The effect of watchful waiting compared to immediate test ordering instructions on general practitioners' blood test ordering behaviour for patients with unexplained complaints; a randomized clinical trial (ISRCTN55755886)

Abstract

BackgroundImmediate blood testing for patients presenting with unexplained complaints in family practice is superfluous from a diagnostic point of view. However, many general pracitioners (GPs) order tests immediately. Watchful waiting reduces the number of patients to be tested and the number of false-positive results. The objectives of this study are: to determine the feasibility of watchful waiting compared to immediate test ordering; to determine if a special quality improvement strategy can improve this feasibility; and to determine if watchful waiting leads to testing at a later time.MethodsThe study is a cluster-randomized clinical trial with three groups, on blood test ordering strategies in patients with unexplained complaints. GPs in group one were instructed to order tests immediately and GPs in group two to apply a watchful waiting approach. GPs in group three received the same instruction as group two, but they were supported by a systematically designed quality improvement strategy. A total of 498 patients with unexplained complaints from 63 practices of Dutch GPs participated. We measured: the percentage of patients for whom tests were ordered and number of tests ordered at the first consultation; performance on the strategy's performance objectives (i.e., ordering fewer tests and specific communication skills); the number of tests ordered after four weeks; and GP and patient characteristics.ResultsImmediate test ordering proved feasible in 92% of the patients; watchful waiting in 86% and 84%, respectively, for groups two and three. The two watchful waiting groups did not differ significantly in the achievement of any of the performance objectives. Of the patients who returned after four weeks, none from group one and six from the two watchful waiting groups had tests ordered for them.ConclusionsWatchful waiting is a feasible approach. It does not lead to testing immediately afterwards. Furthermore, watchful waiting was not improved by the quality improvement strategy.Trial registrationClinical trial registration: ISRCTN55755886

Interventions to Educate Family Physicians to Change Test Ordering

“…(1) Overview of the risk of bias assessments: Only 48.5% of studies were at low risk of bias from randomization (they used a strong method of randomization such as by computer), 7% from concealment of allocation from the researchers, 17% from blinding of participants and personnel, 21% from blinding of outcome Only 21% of the outcome assessors were blind as to which study arm the participants were in Attrition 27.5 52 20.5 Only 8 RCTs were assessed as at low risk for attrition. 18,19,26,27,[56][57][58][59][60][61] NB: Three of these studies 27,58,59 had high attrition rates, but the authors conducted intentionto-treat analyses (which assume that those who did not complete the trial failed to benefit from the intervention). Intention-to-treat analyses provide a conservative estimate of the effect of the intervention, and the studies were thus assessed at low risk from attrition.…”

“…(c) Six studies to reduce use of groups of tests: (1) 1 found no decrease in the intervention group and (2) the others ranged from reductions of 5% to 17% of tests. In the unique study of patients with fatigue by Koch et al, 18,19 The data are presented in a graphic overview ( Figure 5), with more detail about the studies in Table 4 (studies are listed by the type of intervention and then for each intervention in increasing order of magnitude of the intervention effect). Unweighted averages for intervention effects are provided only for groups with >5 studies.…”

Association of Clinician Denial of Patient Requests With Patient Satisfaction

“…52 However, few randomized clinical trials of watchful waiting have been conducted, and none have examined the effectiveness of the approach, specifically in responding to patient requests in primary care or the resulting impact on satisfaction, underscoring the need for work in this realm. [53][54][55]…”

Referral interventions from primary to specialist care: a systematic review of international evidence

“…Process change interventions included: designated appointment slots and fast-track clinics for primary care referrals (n = 6), [60][61][62][63][64][65] direct access to screening (n = 9), 66 to referral (individual contact between a specialist and GP) (n = 11), [75][76][77][78][79][80][81][82][83][84][85] electronic referral systems (n = 10), [86][87][88][89][90][91][92][93][94][95] decision support tools (n = 10), [96][97][98][99][100][101][102][103][104][105] and waiting list review or watchful waiting (n = 3). [106][107][108] The overall picture for interventions that aim to moderate referral outcomes by changing an element of the referral process is mixed. Stronger evidence exists for electronic referral interventions (positive effects on referral, appropriate referral, GP satisfaction, reduction in non-attendance, waiting times, and transfer of information) and interventions including specialist consultation prior to referral (positive effects on number of referrals [referrals avoided], time to treatment, accuracy of diagnosis, and patient evaluation of services).…”

“…System change interventions included the community provision of specialist services by GPs (n = 9), [108][109][110][111][112][113][114][115][116][117] outreach or community provision by specialists (wholescale provision of a hospital service within the community) (n = 10), [118][119][120][121][122][123][124][125][126][127] return of inappropriate referrals (n = 2), 128,129 the provision of additional primary care staff (n = 3), [130][131][132] the addition or removal of gatekeeping systems (requiring a primary care provider to give access to secondary care services) (n = 4), [133][134][135][136] changes to payment systems (n = 4), [137][138][139] and referral management centre or other major triage systems (n = 6). [140][141][142][143][144][145][146] The overall picture for interventions that aim to implement large system changes to impact on referral is mixed.…”