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

Abstract

BackgroundInappropriate 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.MethodsThis study was a pragmatic, cluster randomized, open label, controlled clinical trial.Setting280 general practitioners (GPs) from 72 primary care practices in Belgium.PatientsPatients 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.InterventionsThe 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.MeasurementsThe 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.ResultsCDSS 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.ConclusionsA 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 RegistrationClinicaltrials.gov Identifier: NCT02950142

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“…This CDS is integrated into a computerized physician order entry (CPOE) to examine the appropriateness and volume of laboratory test ordering and diagnostic errors in primary care. The results show that a CDS within the CPOE improves the appropriateness of lab tests and decreases the volume of laboratory test ordering without increasing diagnostic error [28].…”

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“…For example, in a seminal work published by one of us nearly 10 years ago, we showed that the adoption of a computerized alert system based on specific re-testing intervals and encompassing the appearance of flexible alerts (i.e., ignorable pop-ups) when a set of predefined appropriateness criteria were violated by the prescribing physicians, was effective to generate a nearly 80% reduction in the burden of theoretically inappropriate tests, accompanied by an approximately 13% decrease of total laboratory costs [13] . In another experience, Delvaux et al [14] developed a clinical decision support systems (CDSS) encompassing a series of evidence-based order sets aimed at proposing the more appropriate lab tests according to the clinical indications provided by the prescribing physician. The authors showed that such system not only was effective to significantly enhance the number of appropriately requested tests by over 50%, but was also associated with significant decrease in potential diagnostic errors.…”