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

van Walraven, C. et al.Do We Know WhatInappropriate LaboratoryUtilization is? ASystematic Review ofLaboratory ClinicalAudits. Journal of theAmerican MedicalAssociation. Vol 280.550-558. 1998.van Wijk, M. et al.Assessment of DecisionSupport for Blood TestOrdering in PrimaryCare: A RandomizedTrial. The Annals ofInternal Medicine. Vol124. 274-281. 2001.Verstappen, W. Effect ofa Practice-Based Strategyon Test OrderingPerformanceof Primary CarePhysicians: ARandomized Trial.Journal of the AmericanMedical Association. Vol289: 18. 2003.were examined over an 18-monthpost-intervention period(May 1999 to October 2000).Assesses studies that measureinappropriate laboratory use inlight of methodological criteria.Systematic review of publishedstudies was undertaken andMEDLINE, HEALTHSTAR, andEMBASE databases weresearched from 1966 to September1997 using a broad and inclusivestrategy with no languagerestriction. In addition, thereferences of all retrieved studiesand 3 textbooks on diagnostictesting were hand-searched.Studies were categorized based onwhether the criteria were implicit(objective criteria forinappropriate utilization notprovided or very broad) orexplicit. Guidelines for evaluationwere applied to each study by asingle reviewer.Randomized trial in 44 generalpractices that aims to compare theeffect of two versions ofBloodLink, a computer-basedclinical decision support system,on blood test ordering amonggeneral practitioners.After stratification by solopractices and grouppractices, practices wererandomly assigned to useBloodLink- Restricted, whichinitially displays a reduced list oftests, or Blood-Link-Guideline,which is based on the guidelinesof the DutchCollege of General Practitioners.Average numbers of blood testsordered per order form perpractice were measured.A research study aimed atdetermining the effects of amultifaceted strategy to improvethe performance of primary carephysicians’ test ordering.A multicentre randomizedcontrolled trial with a balanced,incomplete block design andrandomization at group level wasundertaken. Thirteen groups ofLaboratory utilization has steadily increased withsome studies suggesting inappropriate utilization.Forty-four eligible studies were identified. Elevenstudies used implicit criteria for inappropriatelaboratory utilization and contained small numbersof patients or physicians. Most did not adequatelyassess the reliability of the implicit criteria. Thirtythreestudies used explicit criteria based on theappropriateness of test choice, frequency, andtiming, as well as the probability of a positive result.There were large variations in the estimates ofinappropriate laboratory use (4.5%-95%). Evidencesupporting the explicit criteria was frequently weakby the standards suggested for therapeuticmanoeuvres, but was nonetheless compelling basedon principles of physiology, pharmacology, andprobability.Many studies identify inappropriate laboratory usebased on implicit or explicit criteria that do not meetmethodological standards suggested for audits oftherapeutic manoeuvres. Researchers should developalternative evidentiary standards for measuringinappropriateness of laboratory test use.Different methods for changing blood test–orderingbehaviour in primary care have been proveneffective. However, randomized trials comparingthese methods are lacking.Results of the trial indicated that generalpractitioners who used BloodLink-Guidelinerequested 20% fewer tests on average than didpractitioners who used BloodLink-Restricted.Decision support based on guidelines is moreeffective in changing blood test–ordering behaviourthan is decision support based on initially displayinga limited number of tests. Guideline-driven decisionsupport systems can be effective in reducing thenumber of laboratory tests ordered by primary carepractitioners.Numbers of diagnostic tests ordered by primary carephysicians are growing and many of these tests seemto be unnecessary according to established,evidence-based guidelines. An innovative strategythat focused on clinical problems and associated testswas developed.In this study, a practice-based, multifaceted strategyusing guidelines, feedback, and social interactionresulted in modest improvements in test ordering byprimary care physicians.18