Interventions to Educate Family Physicians to Change Test Ordering

Abstract

The purpose is to systematically review randomised controlled trials (RCTs) to change family physicians’ laboratory test-ordering. We searched 15 electronic databases (no language/date limitations). We identified 29 RCTs (4,111 physicians, 175,563 patients). Six studies specifically focused on reducing unnecessary tests, 23 on increasing screening tests. Using Cochrane methodology 48.5% of studies were low risk-of-bias for randomisation, 7% concealment of randomisation, 17% blinding of participants/personnel, 21% blinding outcome assessors, 27.5% attrition, 93% selective reporting. Only six studies were low risk for both randomisation and attrition. Twelve studies performed a power computation, three an intention-to-treat analysis and 13 statistically controlled clustering. Unweighted averages were computed to compare intervention/control groups for tests assessed by >5 studies. The results were that fourteen studies assessed lipids (average 10% more tests than control), 14 diabetes (average 8% > control), 5 cervical smears, 2 INR, one each thyroid, fecal occult-blood, cotinine, throat-swabs, testing after prescribing, and urine-cultures. Six studies aimed to decrease test groups (average decrease 18%), and two to increase test groups. Intervention strategies: one study used education (no change): two feedback (one 5% increase, one 27% desired decrease); eight education + feedback (average increase in desired direction >control 4.9%), ten system change (average increase 14.9%), one system change + feedback (increases 5-44%), three education + system change (average increase 6%), three education + system change + feedback (average 7.7% increase), one delayed testing. The conclusions are that only six RCTs were assessed at low risk of bias from both randomisation and attrition. Nevertheless, despite methodological shortcomings studies that found large changes (e.g. >20%) probably obtained real change.

Implementation of an intervention to reduce population-based screening for vitamin D deficiency: a cross-sectional study

“…However, the size of the reduction in test volume seen in this study was far greater than that generally reported. 4,5 We anticipated that there may have been more questions or concerns given that a recent survey of Alberta primary care physicians showed that specialized test requisitions for certain tests were felt to be acceptable to only 45% of survey respondents. 17 In the current era of unsustainable increases in laboratory test volumes in Canada, 18,19 the managed exit of low-value tests is needed to ensure resources are available for medically necessary tests.…”

“…This group identified 5 priority recommendations for implementation in Alberta, one of which was the recommendation against population-based screening for serum total 25-hydroxyvitamin D (vitamin D) deficiency. This recommendation was jointly put forward by The Canadian Association of Pathologists 5 Implementation of an intervention to reduce populationbased screening for vitamin D deficiency: a cross-sectional study Vitamin D screening has been particularly problematic for the health system in Alberta because there has been a massive increase in test volumes over the past 10 years, 9 with evidence that testing has been preferentially directed toward low-risk patients. 10 We describe the implementation of an intervention in Alberta in support of the Choosing Wisely Canada recommendation against population screening for vitamin D deficiency.…”

“…Studies on the effectiveness of interventions to manage the use of laboratory testing are often lacking or of limited scope and quality. 4,5 Choosing Wisely Alberta, 6 a physician-led committee of the Alberta Medical Association, is responsible for the coordination and promulgation of Choosing Wisely Canada recommendations. This group identified 5 priority recommendations for implementation in Alberta, one of which was the recommendation against population-based screening for serum total 25-hydroxyvitamin D (vitamin D) deficiency.…”

“…However, the size of the reduction in test volume seen in this study was far greater than that generally reported. 4,5 We anticipated that there may have been more questions or concerns given that a recent survey of Alberta primary care physicians showed that specialized test requisitions for certain tests were felt to be acceptable to only 45% of survey respondents. …”

What the Doctor Ordered: Improving the Use and Value of Laboratory Testing

“…For example, a recent survey of family physicians showed that nearly all (98 percent) were accepting of educational utilization management interventions (Thommasen et al 2016). However, a high-quality randomized controlled trial of such education showed no effect on utilization (Thomas et al 2016).…”