scholarly journals Effect of a price display intervention on laboratory test ordering behavior of general practitioners

2021 ◽  
Vol 22 (1) ◽  
Author(s):  
Dennis M. J. Muris ◽  
Max Molenaers ◽  
Trang Nguyen ◽  
Paul W. M. P. Bergmans ◽  
Bernadette A. C. van Acker ◽  
...  
Keyword(s):  
Primary Care ◽  
The Netherlands ◽  
Laboratory Test ◽  
General Practitioners ◽  
Laboratory Tests ◽  
Future Research ◽  
Post Intervention ◽  
Diagnostic Laboratory ◽  
The Mean ◽  
Test Ordering

Abstract Background Redundant use of diagnostic tests in primary care has shown to be a contributor to rising Dutch healthcare costs. A price display in the test ordering system of the electronic health records (EHRs) could potentially be a low-cost and easy to implement intervention to a decrease in test ordering rate in the primary care setting by creating more cost-awareness among general practitioners (GPs). The aim of this study was to assess the effect of a price display for diagnostic laboratory tests in the EHR on laboratory test ordering behavior of GPs in the Westelijke Mijnstreek region in the Netherlands. Methods A pre-post intervention study among 154 GPs working in 57 general practices was conducted from September 2019, until March 2020, in the Netherlands. The intervention consisted of displaying the costs of 22 laboratory tests at the time of ordering. The primary outcome was the mean test ordering rate per 1.000 patients per month, per general practice. Results Test ordering rates were on average rising prior to the intervention. The total mean monthly test order volume showed a non-statistically significant interruption in this rising trend after the intervention, with the mean monthly test ordering rate levelling out from 322.4 to 322.2 (P = 0.86). A subgroup analysis for solely individually priced tests showed a statistically significant decrease in mean monthly test ordering rate after implementation of the price display for the sum of all tests from 67.2 to 63.3 (P = 0.01), as well as for some of these tests individually (i.e. thrombocytes, ALAT, TSH, folic acid). Leucocytes, ESR, vitamin B12, anti-CCP and NT-proBNP also showed a decrease, albeit not statistically significant (P > 0.05). Conclusions Our study suggests that a price display intervention is a simple tool that can alter physicians order behavior and constrain the expanding use of laboratory tests. Future research might consider alternative study designs and a longer follow-up period. Furthermore, in future studies, the combination with a multitude of interventions, like educational programs and feedback strategies, should be studied, while potentially adverse events caused by reduced testing should also be taken into consideration.

Laboratory Test Form Design Influences Test Ordering by General Practitioners in the Netherlands

Medical Care ◽  
1992 ◽  
Vol 30 (3) ◽  
pp. 189-198 ◽  
Author(s):  
Joost O.M. Zaat ◽  
Jacques Th.M. van Eijk ◽  
Harry A. Bonte
Keyword(s):  
The Netherlands ◽  
Laboratory Test ◽  
General Practitioners ◽  
Test Form ◽  
Form Design ◽  
Test Ordering

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

BJGP Open ◽  
2020 ◽  
pp. bjgpopen20X101146
Author(s):  
Claire Duddy ◽  
Geoff Wong
Keyword(s):  
Primary Care ◽  
Decision Making ◽  
Laboratory Testing ◽  
Laboratory Tests ◽  
Secondary Data ◽  
Realist Review ◽  
Future Research ◽  
Underlying Causes ◽  
Important Means ◽  
Test Ordering

Background: Existing research demonstrates significant variation in test-ordering practice, and growth in the use of laboratory tests in primary care. Reviews of interventions designed to change test-ordering practice report heterogeneity in design and effectiveness. Improving understanding of clinicians’ decision making in relation to laboratory testing is an important means of understanding practice patterns and developing theory-informed interventions. Aim: To develop explanations for the underlying causes of patterns of variation and increasing use of laboratory tests in primary care and make recommendations for future research and intervention design. Design and setting: Realist review of secondary data from primary care. Method: Diverse evidence including data from qualitative and quantitative studies was gathered via systematic and iterative searching processes. Data was synthesised according to realist principles to develop explanations accounting for clinicians’ decision-making in relation to laboratory tests. Results: 145 documents contributed data to the synthesis. Laboratory test ordering can fulfil many roles in primary care. Decisions about tests are incorporated into practice heuristics and tests are deployed as a tool to manage patient interactions. Ordering tests may be easier than not ordering tests in existing systems. Alongside high workloads and limited time to devote to decision-making, there is a common perception that laboratory tests are relatively inconsequential interventions. Clinicians prioritise efficiency over thoroughness in decision-making about laboratory tests. Conclusions: Interventions to change test-ordering practice can be understood as aiming to preserve efficiency or encourage thoroughness in decision-making. Intervention designs and evaluations should consider how testing decisions are made in real-world clinical practice.

scholarly journals 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

2020 ◽  
Vol 37 (6) ◽  
pp. 845-853
Author(s):  
Martha M C Elwenspoek ◽  
Lauren J Scott ◽  
Katharine Alsop ◽  
Rita Patel ◽  
Jessica C Watson ◽  
...  
Keyword(s):  
Primary Care ◽  
Health Care ◽  
Scoping Review ◽  
Laboratory Tests ◽  
Evidence Base ◽  
Future Research ◽  
Patient Harm ◽  
Long Term Conditions ◽  
Test Ordering

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.

Profile of General Practices in Malaysia

1998 ◽  
Vol 10 (2) ◽  
pp. 88-93
Author(s):  
Khoo Ee Ming ◽  
Christina Tan Phoay Lay
Keyword(s):  
Primary Care ◽  
General Practitioners ◽  
Laboratory Tests ◽  
Response Rate ◽  
Medical Practitioners ◽  
Community Activities ◽  
Postgraduate Qualification ◽  
General Practices ◽  
The Mean ◽  
Primary Care Medicine

In this survey all practices under the headings of “Clinics”, “Medical Practitioners” and “Medical Practitioners - Registered” in the Yellow Pages telephone directories for the thirteen states of Malaysia were selected. Those excluded were clinics or medical practitioners who advertised themselves as specialists in other disciplines. A total of 2291 practices were surveyed and a response rate of 51.2% was obtained. 383(33%) of the general practitioners were trained locally for the first degree. 258(22%) had at least one postgraduate qualification. 69(6%) possessed a postgraduate qualification in primary care medicine. About 80% of general practitioners participated in continuing medical education and 4% did research in the last 3 years. 42% were involved in community activities. 75% ran solo practices. Over 90% of the practices opened six or seven days a week. The mean workload per doctor per day was 44.66. Most practices provided a comprehensive range of services including curative, preventive, dispensing services, counselling, laboratory tests, and home visits. 43% of practices had a computer.

scholarly journals Clinical and Healthcare Improvement through My Health Record usage and Education in General Practice (CHIME-GP): A study protocol for a cluster-randomised controlled trial

2021 ◽  
Author(s):  
Andrew Bonney ◽  
Christine Metusela ◽  
Judy Mullan ◽  
Stephen Barnett ◽  
Joel Rhee ◽  
...  
Keyword(s):  
Primary Care ◽  
General Practice ◽  
General Practitioners ◽  
Educational Intervention ◽  
Digital Health ◽  
Health Record ◽  
Post Intervention ◽  
Record System ◽  
Cluster Randomised ◽  
Test Ordering

Abstract Background: There is international interest in whether improved primary care can lead to a more rational use of health resources and whether the use of a national digital health record system by primary health care professionals can help achieve this goal. This trial (CHIME-GP) will investigate whether a multifaceted education intervention in an Australian general practice setting on the use of a national digital health record system leads to reductions in health-service utilisation and costs.Methods: The trial will be undertaken in Australian general practices. The aim of the research is to evaluate the effectiveness of a web-based educational intervention for general practitioners, regarding use of a national digital health record system, My Health Record (MHR), and rational use of medicines, pathology and imaging. Our target is to recruit 120 general practitioners from urban and regional regions across Australia. We will use a mixed methods approach incorporating a three-arm pragmatic cluster randomised parallel trial and a prospective qualitative inquiry. The effect of the intervention in each arm will be assessed, using the other two arms as controls. The evaluation will synthesise the results embedding qualitative pre/post interviews in the quantitative results to investigate implementation of the intervention, clinical behaviour change and mechanisms such as attitudes, that may influence change. The primary outcome will be an economic analysis of the cost per 100 consultations of selected prescriptions, pathology and radiology test ordering in the six months following the intervention compared with six months prior to the intervention. Secondary outcome measures include the rates per 100 consultations of selected prescriptions, pathology and radiology test ordering six months pre and post intervention; and comparison of knowledge assessment tests pre and post intervention.Discussion: The trial will produce robust health economic analyses on the evidence on educational intervention in reducing unnecessary prescribing, pathology and imaging ordering, and in improving the use of MHR. In addition, the study will contribute to the evidence-base concerning the implementation of interventions to improve the quality of care in primary care practice.Trial registration: Australian New Zealand Clinical Trials Registry ACTRN12620000010998. Registered on 09 January 2020.http://www.ANZCTR.org.au/ACTRN12620000010998.aspx

scholarly journals Clinical and healthcare improvement through My Health Record usage and education in general practice (CHIME-GP): a study protocol for a cluster-randomised controlled trial

Trials ◽  
2021 ◽  
Vol 22 (1) ◽  
Author(s):  
Andrew Bonney ◽  
Christine Metusela ◽  
Judy Mullan ◽  
Stephen Barnett ◽  
Joel Rhee ◽  
...  
Keyword(s):  
Primary Care ◽  
General Practice ◽  
General Practitioners ◽  
Educational Intervention ◽  
Health Record ◽  
Post Intervention ◽  
Rational Use ◽  
Cluster Randomised ◽  
Test Ordering

Abstract Background There is an international interest in whether improved primary care can lead to a more rational use of health resources. There is evidence that educational interventions can lead to improvements in the quality of rational prescribing and test ordering. A new national platform for shared medical records in Australia, My Health Record (MHR), poses new opportunities and challenges for system-wide implementation. This trial (CHIME-GP) will investigate whether components of a multifaceted education intervention in an Australian general practice setting on rational prescribing and investigation ordering leads to reductions in health-service utilisation and costs in the context of the use of a national digital health record system. Methods The trial will be undertaken in Australian general practices. The aim of the research is to evaluate the effectiveness of components of a web-based educational intervention for general practitioners, regarding rational use of medicines, pathology and imaging in the context of the use of the MHR system. Our target is to recruit 120 general practitioners from urban and regional regions across Australia. We will use a mixed methods approach incorporating a three-arm pragmatic cluster randomised parallel trial and a prospective qualitative inquiry. The effect of each education component in each arm will be assessed, using the other two arms as controls. The evaluation will synthesise the results embedding qualitative pre/post interviews in the quantitative results to investigate implementation of the intervention, clinical behaviour change and mechanisms such as attitudes, that may influence change. The primary outcome will be an economic analysis of the cost per 100 consultations of selected prescriptions, pathology and radiology test ordering in the 6 months following the intervention compared with 6 months prior to the intervention. Secondary outcome measures include the rates per 100 consultations of selected prescriptions, pathology and radiology test ordering 6 months pre- and post-intervention, and comparison of knowledge assessment tests pre- and post-intervention. Discussion The trial will produce robust health economic analyses on the evidence on educational intervention in reducing unnecessary prescribing, pathology and imaging ordering, in the context of MHR. In addition, the study will contribute to the evidence-base concerning the implementation of interventions to improve the quality of care in primary care practice. Trial registration ClinicalTrials.gov ACTRN12620000010998. Registered on 09 January 2020 with the Australian New Zealand Clinical Trials Registry

scholarly journals Clinical decision support improves the appropriateness of laboratory test ordering in primary care without increasing diagnostic error: the ELMO cluster randomized trial

2020 ◽  
Author(s):  
Nicolas Delvaux ◽  
Veerle Piessens ◽  
Tine De Burghgraeve ◽  
Pavlos Mamouris ◽  
Bert Vaes ◽  
...  
Keyword(s):  
Primary Care ◽  
Decision Support ◽  
Laboratory Test ◽  
Clinical Decision Support ◽  
Clinical Decision ◽  
Diagnostic Error ◽  
Order Sets ◽  
Cluster Randomized ◽  
Physician Order Entry ◽  
Test Ordering

Abstract Background Inappropriate laboratory test ordering poses an important burden for healthcare. Clinical decision support systems (CDSS) have been cited as promising tools to improve laboratory test ordering behavior. The objectives of this study were to evaluate the effects of an intervention that integrated a clinical decision support service into a computerized physician order entry (CPOE) on the appropriateness and volume of laboratory test ordering, and on diagnostic error in primary care.Methods This study was a pragmatic, cluster randomized, open label, controlled clinical trial. Setting 280 general practitioners (GPs) from 72 primary care practices in Belgium. Patients Patients aged ≥18 years with a laboratory test order for at least one of 17 indications; cardiovascular disease management, hypertension, check-up, chronic kidney disease (CKD), thyroid disease, type 2 diabetes mellitus, fatigue, anemia, liver disease, gout, suspicion of acute coronary syndrome (ACS), suspicion of lung embolism, rheumatoid arthritis, sexually transmitted infections (STI), acute diarrhea, chronic diarrhea, and follow-up of medication. Interventions The CDSS was integrated into a computerized physician order entry (CPOE) in the form of evidence-based order sets that suggested appropriate tests based on the indication provided by the general physician. Measurements The primary outcome of the ELMO study was the proportion of appropriate tests over the total number of ordered tests and inappropriately not-requested tests. Secondary outcomes of the ELMO study included diagnostic error, test volume and cascade activities.Results CDSS increased the proportion of appropriate tests by 0.21 (95% CI 0.16 - 0.26, p<.0001) for all tests included in the study. GPs in the CDSS arm ordered 7 (7.15 (95% CI 3.37 - 10.93, p=.0002)) tests fewer per panel. CDSS did not increase diagnostic error. The absolute difference in proportions was a decrease of 0.66% (95% CI 1.4% decrease - 0.05% increase) in possible diagnostic error.Conclusions A CDSS in the form of order sets, integrated within the CPOE improved appropriateness and decreased volume of laboratory test ordering without increasing diagnostic error. Trial Registration Clinicaltrials.gov Identifier: NCT02950142, registered on October 25, 2016Funding source This study was funded through the Belgian Health Care Knowledge Centre (KCE) Trials Programme agreement KCE16011.

scholarly journals Primary care use of laboratory tests in Northern Ireland’s Western Health and Social Care Trust: a cross-sectional study

BMJ Open ◽  
2019 ◽  
Vol 9 (6) ◽  
pp. e026647
Author(s):  
Magda Bucholc ◽  
Maurice O’Kane ◽  
Ciaran Mullan ◽  
Siobhan Ashe ◽  
Liam Maguire
Keyword(s):  
Northern Ireland ◽  
Laboratory Test ◽  
Laboratory Tests ◽  
Social Care ◽  
Cross Sectional Study ◽  
Sectional Study ◽  
Cross Sectional ◽  
Socioeconomic Characteristics ◽  
Health And Social Care ◽  
Test Ordering

ObjectivesTo describe the laboratory test ordering patterns by general practitioners (GPs) in Northern Ireland Western Health and Social Care Trust (WHSCT) and explore demographic and socioeconomic associations with test requesting.DesignCross-sectional study.SettingWHSCT, Northern Ireland.Participants55 WHSCT primary care medical practices that remained open throughout the study period 1 April 2011–31 March 2016.OutcomesTo identify the temporal patterns of laboratory test ordering behaviour for eight commonly requested clinical biochemistry tests/test groups in WHSCT. To analyse the extent of variations in laboratory test requests by GPs and to explore whether these variations can be accounted for by clinical outcomes or geographical, demographic and socioeconomic characteristics.ResultsThe median number of adjusted test request rates over 5 consecutive years of the study period decreased by 45.7% for urine albumin/creatinine ratio (p<0.000001) and 19.4% for lipid profiles (p<0.000001) while a 60.6%, 36.6% and 29.5% increase was observed for HbA1c(p<0.000001), immunoglobulins (p=0.000007) and prostate-specific antigen (PSA) (p=0.0003), respectively. The between-practice variation in test ordering rates increased by 272% for immunoglobulins (p=0.008) and 500% for HbA1c(p=0.0001). No statistically significant relationship between ordering activity and either demographic (age and gender) and socioeconomic factors (deprivation) or Quality and Outcome Framework scores was observed. We found the rural–urban differences in between-practice variability in ordering rates for lipid profiles, thyroid profiles, PSA and immunoglobulins to be statistically significant at the Bonferroni-adjusted significance level p<0.01.ConclusionsWe explored potential factors of the interpractice variability in the use of laboratory tests and found that differences in requesting activity appear unrelated to either demographic and socioeconomic characteristics of GP practices or clinical outcome indicators.

scholarly journals Clinical decision support improves the appropriateness of laboratory test ordering in primary care without increasing diagnostic error: the ELMO cluster randomized trial

2020 ◽  
Vol 15 (1) ◽  
Author(s):  
Nicolas Delvaux ◽  
Veerle Piessens ◽  
Tine De Burghgraeve ◽  
Pavlos Mamouris ◽  
Bert Vaes ◽  
...  
Keyword(s):  
Primary Care ◽  
Decision Support ◽  
Laboratory Test ◽  
Clinical Decision Support ◽  
Clinical Decision ◽  
Diagnostic Error ◽  
Order Sets ◽  
Cluster Randomized ◽  
Physician Order Entry ◽  
Test Ordering

Abstract Background Inappropriate laboratory test ordering poses an important burden for healthcare. Clinical decision support systems (CDSS) have been cited as promising tools to improve laboratory test ordering behavior. The objectives of this study were to evaluate the effects of an intervention that integrated a clinical decision support service into a computerized physician order entry (CPOE) on the appropriateness and volume of laboratory test ordering, and on diagnostic error in primary care. Methods This study was a pragmatic, cluster randomized, open-label, controlled clinical trial. Setting Two hundred eighty general practitioners (GPs) from 72 primary care practices in Belgium. Patients Patients aged ≥ 18 years with a laboratory test order for at least one of 17 indications: cardiovascular disease management, hypertension, check-up, chronic kidney disease (CKD), thyroid disease, type 2 diabetes mellitus, fatigue, anemia, liver disease, gout, suspicion of acute coronary syndrome (ACS), suspicion of lung embolism, rheumatoid arthritis, sexually transmitted infections (STI), acute diarrhea, chronic diarrhea, and follow-up of medication. Interventions The CDSS was integrated into a computerized physician order entry (CPOE) in the form of evidence-based order sets that suggested appropriate tests based on the indication provided by the general physician. Measurements The primary outcome of the ELMO study was the proportion of appropriate tests over the total number of ordered tests and inappropriately not-requested tests. Secondary outcomes of the ELMO study included diagnostic error, test volume, and cascade activities. Results CDSS increased the proportion of appropriate tests by 0.21 (95% CI 0.16–0.26, p < 0.0001) for all tests included in the study. GPs in the CDSS arm ordered 7 (7.15 (95% CI 3.37–10.93, p = 0.0002)) tests fewer per panel. CDSS did not increase diagnostic error. The absolute difference in proportions was a decrease of 0.66% (95% CI 1.4% decrease–0.05% increase) in possible diagnostic error. Conclusions A CDSS in the form of order sets, integrated within the CPOE improved appropriateness and decreased volume of laboratory test ordering without increasing diagnostic error. Trial registration ClinicalTrials.gov Identifier: NCT02950142, registered on October 25, 2016

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