GP’s perspectives on laboratory test use for monitoring long-term conditions: an audit of current testing practice

Abstract

Background We have shown previously that current recommendations in UK guidelines for monitoring long-term conditions are largely based on expert opinion. Due to a lack of robust evidence on optimal monitoring strategies and testing intervals, the guidelines are unclear and incomplete. This uncertainty may underly variation in testing that has been observed across the UK between GP practices and regions. Methods Our objective was to audit current testing practices of GPs in the UK; in particular, perspectives on laboratory tests for monitoring long-term conditions, the workload, and how confident GPs are in ordering and interpreting these tests. We designed an online survey consisting of multiple-choice and open-ended questions that was promoted on social media and in newsletters targeting GPs practicing in UK. The survey was live between October–November 2019. The results were analysed using a mixed-methods approach. Results The survey was completed by 550 GPs, of whom 69% had more than 10 years of experience. The majority spent more than 30 min per day on testing (78%), but only half of the respondents felt confident in dealing with abnormal results (53%). There was a high level of disagreement for whether liver function tests and full blood counts should be done ‘routinely’, ‘sometimes’, or ‘never’ in patients with a certain long-term condition. The free text comments revealed three common themes: (1) pressures that promote over-testing, i.e. guidelines or protocols, workload from secondary care, fear of missing something, patient expectations; (2) negative consequences of over-testing, i.e. increased workload and patient harm; and (3) uncertainties due to lack of evidence and unclear guidelines. Conclusion These results confirm the variation that has been observed in test ordering data. The results also show that most GPs spent a significant part of their day ordering and interpreting monitoring tests. The lack of confidence in knowing how to act on abnormal test results underlines the urgent need for robust evidence on optimal testing and the development of clear and unambiguous testing recommendations. Uncertainties surrounding optimal testing has resulted in an over-use of tests, which leads to a waste of resources, increased GP workload and potential patient harm.

Cost-Effectiveness of Routine Monitoring of Long-Term Conditions in Primary Care: Informing Decision Modelling with a Systematic Review in Hypertension, Type 2 Diabetes and Chronic Kidney Disease

“…We have begun developing a comorbidity cost-effectiveness model to compare routine monitoring strategies for hypertension, T2DM and CKD [ 8 , 18 , 19 ]. This will compare tests and testing frequencies, jointly referred to as testing strategies, for these three LTCs in a UK setting.…”

Liver function tests in patients with hypertension in primary care: a prospective cohort study

“… 5 A recent survey of 550 GPs demonstrated a high level of disagreement for whether liver function tests should be done ‘routinely’, ‘sometimes’, or ‘never’ for patients with hypertension, and a lack of confidence in dealing with abnormal results. 6 …”

“… 8 Overuse of LFTs could potentially increase the risk of false-positive results, which may cause patient anxiety and potentially unnecessary follow-up appointments, blood tests, or referrals. 5 , 6 …”

Variation in laboratory testing for patients with long-term conditions: a longitudinal cohort study in UK primary care

“…3 In the context of an increasingly risk-averse society, and with a lack of clear, easy to follow guidelines, clinicians may add additional tests for disease monitoring 'just in case'. 5,6 There is increasing recognition that some of this testing may be wasteful; the Carter report in 2008 estimated that around 25% of pathology testing overall may be unneccesary; 7 and more recently the Organisation for Economic Co-operation and Development (OECD) estimated that one fifth of healthcare expenditure is wasted. 8 In addition, there is increasing strain on the National Health Service (NHS) as highlighted by the Care Quality Commission report, 2016/17, 9 which has been further exacerbated by the COVID-19 pandemic.…”

“…It also has a significant impact on GP workload and costs through reviewing test results and further investigations following abnormal tests. 6 On the other hand, failure to test may lead to delayed diagnoses, complications, patient harm, and litigation.…”