respondents (67%) admitted that tests were ordered that would not influence treatment policy directly and 48% of the doctors stated that tests were ordered that do not impact treatment at all. The frequency of such orders was “sometimes” and “frequent” in a 50:50 ratio. Interestingly, tests that could prove relevant at a later stage are often ordered simultaneously to reduce burden on the patient. None of the respondents spent more than 3 min on the ordering process and very few (8%) desired more time for ordering. Most respondents (81%) declared to have limited knowledge of the costs of laboratory tests. A random survey covering four tests confirmed this. Generally, turnaround time did influence ordering behavior while time of the day did not.Conclusions:In conclusion, doctors in an ED – besides first of all medical motives – heavily exploit practical (non-medical) reasoning for laboratory test ordering, e.g. taking availability of tests into account and ordering non-immediate tests.
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Cadogan SL, McHugh SM, Bradley CP, Browne JP, Cahill MR. General practitioner views on the determinants of test ordering: a theory-based qualitative approach to the development of an intervention to improve immunoglobulin requests in primary care. Implement Sci 2016; 11:102. [PMID: 27435839 PMCID: PMC4952272 DOI: 10.1186/s13012-016-0465-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 07/02/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Research suggests that variation in laboratory requesting patterns may indicate unnecessary test use. Requesting patterns for serum immunoglobulins vary significantly between general practitioners (GPs). This study aims to explore GP's views on testing to identify the determinants of behaviour and recommend feasible intervention strategies for improving immunoglobulin test use in primary care. METHODS Qualitative semi-structured interviews were conducted with GPs requesting laboratory tests at Cork University Hospital or University Hospital Kerry in the South of Ireland. GPs were identified using a Health Service Executive laboratory list of GPs in the Cork-Kerry region. A random sample of GPs (stratified by GP requesting patterns) was generated from this list. GPs were purposively sampled based on the criteria of location (urban/rural); length of time qualified; and practice size (single-handed/group). Interviews were carried out between December 2014 and February 2015. Interviews were transcribed verbatim using NVivo 10 software and analysed using the framework analysis method. Emerging themes were mapped to the theoretical domains framework (TDF), which outlines 12 domains that can enable or inhibit behaviour change. The behaviour change wheel and behaviour change technique (BCT) taxonomy were then used to identify potential intervention strategies. RESULTS Sixteen GPs were interviewed (ten males and six females). Findings suggest that intervention strategies should specifically target the key barriers to effective test ordering, while considering the context of primary care practice. Seven domains from the TDF were perceived to influence immunoglobulin test ordering behaviours and were identified as 'mechanisms for change' (knowledge, environmental context and resources, social/professional role and identity, beliefs about capabilities, beliefs about consequences, memory, attention and decision-making processes and behavioural regulation). Using these TDF domains, seven BCTs emerged as feasible 'intervention content' for targeting GPs' ordering behaviour. These included instructions on how to effectively request the test (how to perform behaviour), information on GPs' use of the test (feedback on behaviour), information about patient consequences resulting from not doing the test (information about health consequences), laboratory/consultant-based advice/education (credible source), altering the test ordering form (restructuring the physical environment), providing guidelines (prompts/cues) and adding interpretive comments to the results (adding objects to the environment). These BCTs aligned to four intervention functions: education, persuasion, environmental restructuring and enablement. CONCLUSIONS This study has effectively applied behaviour change theory to identify feasible strategies for improving immunoglobulin test use in primary care using the TDF, 'behaviour change wheel' and BCT taxonomy. The identified BCTs will form the basis of a theory-based intervention to improve the use of immunoglobulin tests among GPs. Future research will involve the development and evaluation of this intervention.
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Affiliation(s)
- S L Cadogan
- Department of Epidemiology and Public Health, University College Cork, Cork, Ireland.
| | - S M McHugh
- Department of Epidemiology and Public Health, University College Cork, Cork, Ireland
| | - C P Bradley
- Department of General Practice, University College Cork, Cork, Ireland
| | - J P Browne
- Department of Epidemiology and Public Health, University College Cork, Cork, Ireland
| | - M R Cahill
- Department of Haematology, Cork University Hospital, Cork, Ireland
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Thomas RE, Vaska M, Naugler C, Chowdhury TT. Interventions to Educate Family Physicians to Change Test Ordering: Systematic Review of Randomized Controlled Trials. Acad Pathol 2016; 3:2374289516633476. [PMID: 28725760 PMCID: PMC5497906 DOI: 10.1177/2374289516633476] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 01/14/2016] [Accepted: 01/23/2016] [Indexed: 11/16/2022] Open
Abstract
The purpose is to systematically review randomised controlled trials (RCTs) to change family physicians’ laboratory test-ordering. We searched 15 electronic databases (no language/date limitations). We identified 29 RCTs (4,111 physicians, 175,563 patients). Six studies specifically focused on reducing unnecessary tests, 23 on increasing screening tests. Using Cochrane methodology 48.5% of studies were low risk-of-bias for randomisation, 7% concealment of randomisation, 17% blinding of participants/personnel, 21% blinding outcome assessors, 27.5% attrition, 93% selective reporting. Only six studies were low risk for both randomisation and attrition. Twelve studies performed a power computation, three an intention-to-treat analysis and 13 statistically controlled clustering. Unweighted averages were computed to compare intervention/control groups for tests assessed by >5 studies. The results were that fourteen studies assessed lipids (average 10% more tests than control), 14 diabetes (average 8% > control), 5 cervical smears, 2 INR, one each thyroid, fecal occult-blood, cotinine, throat-swabs, testing after prescribing, and urine-cultures. Six studies aimed to decrease test groups (average decrease 18%), and two to increase test groups. Intervention strategies: one study used education (no change): two feedback (one 5% increase, one 27% desired decrease); eight education + feedback (average increase in desired direction >control 4.9%), ten system change (average increase 14.9%), one system change + feedback (increases 5-44%), three education + system change (average increase 6%), three education + system change + feedback (average 7.7% increase), one delayed testing. The conclusions are that only six RCTs were assessed at low risk of bias from both randomisation and attrition. Nevertheless, despite methodological shortcomings studies that found large changes (e.g. >20%) probably obtained real change.
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Affiliation(s)
- Roger Edmund Thomas
- Department of Family Medicine, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Marcus Vaska
- Knowledge Resource Service, Holy Cross Centre, Calgary, Alberta, Canada
| | - Christopher Naugler
- Department of Family Medicine, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada.,Departments of Pathology & Laboratory Medicine, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Tanvir Turin Chowdhury
- Department of Family Medicine, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
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Elnenaei MO, Campbell SG, Thoni AJ, Lou A, Crocker BD, Nassar BA. An effective utilization management strategy by dual approach of influencing physician ordering and gate keeping. Clin Biochem 2016; 49:208-12. [DOI: 10.1016/j.clinbiochem.2015.11.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Revised: 11/03/2015] [Accepted: 11/05/2015] [Indexed: 10/22/2022]
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Seppänen K, Kauppila T, Pitkälä K, Kautiainen H, Puustinen R, Iivanainen A, Mäki T. Altering a computerized laboratory test order form rationalizes ordering of laboratory tests in primary care physicians. Int J Med Inform 2016; 86:49-53. [DOI: 10.1016/j.ijmedinf.2015.11.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2015] [Revised: 11/25/2015] [Accepted: 11/26/2015] [Indexed: 10/22/2022]
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Morgan S, Henderson KM, Tapley A, Scott J, Van Driel ML, Spike NA, Mcarthur LA, Davey AR, Oldmeadow C, Ball J, Magin PJ. Pathology test-ordering behaviour of Australian general practice trainees: a cross-sectional analysis. Int J Qual Health Care 2015; 27:528-35. [DOI: 10.1093/intqhc/mzv086] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2015] [Indexed: 12/16/2022] Open
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Thomas RE, Vaska M, Naugler C, Turin TC. Interventions at the laboratory level to reduce laboratory test ordering by family physicians: Systematic review. Clin Biochem 2015; 48:1358-65. [PMID: 26436568 DOI: 10.1016/j.clinbiochem.2015.09.014] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Revised: 09/29/2015] [Accepted: 09/29/2015] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To assess the effectiveness of interventions by laboratories and to increase rational and reduce unnecessary family physician test ordering. DESIGN AND METHODS MEDLINE [1946-present], EMBASE [1980-present], EBM Reviews [1991-present](Cochrane Database of Systematic Reviews, ACP Journal Club, Database of Abstracts of Reviews of Effects, - Cochrane Central Register of Controlled Trials, Cochrane Methodology Register, Health Technology Assessment, NHS Economic Evaluation Database), PubMed [1966-present], PubMed Central [1900-present], Scopus [1960-present], Web of Science [1900-present] and CINAHL [1982-present] were searched with no language or publication limits. Non-randomised studies were assessed with the Newcastle-Ottawa scale. RESULTS The search identified 9282 titles and abstracts, 238 were read in full-text and 3 cohort and 7 before- and after-studies were included. Most focused on changing a few tests and evaluated the interventions over several months. Seven changed laboratory forms (the two largest involved 5.2 million and 3.2 million tests), one negotiated a test ordering protocol with family physicians, and two required laboratory approval. They achieved an average 35% reduction in the 19 targeted tests, with a wide range (0%-100% reduction). CONCLUSIONS Ten studies were identified which tested interventions by laboratories to reduce test ordering by family physicians, and achieved an average 35% reduction in the 19 targeted tests. The rationale for choosing specific tests for intervention was often not explained, most studies targeted a few tests for several months, the tests and test volumes differed widely across studies, no author improved the results of previous interventions or asked participants their opinions about the intervention or assessed factors impeding change.
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Affiliation(s)
- Roger E Thomas
- Department of Family Medicine, Faculty of Medicine, University of Calgary, Calgary, Alberta T2N 4N1, Canada.
| | - Marcus Vaska
- Knowledge Resource Service, Holy Cross Centre, Room 615A, 2210 2nd St. S.W., Calgary, Alberta T2S 3C3, Canada,.
| | - Christopher Naugler
- Department of Pathology & Laboratory Medicine and Family Medicine, Faculty of Medicine, University of Calgary, Calgary, Alberta T2N 4N1, Canada; Department of Family Medicine, Faculty of Medicine, University of Calgary, Calgary, Alberta T2N 4N1, Canada.
| | - Tanvir C Turin
- Department of Family Medicine, Faculty of Medicine, University of Calgary, Calgary, Alberta T2N 4N1, Canada.
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Pedersen A, Vedsted P. General practitioners' anticipated risk of cancer at referral and their attitude to risk taking and to their role as gatekeeper. J Health Serv Res Policy 2015; 20:210-6. [PMID: 26377726 DOI: 10.1177/1355819615601822] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES General practitioners have to deal with situations characterized by real but low likelihoods of serious illness. We aimed to investigate variations in general practitioners' anticipated risk of cancer when referring a patient and associations both with general practitioners' attitudes to risk taking and with their gatekeeper role. METHODS In January 2012, all 835 active general practitioners in the county of Aarhus, Denmark, received a questionnaire including the Physician Reaction to Uncertainty scale, The Tolerance for Ambiguity scale, the Physician Risk Attitude scale and a number of single items assessing anticipated risk of cancer when referring a hypothetical 50-year-old patient, use of intuition and perception of their role as a gatekeeper. RESULTS A total of 568 (68.0%) practitioners completed and returned the questionnaire. The median anticipated risk of cancer was 30% (inter-quartile range: 15%-50%) and the 5%-95% centiles were 5% and 80%. Increasing tolerance for ambiguity was strongly related to a declining anticipated risk of cancer. None of the other risk attitudes were associated with the anticipated risk of cancer at referral. Increased general practitioners' age was related to increased anticipated risk of cancer when referring (25% for general practitioners under 45 years to 43% for those 60 years or over) but not statistically important. CONCLUSIONS General practitioners either overestimate the risk of cancer when referring for suspected cancer or they appear to need to be very sure of the cancer diagnosis before referral. Further, focus on tolerance for ambiguity should be included in the education of general practitioners.
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Affiliation(s)
- Anette Pedersen
- Postdoctoral Researcher, Research Centre for Cancer Diagnosis in Primary Care, Research Unit for General Practice, Aarhus University, Denmark
| | - Peter Vedsted
- Professor, Research Centre for Cancer Diagnosis in Primary Care, Research Unit for General Practice, Aarhus University, Denmark
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Bussières AE, Al Zoubi F, Quon JA, Ahmed S, Thomas A, Stuber K, Sajko S, French S. Fast tracking the design of theory-based KT interventions through a consensus process. Implement Sci 2015; 10:18. [PMID: 25880218 PMCID: PMC4330935 DOI: 10.1186/s13012-015-0213-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Accepted: 01/24/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite available evidence for optimal management of spinal pain, poor adherence to guidelines and wide variations in healthcare services persist. One of the objectives of the Canadian Chiropractic Guideline Initiative is to develop and evaluate targeted theory- and evidence-informed interventions to improve the management of non-specific neck pain by chiropractors. In order to systematically develop a knowledge translation (KT) intervention underpinned by the Theoretical Domains Framework (TDF), we explored the factors perceived to influence the use of multimodal care to manage non-specific neck pain, and mapped behaviour change techniques to key theoretical domains. METHODS Individual telephone interviews exploring beliefs about managing neck pain were conducted with a purposive sample of 13 chiropractors. The interview guide was based upon the TDF. Interviews were digitally recorded, transcribed verbatim and analysed by two independent assessors using thematic content analysis. A 15-member expert panel formally met to design a KT intervention. RESULTS Nine TDF domains were identified as likely relevant. Key beliefs (and relevant domains of the TDF) included the following: influence of formal training, colleagues and patients on clinicians (Social Influences); availability of educational material (Environmental Context and Resources); and better clinical outcomes reinforcing the use of multimodal care (Reinforcement). Facilitating factors considered important included better communication (Skills); audits of patients' treatment-related outcomes (Behavioural Regulation); awareness and agreement with guidelines (Knowledge); and tailoring of multimodal care (Memory, Attention and Decision Processes). Clinicians conveyed conflicting beliefs about perceived threats to professional autonomy (Social/Professional Role and Identity) and speed of recovery from either applying or ignoring the practice recommendations (Beliefs about Consequences). The expert panel mapped behaviour change techniques to key theoretical domains and identified relevant KT strategies and modes of delivery to increase the use of multimodal care among chiropractors. CONCLUSIONS A multifaceted KT educational intervention targeting chiropractors' management of neck pain was developed. The KT intervention consisted of an online education webinar series, clinical vignettes and a video underpinned by the Brief Action Planning model. The intervention was designed to reflect key theoretical domains, behaviour change techniques and intervention components. The effectiveness of the proposed intervention remains to be tested.
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Affiliation(s)
- André E Bussières
- School of Physical and Occupational Therapy, Faculty of Medicine, McGill University, 3630 Promenade Sir-William-Osler, H3G 1Y5, Montreal, QC, Canada.
- Département chiropratique, Université du Québec à Trois-Rivières, Trois-Rivières, QC, Canada.
- Centre de recherche interdisciplinaire en réadaptation (CRIR), Montréal, QC, Canada.
| | - Fadi Al Zoubi
- School of Physical and Occupational Therapy, Faculty of Medicine, McGill University, 3630 Promenade Sir-William-Osler, H3G 1Y5, Montreal, QC, Canada.
| | - Jeffrey A Quon
- School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.
- International Collaboration on Repair Discoveries (ICORD), Vancouver Coastal Health Research Institute, Vancouver, BC, Canada.
- Spine Program, Department of Orthopaedics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.
| | - Sara Ahmed
- School of Physical and Occupational Therapy, Faculty of Medicine, McGill University, 3630 Promenade Sir-William-Osler, H3G 1Y5, Montreal, QC, Canada.
- Centre de recherche interdisciplinaire en réadaptation (CRIR), Montréal, QC, Canada.
- Clinical Epidemiology, McGill University Health Center, Montréal, QC, Canada.
| | - Aliki Thomas
- School of Physical and Occupational Therapy, Faculty of Medicine, McGill University, 3630 Promenade Sir-William-Osler, H3G 1Y5, Montreal, QC, Canada.
- Centre de recherche interdisciplinaire en réadaptation (CRIR), Montréal, QC, Canada.
- Center for Medical Education, Faculty of Medicine, McGill University, Montréal, QC, Canada.
| | - Kent Stuber
- Division of Graduate Education and Research, Canadian Memorial Chiropractic College, Toronto, ON, Canada.
| | | | - Simon French
- School of Rehabilitation Therapy, Faculty of Health Sciences, Queen's University, Kingston, ON, Canada.
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Gómez-Sáez N, González-Álvarez I, Vilar J, Hernández-Aguado I, Domingo ML, Lorente MF, Pastor-Valero M, Parker LA, Picazo N, Calbo J, Lumbreras B. Prevalence and variables associated with solitary pulmonary nodules in a routine clinic-based population: a cross-sectional study. Eur Radiol 2014; 24:2174-82. [PMID: 24962823 PMCID: PMC4126995 DOI: 10.1007/s00330-014-3249-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2013] [Revised: 05/06/2014] [Accepted: 05/15/2014] [Indexed: 12/19/2022]
Abstract
Objective To determine the prevalence of solitary pulmonary nodules (SPNs) in chest radiology studies and patient’s features associated with malignancy in a non-high-risk clinical population. Methods Patients ≥35 years were referred for thoracic imaging in two hospitals (2010-2011). Eight radiologists determined the presence and characteristics of SPN. Selected variables were collected from radiological register and medical records. Observer agreement in the diagnosis of SPN was assessed. Results 25,529 patients were included: 23,102 (90.5 %) underwent chest radiograph and 2,497 (9.5 %) a CT. The prevalence of SPN was 2.1 % (95 % CI 1.9 – 2.3) in radiographs and 17.0 % (95 % CI 15.5 – 18.5) in CT. In patients undergoing chest radiograph, detection of SPN with an irregular border was more frequent among smokers. In patients who had a CT, larger SPNs appeared to be associated with 60 years of age or over, diagnosis of a respiratory illness, or male gender. In addition, an irregular border was also more common among men. Conclusions The prevalence of SPNs detected by both radiograph and CT was lower than that shown in screening studies. Patient characteristics such as age, sex, respiratory disease, or smoking habit were associated with nodule characteristics that are known to be related with malignancy. Key Points • There is a lower SPN prevalence in the clinical population than in screening studies. • SPN prevalence is associated with some patient characteristics: sex, age, imaging test. • Nodule characteristics related to malignancy were associated with some patient characteristics.
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Affiliation(s)
- N. Gómez-Sáez
- Public Health Department, Miguel Hernández University, Alicante, Spain
| | | | - J. Vilar
- Radiodiagnostic Department, Peset Hospital, Valencia, Spain
| | - I. Hernández-Aguado
- Public Health Department, Miguel Hernández University, Alicante, Spain
- Ciber en Epidemiología y Salud Pública, Barcelona, Spain
| | - M. L. Domingo
- Radiodiagnostic Department, Peset Hospital, Valencia, Spain
| | - M. F. Lorente
- Radiodiagnostic Department, San Juan Hospital, Alicante, Spain
| | - M. Pastor-Valero
- Public Health Department, Miguel Hernández University, Alicante, Spain
- Ciber en Epidemiología y Salud Pública, Barcelona, Spain
| | - L. A. Parker
- Public Health Department, Miguel Hernández University, Alicante, Spain
- Ciber en Epidemiología y Salud Pública, Barcelona, Spain
| | - N. Picazo
- Radiodiagnostic Department, San Juan Hospital, Alicante, Spain
| | - J. Calbo
- Radiodiagnostic Department, San Juan Hospital, Alicante, Spain
| | - B. Lumbreras
- Public Health Department, Miguel Hernández University, Alicante, Spain
- Ciber en Epidemiología y Salud Pública, Barcelona, Spain
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Temporal growth and geographic variation in the use of laboratory tests by NHS general practices: using routine data to identify research priorities. Br J Gen Pract 2014; 63:e256-66. [PMID: 23540482 DOI: 10.3399/bjgp13x665224] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Laboratory tests are extensively used for diagnosis and monitoring in UK primary care. Test usage by GPs, and associated costs, have grown substantially in recent years. AIM This study aimed to quantify temporal growth and geographic variation in utilisation of laboratory tests. DESIGN AND SETTING Retrospective cohort study using data from general practices in the UK. METHOD Data from the General Practice Research Database, including patient demographics, clinical details, and laboratory test results, were used to estimate rates of change in utilisation between 2005 and 2009, and identify tests with greatest inter-regional variation, by fitting random-effects Poisson regression models. The study also investigated indications for test requests, using diagnoses and symptoms recorded in the 2 weeks before each test. RESULTS Around 660 000 tests were recorded in 230 000 person-years of follow-up. Test use increased by 24.2%, from 23 872 to 29 644 tests per 10 000 person-years, between 2005 and 2009. Tests with the largest increases were faecal occult blood (121%) and C-reactive protein (86%). There was substantial geographic variation in test utilisation; GPs in some regions requested tests such as plasma viscosity and cardiac enzymes at a rate more than three times the national average. CONCLUSION Increases in the use of laboratory tests have substantial resource implications. Rapid increases in particular tests may be supported by evidence-based guidelines, but these are often vague about who should be tested, how often, and for how long. Substantial regional variation in test use may reflect uncertainty about diagnostic accuracy and appropriate indications for the laboratory test. There is a need for further research on the diagnostic accuracy, therapeutic impact, and effect on patient health outcomes of the most rapidly increasing and geographically variable tests.
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Abstract
Demand for laboratory testing is increasing disproportionately to medical activity, and the tests involved are becoming increasingly complex. When this phenomenon is seen in parallel with declining teaching of laboratory medicine in the medical curriculum, a need emerges to manage demand to avoid unnecessary expenditure and improve the use of laboratory services: 'the right test in the right patient at the right time.' Various methods have been tried to manage demand, with success depending on the medical context, type of health service and preintervention situation. Because many factors contribute to demand, and the different settings in which these exist, it is not realistic to meta-analyse the studies and we are limited to trying to identify trends in results in particular situations. The studies suggest that education combined with facilitating interventions, such as feedback, prompts and changes to laboratory request forms are the most successful. From the perspective of a whole health service, it is important that results are not exaggerated by assessing benefits in terms of total rather than marginal cost. It would be desirable, although difficult, to include the impact on downstream clinical activity caused or avoided by the interventions. Advances in information and web technology may make the elusive goal of achieving substantial demand control more achievable.
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Affiliation(s)
- W S A Smellie
- Department of Chemical Pathology, Bishop Auckland General Hospital, Cockton Hill Road, Bishop Auckland, County Durham DL14 6AD, UK.
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Prevedello LM, Raja AS, Zane RD, Sodickson A, Lipsitz S, Schneider L, Hanson R, Mukundan S, Khorasani R. Variation in use of head computed tomography by emergency physicians. Am J Med 2012; 125:356-64. [PMID: 22325235 DOI: 10.1016/j.amjmed.2011.06.023] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2011] [Revised: 06/23/2011] [Accepted: 06/24/2011] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Variation in emergency department head computed tomography (CT) use in patients with atraumatic headaches between hospitals is being measured nationwide. However, the magnitude of interphysician variation within a hospital is currently unknown. We hypothesized that there was significant variation in the rates of physician head CT use, both overall and for patients diagnosed with atraumatic headaches. METHODS This cross-sectional study was conducted in the emergency department of a large urban academic hospital, and institutional review board approval was obtained. All emergency department visits from 2009 were analyzed, and the primary outcome measure was whether or not head CT was performed. Logistic regression was used to control for patient, physician, and visit characteristics potentially associated with head CT ordering. The degree of interphysician variability was tested, both before and after controlling for these variables. RESULTS Of 55,286 emergency department patient encounters, 4919 (8.9%) involved head CT examinations. Unadjusted head CT ordering rates per physician ranged from 4.4% to 16.9% overall and from 15.2% to 61.7% in patients diagnosed with atraumatic headaches, with both rates varying significantly between physicians. Two-fold variation in head CT ordering overall (6.5%-13.5%) and approximately 3-fold variation in head CT ordering for atraumatic headaches (21.2%-60.1%) persisted even after controlling for pertinent variables. CONCLUSION Emergency physicians vary significantly in their use of head CT both overall and in patients with atraumatic headaches. Further studies are needed to identify strategies to reduce interphysician variation in head CT use.
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Affiliation(s)
- Luciano M Prevedello
- Center for Evidence-Based Imaging, Brigham and Women's Hospital, Boston, Mass., USA.
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Munkerud SF. Decision-making in general practice: the effect of financial incentives on the use of laboratory analyses. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2012; 13:169-180. [PMID: 21213118 DOI: 10.1007/s10198-010-0295-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2010] [Accepted: 12/22/2010] [Indexed: 05/30/2023]
Abstract
This paper examines the reaction of general practitioners (GPs) to a reform in 2004 in the remuneration system for using laboratory services in general practice. The purpose of this paper is to study whether income motivation exists regarding the use of laboratory services in general practice, and if so, the degree of income motivation among general practitioners (GPs) in Norway. We argue that the degree of income motivation is stronger when the physicians are uncertain about the utility of the laboratory service in question. We have panel data from actual physician-patient encounters in general practices in the years 2001-2004 and use discrete choice analysis and random effects models. Estimation results show that an increase in the fees will lead to a small but significant increase in use. The reform led to minor changes in the use of laboratory analyses in GPs' offices, and we argue that financial incentives were diluted because they were in conflict with medical recommendations and existing medical practice. The patient's age has the most influence and the results support the hypothesis that the impact of income increases with increasing uncertainty about diagnosis and treatment. The policy implication of our results is that financial incentives alone are not an effective tool for influencing the use of laboratory services in GPs' offices.
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Schellart AJM, Steenbeek R, Mulders HPG, Anema JR, Kroneman H, Besseling JJM. Can self-reported disability assessment behaviour of insurance physicians be explained? Applying the ASE model. BMC Public Health 2011; 11:576. [PMID: 21771326 PMCID: PMC3155499 DOI: 10.1186/1471-2458-11-576] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2010] [Accepted: 07/19/2011] [Indexed: 12/02/2022] Open
Abstract
Background Very little is known about the attitudes and views that might underlie and explain the variation in occupational disability assessment behaviour between insurance physicians. In an earlier study we presented an adjusted ASE model (Attitude, Social norm, Self-efficacy) to identify the determinants of the disability assessment behaviour among insurance physicians. The research question of this study is how Attitude, Social norm, Self-efficacy and Intention shape the behaviour that insurance physicians themselves report with regard to the process (Behaviour: process) and content of the assessment (Behaviour: assessment) while taking account of Knowledge and Barriers. Methods This study was based on 231 questionnaires filled in by insurance physicians, resulting into 48 scales and dimension scores. The number of variables was reduced by a separate estimation of each of the theoretical ASE constructs as a latent variable in a measurement model. The saved factor scores of these latent variables were treated as observed variables when we estimated a path model with Lisrel to confirm the ASE model. We estimated latent ASE constructs for most of the assigned scales and dimensions. All could be described and interpreted. We used these constructs to build a path model that showed a good fit. Results Contrary to our initial expectations, we did not find direct effects for Attitude on Intention and for Intention on self reported assessment behaviour in the model. This may well have been due to the operationalization of the concept of 'Intention'. We did, however, find that Attitude had a positive direct effect on Behaviour: process and Behaviour: Assessment and that Intention had a negative direct effect on Behaviour: process. Conclusion A path model pointed to the existence of relationships between Attitude on the one hand and self-reported behaviour by insurance physicians with regard to process and content of occupational disability assessments on the other hand. In addition, Intention was only related to the self reported behaviour with regard to the process of occupational disability assessments. These findings provide some evidence of the relevance of the ASE model in this setting. Further research is needed to determine whether the ASE variables measured for insurance physicians are related to the real practice outcomes of occupational disability assessments.
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Affiliation(s)
- Antonius J M Schellart
- VU University Medical Center, Department of Public and Occupational Health, EMGO Institute for Health and Care Research, Amsterdam, the Netherlands.
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Steenbeek R, Schellart AJ, Mulders H, Anema JR, Kroneman H, Besseling J. The development of instruments to measure the work disability assessment behaviour of insurance physicians. BMC Public Health 2011; 11:1. [PMID: 21199570 PMCID: PMC3086528 DOI: 10.1186/1471-2458-11-1] [Citation(s) in RCA: 250] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2010] [Accepted: 01/03/2011] [Indexed: 11/21/2022] Open
Abstract
Background Variation in assessments is a universal given, and work disability assessments by insurance physicians are no exception. Little is known about the considerations and views of insurance physicians that may partly explain such variation. On the basis of the Attitude - Social norm - self Efficacy (ASE) model, we have developed measurement instruments for assessment behaviour and its determinants. Methods Based on theory and interviews with insurance physicians the questionnaire included blocks of items concerning background variables, intentions, attitudes, social norms, self-efficacy, knowledge, barriers and behaviour of the insurance physicians in relation to work disability assessment issues. The responses of 231 insurance physicians were suitable for further analysis. Factor analysis and reliability analysis were used to form scale variables and homogeneity analysis was used to form dimension variables. Thus, we included 169 of the 177 original items. Results Factor analysis and reliability analysis yielded 29 scales with sufficient reliability. Homogeneity analysis yielded 19 dimensions. Scales and dimensions fitted with the concepts of the ASE model. We slightly modified the ASE model by dividing behaviour into two blocks: behaviour that reflects the assessment process and behaviour that reflects assessment behaviour. The picture that emerged from the descriptive results was of a group of physicians who were motivated in their job and positive about the Dutch social security system in general. However, only half of them had a positive opinion about the Dutch Work and Income (Capacity for Work) Act (WIA). They also reported serious barriers, the most common of which was work pressure. Finally, 73% of the insurance physicians described the majority of their cases as 'difficult'. Conclusions The scales and dimensions developed appear to be valid and offer a promising basis for future research. The results suggest that the underlying ASE model, in modified form, is suitable for describing the assessment behaviour of insurance physicians and the determinants of this behaviour. The next step in this line of research should be to validate the model using structural equation modelling. Finally, the predictive value should be tested in relation to outcome measurements of work disability assessments.
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Affiliation(s)
- Romy Steenbeek
- TNO Work and Employment, PO Box 718, 2130 AS Hoofddorp, the Netherlands.
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Tosetti C, Bellentani S, Benedetto E, Ubaldi E, Cardin F, Bozzani A. The management of patients with new onset of upper gastro-intestinal symptoms in primary care. Dig Liver Dis 2010; 42:860-4. [PMID: 20558116 DOI: 10.1016/j.dld.2010.05.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2009] [Revised: 04/14/2010] [Accepted: 05/06/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND Data dealing with dyspepsia management in general practice are lacking, and most of the studies investigated a subset of patients with suspected peptic ulcer disease either with or without previous complaints. AIMS To evaluate the one-year management of patients presenting new onset upper abdominal symptoms without alarming features. METHODS 275 patients were enrolled by 63 Italian general practitioners. RESULTS Referral to upper gastro-intestinal tract endoscopy resulted significantly higher in patients with predominant epigastric pain compared to subjects with non-painful symptoms or non-dominant symptoms. Amongst drug therapies, only prokinetics and antacids and anti-secretory therapies were prescribed differently amongst clinical subgroups. The rate and type of management and referrals resulted were not influenced by the age of patients or the use of anti-inflammatory drugs. The most frequent diagnosis at one-year follow-up was reflux oesophagitis. The absence of organic disease was less frequent in patients with dominant epigastric pain than non-painful or non-dominant symptoms. CONCLUSION The management of these patients in primary care in Italy is mainly determined by clinical presentation, independent of age. Any judgement about appropriateness of the treatment should consider not only conventional features such as age, but the more complex individual frameworks as well.
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Affiliation(s)
- Cesare Tosetti
- Primary Care Gastroenterology Study Group of the Italian Society of Gastroenterology (SIGE), Italy.
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Janssens PM. Managing the demand for laboratory testing: Options and opportunities. Clin Chim Acta 2010; 411:1596-602. [DOI: 10.1016/j.cca.2010.07.022] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2010] [Revised: 07/17/2010] [Accepted: 07/18/2010] [Indexed: 11/29/2022]
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Dalemo S, Hjerpe P, Ohlsson H, Eggertsen R, Merlo J, Boström KB. Variation in plasma calcium analysis in primary care in Sweden--a multilevel analysis. BMC FAMILY PRACTICE 2010; 11:43. [PMID: 20509973 PMCID: PMC2889884 DOI: 10.1186/1471-2296-11-43] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/09/2009] [Accepted: 05/30/2010] [Indexed: 11/26/2022]
Abstract
Background Primary hyperparathyroidism (pHPT) is a common disease that often remains undetected and causes severe disturbance especially in postmenopausal women. Therefore, national recommendations promoting early pHPT detection by plasma calcium (P-Ca) have been issued in Sweden. In this study we aimed to investigate variation of P-Ca analysis between physicians and health care centres (HCCs) in primary care in county of Skaraborg, Sweden. Methods In this cross sectional study of patients' records during 2005 we analysed records from 154 629 patients attending 457 physicians at 24 HCCs. We used multilevel logistic regression analysis (MLRA) and adjusted for patient, physician and HCC characteristics. Differences were expressed as median odds ratio (MOR). Results There was a substantial variation in number of P-Ca analyses between both HCCs (MORHCC 1.65 [1.44-2.07]) and physicians (MORphysician 1.95 [1.85-2.08]). The odds for a P-Ca analysis were lower for male patients (OR 0.80 [0.77-0.83]) and increased with the number of diagnoses (OR 25.8 [23.5-28.5]). Sex of the physician had no influence on P-Ca test ordering (OR 0.93 [0.78-1.09]). Physicians under education ordered most P-Ca analyses (OR 1.69 [1.35-2.24]) and locum least (OR 0.73 [0.57-0.94]). More of the variance was attributed to the physician level than the HCC level. Different mix of patients did not explain this variance between physicians. Theoretically, if a patient were able to change both GP and HCC, the odds of a P-Ca analysis would in median increase by 2.45. Including characteristics of the patients, physicians and HCCs in the MLRA model did not explain the variance. Conclusions The physician level was more important than the HCC level for the variation in P-Ca analysis, but further exploration of unidentified contextual factors is crucial for future monitoring of practice variation.
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Affiliation(s)
- Sofia Dalemo
- Dept of Public Health and Community Medicine/Primary Health Care, Sahlgrenska academy Gothenburg University, PO Box 454, SE-405 30 Gothenburg, Sweden.
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Houben PHH, van der Weijden T, Winkens B, Winkens RAG, Grol RPTM. Pretest expectations strongly influence interpretation of abnormal laboratory results and further management. BMC FAMILY PRACTICE 2010; 11:13. [PMID: 20158908 PMCID: PMC2829524 DOI: 10.1186/1471-2296-11-13] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/31/2009] [Accepted: 02/16/2010] [Indexed: 11/10/2022]
Abstract
Background Abnormal results of diagnostic laboratory tests can be difficult to interpret when disease probability is very low. Although most physicians generally do not use Bayesian calculations to interpret abnormal results, their estimates of pretest disease probability and reasons for ordering diagnostic tests may - in a more implicit manner - influence test interpretation and further management. A better understanding of this influence may help to improve test interpretation and management. Therefore, the objective of this study was to examine the influence of physicians' pretest disease probability estimates, and their reasons for ordering diagnostic tests, on test result interpretation, posttest probability estimates and further management. Methods Prospective study among 87 primary care physicians in the Netherlands who each ordered laboratory tests for 25 patients. They recorded their reasons for ordering the tests (to exclude or confirm disease or to reassure patients) and their pretest disease probability estimates. Upon receiving the results they recorded how they interpreted the tests, their posttest probability estimates and further management. Logistic regression was used to analyse whether the pretest probability and the reasons for ordering tests influenced the interpretation, the posttest probability estimates and the decisions on further management. Results The physicians ordered tests for diagnostic purposes for 1253 patients; 742 patients had an abnormal result (64%). Physicians' pretest probability estimates and their reasons for ordering diagnostic tests influenced test interpretation, posttest probability estimates and further management. Abnormal results of tests ordered for reasons of reassurance were significantly more likely to be interpreted as normal (65.8%) compared to tests ordered to confirm a diagnosis or exclude a disease (27.7% and 50.9%, respectively). The odds for abnormal results to be interpreted as normal were much lower when the physician estimated a high pretest disease probability, compared to a low pretest probability estimate (OR = 0.18, 95% CI = 0.07-0.52, p < 0.001). Conclusions Interpretation and management of abnormal test results were strongly influenced by physicians' estimation of pretest disease probability and by the reason for ordering the test. By relating abnormal laboratory results to their pretest expectations, physicians may seek a balance between over- and under-reacting to laboratory test results.
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Affiliation(s)
- Paul H H Houben
- Department of General Practice, PMaastricht University, School of Public Health and Primary Care (CAPHRI), O Box 616, 6200 MD Maastricht, the Netherlands.
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Mindemark M, Larsson A. Long-term effects of an education programme on the optimal use of clinical chemistry testing in primary health care. Scandinavian Journal of Clinical and Laboratory Investigation 2009; 69:481-6. [PMID: 19340700 DOI: 10.1080/00365510902749123] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The aim of this study was to investigate whether continuing education on the optimal use of clinical chemistry testing in primary health care has had any long-term effects on the test-ordering behaviour of the participating physicians. METHODS The effects were monitored using 12 laboratory test ratios. Twenty-three general practitioners at 16 primary health-care centres in the county of Uppsala, Sweden, participated. A sign test was used to evaluate how individual physicians' test-ordering patterns have changed during the 8 years since implementation of the educational programme. Maintained or improved ratios were interpreted as a sustained effect on the primary health-care physician's test-ordering habits. RESULTS Eleven out of 12 of the investigated ratios were the same or improved since the time of the short-term follow-up 6 months after the education. CONCLUSION A short continuation course on optimal use of clinical chemistry assays can achieve permanent changes in the test-ordering patterns of primary health-care physicians. These findings highlight education as one possible means towards achieving cost-efficiency and quality in test-ordering.
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Affiliation(s)
- Mirja Mindemark
- Department of Clinical Chemistry, Akademiska sjukhuset, Uppsala, Sweden.
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Trietsch J, van der Weijden T, Verstappen W, Janknegt R, Muijrers P, Winkens R, van Steenkiste B, Grol R, Metsemakers J. A cluster randomized controlled trial aimed at implementation of local quality improvement collaboratives to improve prescribing and test ordering performance of general practitioners: study protocol. Implement Sci 2009; 4:6. [PMID: 19222840 PMCID: PMC2656449 DOI: 10.1186/1748-5908-4-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2008] [Accepted: 02/17/2009] [Indexed: 11/10/2022] Open
Abstract
Background The use of guidelines in general practice is not optimal. Although evidence-based methods to improve guideline adherence are available, variation in physician adherence to general practice guidelines remains relatively high. The objective for this study is to transfer a quality improvement strategy based on audit, feedback, educational materials, and peer group discussion moderated by local opinion leaders to the field. The research questions are: is the multifaceted strategy implemented on a large scale as planned?; what is the effect on general practitioners' (GPs) test ordering and prescribing behaviour?; and what are the costs of implementing the strategy? Methods In order to evaluate the effects, costs and feasibility of this new strategy we plan a multi-centre cluster randomized controlled trial (RCT) with a balanced incomplete block design. Local GP groups in the south of the Netherlands already taking part in pharmacotherapeutic audit meeting groups, will be recruited by regional health officers. Approximately 50 groups of GPs will be randomly allocated to two arms. These GPs will be offered two different balanced sets of clinical topics. Each GP within a group will receive comparative feedback on test ordering and prescribing performance. The feedback will be discussed in the group and working agreements will be created after discussion of the guidelines and barriers to change. The data for the feedback will be collected from existing and newly formed databases, both at baseline and after one year. Discussion We are not aware of published studies on successes and failures of attempts to transfer to the stakeholders in the field a multifaceted strategy aimed at GPs' test ordering and prescribing behaviour. This pragmatic study will focus on compatibility with existing infrastructure, while permitting a certain degree of adaptation to local needs and routines. Trial registration Nederlands Trial Register ISRCTN40008171
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Affiliation(s)
- Jasper Trietsch
- Maastricht University, Dept. of General Practice, School for Public Health and Primary Care (CAPRHI), Maastricht, The Netherlands.
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Pearson SA, Ringland CL, Ward RL. Use of Trastuzumab for Metastatic Breast Cancer in Australia: Interpreting Findings From a Cohort of 1,469 Women on a National Access Program Versus 41 Women Treated by Two Medical Oncologists. J Clin Oncol 2007. [DOI: 10.1200/jco.2007.14.3099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | - Clare L. Ringland
- University of New South Wales, Prince of Wales Hospital, Sydney, Australia
| | - Robyn L. Ward
- University of New South Wales, Prince of Wales Hospital, Sydney, Australia
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Whiting P, Toerien M, de Salis I, Sterne JAC, Dieppe P, Egger M, Fahey T. A review identifies and classifies reasons for ordering diagnostic tests. J Clin Epidemiol 2007; 60:981-9. [PMID: 17884591 DOI: 10.1016/j.jclinepi.2007.01.012] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2006] [Revised: 12/20/2006] [Accepted: 01/19/2007] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To consider the reasons and context for test ordering by doctors when faced with an undiagnosed complaint in primary or secondary care. STUDY DESIGN AND SETTING We reviewed any study of any design that discussed factors that may affect a doctor's decision to order a test. Articles were located through searches of electronic databases, authors' files on diagnostic methodology, and reference lists of relevant studies. We extracted data on: study design, type of analysis, setting, topic area, and any factors reported to influence test ordering. RESULTS We included 37 studies. We carried out a thematic analysis to synthesize data. Five key groupings arose from this process: diagnostic factors, therapeutic and prognostic factors, patient-related factors, doctor-related factors, and policy and organization-related factors. To illustrate how the various factors identified may influence test ordering we considered the symptom low back pain and the diagnosis multiple sclerosis as examples. CONCLUSIONS A wide variety of factors influence a doctor's decision to order a test. These are integral to understanding diagnosis in clinical practice. Traditional diagnostic accuracy studies should be supplemented with research into the broader context in which doctors perform their work.
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Affiliation(s)
- Penny Whiting
- MRC Health Services Research Collaboration, Department of Social Medicine, Canynge Hall, Whiteladies Road, Bristol BS8 2PR, UK
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Research on Geographic Variations in Health Services Utilization in the United States: A Critical Review and Implications. HEALTH POLICY AND MANAGEMENT 2007. [DOI: 10.4332/kjhpa.2007.17.1.094] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Kwok J, Jones B. Unnecessary repeat requesting of tests: an audit in a government hospital immunology laboratory. J Clin Pathol 2005; 58:457-62. [PMID: 15858114 PMCID: PMC1770647 DOI: 10.1136/jcp.2004.021691] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Unnecessary repeat requesting of tests can make up a large proportion of a laboratory's workload. This audit set out to establish the size of this problem and to identify the circumstances under which these repeat requests were made in a government tertiary hospital immunology laboratory. The numbers of tests for immunoglobulin measurement, common autoantibodies, and tumour markers that were repeated over a 12 month period were analysed by interrogating the Delphic laboratory computer system using a management information system for raw data enquiry protocol. Repeat requests within 12 weeks of a previous request made up 16.78% of the total workload. The total cost of the tests was estimated at 132 151 US dollars. The waste of technician time and reagents as a result of unnecessary repeat testing is excessive. Many of these tests might be eliminated with the use of interventions such as computerised reminders.
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Affiliation(s)
- J Kwok
- Clinical Immunology Division, Department of Pathology, Queen Mary Hospital, Pokfulam Road, Hong Kong.
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