Scope Of Practice Review - Health Professions Regulatory Advisory ...

Solomon, D. et al.Techniques to ImprovePhysicians’ Use ofDiagnostic Tests: A NewConceptual Framework.Journal of the AmericanMedical Association. Vol280: 23. 1998.Stuart, P. et al. AnInterventional Programfor Diagnostic Testing inthe EmergencyDepartment. MedicalJournal of Australia. Vol177. 2002.A review of the publishedliterature on interventions aimedat improving physicians’ testingpractices and proposemethodological standards forthese studies and to reviewselected studies using thePRECEDE framework, abehavioural model that helpscategorize interventions based onwhich behavioural factors arebeing affected.MEDLINE, EMBASE, andHEALTHStar databases weresearched for the years 1966 toJanuary 1, 1998, for Englishlanguagearticles pertaining todiagnostic testing behaviour;bibliographies were scanned toidentify articles of potentialinterest; and researchers in healthservices, health behaviour, andbehaviour modification werecontacted for proprietary andother unpublished articles.A total of 102 articles wereidentified that described theresults of interventions aimed atchanging physicians’ testingpractices. The review included 49studies that compared diagnostictesting practices in interventionand control groups. Twoinvestigators independentlyreviewed each article in a blindedfashion using a standard datacollection form to obtain amethodologic score and toabstract the key elements of eachintervention.Evaluation of an interventiondeveloped to improve testorderingpractice. Theintervention comprised threeintegrated components:implementation of a protocol fortest ordering; education programfor medical staff; andaudit/feedback process.Main outcome measure was testutilisation (assessed as cost perpatient).Setting: Public hospitalemergency department with anannual census of 42 500.The study comprised a six-monthpre-intervention stage (November1998 to April 1999), which wascompared with a similar postinterventionperiod (November1999 to April 2000), and trendsOn a 38-point methodologic criteria scale, the mean±SD score was 13 ± 4.4. The desired behaviourchange was reported in the intervention group in 37(76%) of 49 studies. Twenty-four (86%) of 28interventions targeted at many behavioural factorswere successful, while 13 (62%) of 21 studies aimedat a single behavioural factor were successful.A majority of interventions to improve physicians’testing practices reported in the literature claimedsuccess, with interventions based on multiplebehavioural factors trending toward being moresuccessful. While methodological flaws hamperdrawing strong conclusions from this literature,application of a behavioural framework appears to beuseful in explaining interventions that are successfuland can facilitate interpretation of interventionresults.The intervention appears to have produced long termmodification of test ordering in the emergencydepartment of a public teaching hospital. There wasa 40% decrease in the ordering of investigations inthe emergency department, with test utilisationfalling from a mean of $39.32/patient to$23.72/patient. The decrease was similar for bothlaboratory and imaging tests and was sustained forthe duration of the 18-month follow-up.17