Short summary

General practitioners (GPs) are the gatekeepers of the health care system and usage of laboratory tests is an important and integral part of their daily practice. However, there are indications that the use of the tests is sometimes inappropriate and some requests do not benefit patient care.This project concerns research in methods for quality improvement and the aim is to investigate different strategies to optimize GPs decision making in regards to the use of laboratory testing. 

Rationale

General practitioners (GPs) are gate keepers of the healthcare system and are met with a wide specter of complaints and diseases. They are expected always to make professional decisions on the basis of scientific evidence, official guidelines and rules, seeking the most relevant and optimal investigations and treatments for the patients. Furthermore, this must be done within the short time usually available for the individual patient visits. Thus, there is a great need of support for GPs when executing their job. It has been recognized both in Denmark and worldwide that among other reasons new treatment modalities, new investigations and tests, higher patient expectations, regular check-ups and defensive medicine have disproportionately increased the number of investigations including laboratory tests to the number of patients and there are indications that the use of the tests is sometimes inappropriate and some requests do not benefit patient care. So the attention should be focused on optimizing the use of resources in healthcare.

Several strategies to improve clinical use of laboratory tests have been reported in the literature. They can be categorized into:

Educational strategies, like lectures, development and implementation of guidelines, audit and feedback, reminder email/letter, vetting initiative or check-lists enhance professional knowledge and skills and represent a traditional way of handling inappropriate practices in a knowledge-based organization such as healthcare facilities. 

Administrative changes often consist of changes to the test requisition form to guide clinicians in the intended direction (new requesting format, removing tests from a profile or unbundling of panels). These methods have been reported to be powerful and efficient methods to create long-lasting changes. However, this is system dependent, and GPs in Denmark can build-up their own laboratory tests profiles, making these strategies difficult to use. 

Information technology tools, like computerized physician order entry (CPOE) system, can offer advanced decision support by providing non-interruptive or interruptive alerts. The non-interrupted alert passively displays information concerning patient-specific issues such as redundant testing or suggests corollary orders. This alert does not require actions on the part of the ordering physician. The interruptive alert stops the workflow by requiring the user to acknowledge the alert and specifying an action, such as entering an indication for testing or alternatively cancellation of the test. 

 Financial programs can include both rewards and penalties for the provider. Both rationing and reward/penalty initiatives seem to be unpopular among physicians and do not give positive results, probably because the diagnostic tests are seen as regulated on financial considerations rather than on clinical needs of the patients. 

Most of the studies describing different strategies have been applied to improve use of laboratory tests are heterogeneous in design. They also differ widely in size and presentation of results, which complicates attempts to make general conclusions about effectiveness of the strategies. However, it seems that the most successful investigations have included combinations of education, guidelines and feedback combined with changes in computerized order entry. 

PurposeGeneral Practitioners (GPs) working in Region of Southern Denmark 

This project concerns research in methods for quality improvement and the aim is to investigate different strategies to optimize GPs decision making in regards to the use of laboratory testing. 

An advisory board with GPs and laboratory staff will design all materials used for the contact with GPs.

The GPs in the Region of Southern Denmark will be randomized in 7 groups, including the control group. Six different combinations of strategies will be applied, consisting of education to all groups, including distribution of guideline.  This will, for two groups be supplemented with a non-interruptive pop-up alert and for two other groups with an interruptive pop-up alert, both displayed in the requesting system (WebReq) of GPs. Furthermore, half of the groups will receive monthly feedback reports. 

Vitamin D will be used in the study, as it fulfills the criteria for a model test: the test should be used extensively by the requesters, and generally accepted recommendations for its use exit. 

The main outcome of the study will be the GPs perceived value of support obtained by questionnaires and interviews. Also an economical evaluation for establishing and running the strategies as well as the change in the number of tests will be assessed.

Description of the cohort

General Practitioners (GPs) working in Region of Southern Denmark 

Collaborating researchers and departments

Department of biochemistry, OUH, Svendborg Sygehus- main location of the project

Department of clinical biochemistry and pharmacology, OUH Odense

Department of clinical biochemistry Esbjerg

Department of clinical biochemistry and immunology, Sygehus Sønderjylland

Department of immunology and clinical biochemistry Sygehus Lillebælt

Research Department of general practice

• SDU-Professor Jens Søndergaard, PhD