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.

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.

scholarly journals Alopecia and Iron Deficiency: An Interventional Pilot Study in Primary Care to Improve the Request of Ferritin

2020 ◽  
Vol 2020 ◽  
pp. 1-6
Author(s):  
Maria Salinas ◽  
Maria Leiva-Salinas ◽  
Emilio Flores ◽  
Maite López-Garrigós ◽  
Carlos Leiva-Salinas
Keyword(s):  
Primary Care ◽  
General Practitioner ◽  
Pilot Study ◽  
Iron Deficiency ◽  
Laboratory Testing ◽  
Laboratory Tests ◽  
Young Female ◽  
Cross Sectional ◽  
Primary Care Patients ◽  
Cross Sectional Studies

Background. The aim was to study the demographic and laboratory pattern of primary care patients with alopecia undergoing laboratory testing, more specifically, the request of hemoglobin and ferritin and values showing anemia and iron deficiency, and to evaluate the effects of an intervention involving automatic ferritin registration and measurement when not requested. Methods. Retrospective and prospective observational cross-sectional studies were conducted, as well as an intervention to automatically register and measure ferritin when not requested by the general practitioner. Results. There were 343 and 1032 primary care laboratory requests prompted by alopecia in the retrospective and prospective studies. Hemoglobin was requested in almost every patient and ferritin in 88%. 5% of the cohort had anemia, and 25% had iron deficiency. The intervention registered and measured that 123 ferritin and 24 iron deficiencies were detected in patients with alopecia, all women, at a cost of 10.6€. Conclusion. Primary care patients with alopecia and laboratory tests request were mainly young female. Our intervention added ferritin when not requested, detecting iron deficiency in 27.9% of women, potentially avoiding the adverse effects of iron deficiency on hair loss.

scholarly journals Attitudes Toward Family Medicine Among Students Choosing Other Primary Care Specialties

2020 ◽  
Vol 52 (7) ◽  
pp. 491-496
Author(s):  
Jacob Prunuske ◽  
Hana Kang ◽  
Andrea L. Wendling ◽  
Jennifer Edwards-Johnson ◽  
Julie P. Phillips
Keyword(s):  
Primary Care ◽  
Medical Students ◽  
Family Medicine ◽  
Secondary Data ◽  
Future Research ◽  
Curricular Development ◽  
Career Intention ◽  
Fourth Year Medical Students ◽  
Post Hoc ◽  
Career Advising

Background and Objectives: Little is known about how medical students choose between primary care specialties. We compared the attitudes toward family medicine of medical students intending to practice primary care but not family medicine (PCNFM), with students intending to practice family medicine (FM) and those intending nonprimary care (NPC) careers. Methods: The Family Medicine Attitudes Questionnaire (FMAQ) was distributed to 2,644 fourth-year medical students at 16 medical schools in spring 2017. Respondents were stratified by career intention. In this secondary data analysis, we used descriptive statistics to characterize responses to each questionnaire item and FMAQ total score, and analysis of variance with Bonferroni post hoc analyses to compare category and item mean responses. Results: Of 2,644 fourth-year medical students who received the FMAQ, 1,188 (41.8%) submitted usable responses. The 14-item FMAQ has a maximum score of 70. Mean total scores differed by category: 59.05 for FM, 52.88 for NPC, and 54.83 for PCNFM (F=108.96, P<.01); the differences between each possible pairing were significant (P<.05). Comparing the responses of students intending PCNFM careers with those of students intending NPC careers, there were no differences in mean responses for 8 of 14 FMAQ items. Responses of students intending PCNFM careers were similar to students intending FM for only 4 of 14 items (P<.05). Conclusions: Fourth-year students intending to match into PCNFM have attitudes toward FM that more closely approximate the attitudes of NPC students than the attitudes of FM students. Future research should explore implications for curricular development, student mentorship, and career advising.

scholarly journals Diagnostic and laboratory test ordering in Northern Portuguese Primary Health Care: a cross-sectional study

BMJ Open ◽  
2017 ◽  
Vol 7 (11) ◽  
pp. e018509 ◽  
Author(s):  
Luísa Sá ◽  
Andreia Sofia Costa Teixeira ◽  
Fernando Tavares ◽  
Cristina Costa-Santos ◽  
Luciana Couto ◽  
...  
Keyword(s):  
Primary Care ◽  
Laboratory Tests ◽  
Family Health ◽  
Family Physicians ◽  
Cross Sectional Study ◽  
Health Administration ◽  
Regional Health ◽  
Cross Sectional ◽  
Primary Health ◽  
Test Ordering

ObjectivesTo 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.DesignCross-sectional study.SettingNorthern Primary Health Care, Portugal.ParticipantsRecords 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.OutcomesTo 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.ResultsThe 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.ConclusionsThe 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.

scholarly journals Investor Activity in Chinese Financial Institutions: A Precursor to Economic Sustainability

2021 ◽  
Vol 13 (21) ◽  
pp. 12267
Author(s):  
Rob Kim Marjerison ◽  
Chungil Chae ◽  
Shitong Li
Keyword(s):  
Decision Making ◽  
Financial Institutions ◽  
Asset Allocation ◽  
Information Acquisition ◽  
Rapid Development ◽  
Secondary Data ◽  
Future Research ◽  
Individual Investors ◽  
Market Information ◽  
Investment In China

One requirement for sustainable economic development is established, trusted, and utilized financial institutions to facilitate investment. The rapid development of financial markets in China, combined with the recency and magnitude of middle-class wealth, has resulted in a rapidly changing investment landscape, as well as changes in people’s investing activities. The extent to which economic growth is sustainable will depend, at least in part, on how financial institutions are perceived, as well as the extent to which they are utilized. The objective of this study was to examine the investment behaviors of individual investors as a way to ascertain the perceived level of trust and stability in the relatively recently developed financial institutions. The influence of market information acquisition on asset allocation and value investment in China was analyzed. This study used secondary data from a China securities corporation from previous research. The analyses utilized the general decision-making style test to assess respondents’ decision-making models and quantitative research methodology culminating in the use of correlation analysis. The results indicated that the acquisition of market information had a positive correlation with the number of assets and investment portfolios. Practical implications and suggestions for future research are provided. The results may be of interest to individual and institutional investors in China, as well as those with an interest in current trends in market information acquisition, asset allocation, and value investment in China.

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

BMJ Open ◽  
2018 ◽  
Vol 8 (9) ◽  
pp. e023117 ◽  
Author(s):  
Claire Duddy ◽  
Geoffrey Wong
Keyword(s):  
Primary Care ◽  
Realist Review ◽  
Programme Theory ◽  
Dissemination Strategy ◽  
Care Protocol ◽  
Ethical Approval ◽  
Registration Number ◽  
Primary Care Doctors ◽  
Generative Mechanisms ◽  
Test Ordering

IntroductionStudies 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 analysisThis 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 disseminationEthical 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 numberCRD42018091986

scholarly journals A stepwise approach to implementing pharmacogenetic testing in the primary care setting

2019 ◽  
Vol 20 (15) ◽  
pp. 1103-1112 ◽  
Author(s):  
Kristin Wiisanen Weitzel ◽  
Benjamin Q Duong ◽  
Meghan J Arwood ◽  
Aniwaa Owusu-Obeng ◽  
Noura S Abul-Husn ◽  
...  
Keyword(s):  
Primary Care ◽  
Decision Making ◽  
Clinical Decision Making ◽  
Clinical Decision ◽  
Primary Care Providers ◽  
Test Results ◽  
Implementation Barriers ◽  
Pharmacogenetic Testing ◽  
Stepwise Approach ◽  
Test Ordering

Pharmacogenetic testing can help identify primary care patients at increased risk for medication toxicity, poor response or treatment failure and inform drug therapy. While testing availability is increasing, providers are unprepared to routinely use pharmacogenetic testing for clinical decision-making. Practice-based resources are needed to overcome implementation barriers for pharmacogenetic testing in primary care.The NHGRI’s IGNITE I Network (Implementing GeNomics In pracTicE; www.ignite-genomics.org ) explored practice models, challenges and implementation barriers for clinical pharmacogenomics. Based on these experiences, we present a stepwise approach pharmacogenetic testing in primary care: patient identification; pharmacogenetic test ordering; interpretation and application of test results, and patient education. We present clinical factors to consider, test-ordering processes and resources, and provide guidance to apply test results and counsel patients. Practice-based resources such as this stepwise approach to clinical decision-making are important resources to equip primary care providers to use pharmacogenetic testing.

scholarly journals P044: Factors influencing laboratory test ordering by physicians and nurses in the emergency department

CJEM ◽  
2017 ◽  
Vol 19 (S1) ◽  
pp. S92-S93
Author(s):  
L. Delaney ◽  
A. Gallant ◽  
S. Stewart ◽  
J. Curran ◽  
S.G. Campbell
Keyword(s):  
Decision Making ◽  
Laboratory Test ◽  
Laboratory Tests ◽  
Theoretical Domains Framework ◽  
Emergency Physicians ◽  
Factors Influencing ◽  
High Acuity ◽  
Chi Square Analysis ◽  
Test Ordering ◽  
Significant Factors

Introduction: Understanding factors that influence laboratory test ordering in emergency departments (EDs) can help to improve current laboratory test ordering practices. The aim of this study is to compare patterns and influences in laboratory test ordering between emergency physicians and nurses at two ED sites, Halifax Infirmary (HI) and Dartmouth General (DG). Methods: A mixed-methods approach involving administrative data and telephone interviews was employed. Data from 211,279 patients at HI and DG EDs were analyzed. Chi-square analysis and binary logistic regression were used to determine significant factors influencing whether a test was ordered, as well as significant factors predicting likelihood of a nurse or a physician ordering a test. All significant associations had a p-value of &lt;0.0001. Interviews were conducted (n=25) with doctors and nurses in order to explore areas of potential influence in a clinician’s decision-making process, and discuss what makes decision making difficult or inconsistent in the ED. These interviews were analyzed according to the Theoretical Domains Framework. The interviews were coded by two individuals using a consensus methodology in order to ensure accuracy of coding. Results: Overall, laboratory tests were more likely to be ordered at DG than at HI (OR=1.52, 95% CI: [1.48, 1.55]). Laboratory tests were more likely to be ordered by nurses at DG than at HI (OR=1.58, 95% CI: [1.54, 1.62]). Laboratory tests were more likely to be ordered if the ED was not busy, if the patient was over 65, had a high acuity, had a long stay in the ED, required consults, or was admitted to hospital. Doctors were more likely to order a laboratory test in patients over 65, requiring consults or hospital admission, whereas nurses were more likely to order laboratory tests in patients with high acuity or long stays in the ED. Data from the interviews suggested differing influences on decision making between nurses and doctors, especially in the areas of social influence and knowledge. Conclusion: Currently, there is limited research that investigates behaviour of both emergency physicians and nurses. By determining barriers that are most amenable to behaviour change in emergency physicians and nurses, findings from this work may be used to update practice guidelines, ensuring more consistency and efficiency in laboratory test ordering in the ED.

scholarly journals Barriers to a full scope of pharmacy practice in primary care: A systematic review of pharmacists’ access to laboratory testing

2019 ◽  
Vol 152 (5) ◽  
pp. 317-333
Author(s):  
Jacqueline Donovan ◽  
Ross T. Tsuyuki ◽  
Yazid N. Al Hamarneh ◽  
Beata Bajorek
Keyword(s):  
United States ◽  
Primary Care ◽  
United Kingdom ◽  
New Zealand ◽  
Patient Outcomes ◽  
Laboratory Testing ◽  
Laboratory Tests ◽  
The United States ◽  
Scope Of Practice ◽  
The United Kingdom

Objectives: To describe primary care pharmacists’ current scope of practice in relation to laboratory testing. Method: A 2-tiered search of key databases (PubMed, EMBASE, MEDLINE) and grey literature with the following MeSH headings: prescribing, pharmacist/pharmacy, laboratory test, collaborative practice, protocols/guidelines. We focused on Canada, the United States, the United Kingdom, New Zealand and Australia for this review. Results: There is limited literature exploring primary care pharmacists’ scope of practice in relation to laboratory testing. The majority of literature is from the United States and Canada, with some from the United Kingdom and New Zealand and none from Australia. Overall, there is a difference in regulations between and within these countries, with the key difference being whether pharmacists access and/or order laboratory testing dependently or independently. Canadian pharmacists can access and/or order laboratory tests independently or dependently, depending on the province they practise in. US pharmacists can access and/or order laboratory tests dependently within collaborative practice agreements. In the United Kingdom, laboratory testing can be performed by independent prescribing pharmacists or dependently by supplementary prescribing pharmacists. New Zealand prescribing pharmacists can order laboratory testing independently. Most publications do not report on the types of laboratory tests used by pharmacists, but those that do predominantly resulted in positive patient outcomes. Discussion/Conclusion: Primary care pharmacists’ scope of practice in laboratory testing is presently limited to certain jurisdictions and is often performed in a dependent fashion. As such, a full scope of pharmacy services is almost entirely unavailable to patients in the United States, the United Kingdom, New Zealand and Australia. Just as in the case for pharmacists prescribing, evidence indicates better patient outcomes when pharmacists can access/order laboratory tests, but more research needs to be done alongside the implementation of local guidelines and practice standards for pharmacists who practise in that realm. Patients around the world deserve to receive a full scope of pharmacists’ practice, and lack of access to laboratory testing is one of the major obstacles to this. Can Pharm J (Ott) 2019;152:xx-xx.

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