Exploring the black box of change in improving test-ordering routines

Does admission order form design really matter? A reduction in urea blood test ordering

Introduction

Laboratory blood testing is one of the most high-volume medical procedures and continues to increase steadily with instances of inappropriate testing resulting in significant financial implications. Studies have suggested that the design of a standard hospital admission order form and laboratory request forms influence physician test ordering behaviour, reducing inappropriate ordering and promoting resource stewardship.

Aim/method

To redesign the standard medicine admission order form-laboratory request section to reduce inappropriate blood urea nitrogen (BUN) testing.

Results

A redesign of the standard admission order form used by general internal medicine physicians and residents in two large teaching hospitals in one health zone in Alberta, Canada led to a significant step reduction in the ordering of the BUN test on hospital admission.

Conclusions

Redesigning the standard medicine admission order form-laboratory request section can have a beneficial effect on the reduction in BUN ordering altering physician ordering patterns and behaviour.

The effect of a test ordering software intervention on the prescription of unnecessary laboratory tests - a randomized controlled trial

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The intervention group had a modified software with a basic shortcut menu changes, where some tests were withdrawn or added, and with the implementation of an evidence-based decision support based on United States Preventive Services Task Force (USPSTF) recommendations.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The outcomes were the number of tests prescribed from those: withdrawn from the basic menu; added to the basic menu; marked with green dots (USPSTF’s grade A and B); and marked with red dots (USPSTF’s grade D).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the monthly average number of tests prescribed before and after the software modification, from those tests that were withdrawn from the basic menu, the control group prescribed 33.8 tests per 100 consultations before and 30.8 after (p = 0075); the intervention group prescribed 31.3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 1^st 2014 (retrospectively registered).

The effectiveness of interventions to improve laboratory requesting patterns among primary care physicians: a systematic review

Background

Laboratory testing is an integral part of day-to-day primary care practice, with approximately 30 % of patient encounters resulting in a request. However, research suggests that a large proportion of requests does not benefit patient care and is avoidable. The aim of this systematic review was to comprehensively search the literature for studies evaluating the effectiveness of interventions to improve primary care physician use of laboratory tests.

Methods

A search of PubMed, Cochrane Library, Embase and Scopus (from inception to 09/02/14) was conducted. The following study designs were considered: systematic reviews, randomised controlled trials (RCTs), controlled clinical trials (CCTs), controlled before and after studies (CBAs) and interrupted time series analysis (ITSs). Studies were quality appraised using a modified version of the Effective Practice and Organisation of Care (EPOC) checklist. The population of interest was primary care physicians. Interventions were considered if they aimed to improve laboratory testing in primary care. The outcome of interest was a volume of laboratory tests.

Results

In total, 6,166 titles and abstracts were reviewed, followed by 87 full texts. Of these, 11 papers were eligible for inclusion in the systematic review. This included four RCTs, six CBAs and one ITS study. The types of interventions examined included education, feedback, guidelines, education with feedback, feedback with guidelines and changing order forms. The quality of included studies varied with seven studies deemed to have a low risk of bias, three with unclear risk of bias and one with high risk of bias. All but one study found significant reductions in the volume of tests following the intervention, with effect sizes ranging from 1.2 to 60 %. Due to heterogeneity, meta-analysis was not performed.

Conclusions

Interventions such as educational strategies, feedback and changing test order forms may improve the efficient use of laboratory tests in primary care; however, the level of evidence is quite low and the quality is poor. The reproducibility of findings from different laboratories is also difficult to ascertain from the literature. Some standardisation of both interventions and outcome measures is required to enable formal meta-analysis.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-015-0356-4) contains supplementary material, which is available to authorized users.

Key factors influencing adoption of an innovation in primary health care: a qualitative study based on implementation theory

Background

Bridging the knowledge-to-practice gap in health care is an important issue that has gained interest in recent years. Implementing new methods, guidelines or tools into routine care, however, is a slow and unpredictable process, and the factors that play a role in the change process are not yet fully understood. There is a number of theories concerned with factors predicting successful implementation in various settings, however, this issue is insufficiently studied in primary health care (PHC). The objective of this article was to apply implementation theory to identify key factors influencing the adoption of an innovation being introduced in PHC in Sweden.

Methods

A qualitative study was carried out with staff at six PHC units in Sweden where a computer-based test for lifestyle intervention had been implemented. Two different implementation strategies, implicit or explicit, were used. Sixteen focus group interviews and two individual interviews were performed. In the analysis a theoretical framework based on studies of implementation in health service organizations, was applied to identify key factors influencing adoption.

Results

The theoretical framework proved to be relevant for studies in PHC. Adoption was positively influenced by positive expectations at the unit, perceptions of the innovation being compatible with existing routines and perceived advantages. An explicit implementation strategy and positive opinions on change and innovation were also associated with adoption. Organizational changes and staff shortages coinciding with implementation seemed to be obstacles for the adoption process.

Conclusion

When implementation theory obtained from studies in other areas was applied in PHC it proved to be relevant for this particular setting. Based on our results, factors to be taken into account in the planning of the implementation of a new tool in PHC should include assessment of staff expectations, assessment of the perceived need for the innovation to be implemented, and of its potential compatibility with existing routines. Regarding context, we suggest that implementation concurrent with other major organizational changes should be avoided. The choice of implementation strategy should be given thorough consideration.

GP and staff evaluation of the maturity matrix as a tool to assess and improve organisational development in primary care

PURPOSE

This paper aims to evaluate the maturity matrix (MM) a facilitated formative self-assessment tool for organisational development in primary care) on satisfaction, differences between GP and staff, the extent to which practice teams worked on goals set, and to identify suggestions for change to MM.

DESIGN/METHODOLOGY/APPROACH

The approach taken was a cross-sectional survey administered to all participants by mail in 57 family practices, 278 participants, (143 GPs; 135 staff) in Denmark, one year after participating in the MM project.

FINDINGS

At practice level 44 returned at least one questionnaire. At participant level, 144 returned the questionnaire: 82 GPs; 62 staff. A total of 93 gave positive statements on satisfaction with MM, 16 stated initial expectations were not met, 79 would recommend MM to colleagues. Differences between GPs and staff were only statistically significant regarding "increased insight into organisation of work after participation in the MM project". There was a tendency that GPs were more positive and likely to give an opinion. A total of 22 planned how to meet the goals set at the first MM meeting and 18 felt that they achieved them. In 24 out of 44 practices MM was stated to contribute new ways of working. A total of 12 of 144 stated that they needed more follow-up support.

PRACTICAL IMPLICATIONS

The results indicate that MM is a workable method to assess and gain insight into practice organisation with no major differences between GPs and staff.

ORIGINALITY/VALUE

The paper examines participants views' on MM one year after introduction.