A randomized controlled study of biochemical tests in primary care: interventions can reduce the number of tests but usage does not become more appropriate

Serena Lillo; Trine Rennebod Larsen; Leif Pennerup; Kirsten Ohm Kyvik; Jens Søndergaard; Steen Antonsen

doi:10.1515/cclm-2021-1138

Article

A randomized controlled study of biochemical tests in primary care: interventions can reduce the number of tests but usage does not become more appropriate

Serena Lillo , Trine Rennebod Larsen , Leif Pennerup , Kirsten Ohm Kyvik , Jens Søndergaard and Steen Antonsen

Published/Copyright: December 16, 2021

Published by

Become an author with De Gruyter Brill

Submit Manuscript Author Information

From the journal Clinical Chemistry and Laboratory Medicine (CCLM) Volume 60 Issue 3

Abstract

Objectives

The use of laboratory tests increases worldwide, and to some extent their use is likely to be inappropriate. Although primary care is responsible for a substantial proportion of requests, this sector is less extensively investigated than hospitals.

Methods

We tested the effect of six combinations of four interventions applied to 313 primary care clinics, using vitamin D as model test (253,762 vitamin D results). We evaluated the changes in test numbers in the six intervention groups compared to the control group, and whether interventions resulted in more homogenous test use within groups or affected the distribution of test results. All interventions included information on vitamin D testing guidelines. Four groups were exposed to a non-interruptive alert in the ordering IT-system and in two groups this was supplemented by an interruptive alert. Half of the groups received monthly feedback reports.

Results

Application of alerts, irrespective of the combination with feedback reports, resulted in significantly reduced test numbers (maximum −46%). Guidelines either alone or combined with feedback reports did not cause significant difference from the control group. The within-group requesting pattern changed significantly for only two of the groups. The distribution of low and normal vitamin D results within groups showed no signs of more appropriate use of the test in any of the groups.

Conclusions

Some of the interventions reduced the number of tests, but there were no indications of improved adherence to the guidelines. The interventions may have led to under-utilization of the test and thus should be used with care.

Keywords: interventions; optimization; primary care; vitamin D

Corresponding author: Serena Lillo, MSc, Biochemistry Department, Odense University Hospital (OUH) and Svendborg Hospital, Baagøes Alle 15, 5700 Svendborg, Denmark; and Department of Clinical Research, University of Southern Denmark, J.B. Winsløws Vej 19, 5000 Odense C, Denmark, E-mail: serena.lillo@rsyd.dk

Research funding: None declared.
Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission. The author TRL changed job position during the study period.
Competing interests: Authors state no conflict of interest.
Informed consent: Informed consent was obtained from all individuals included in this study.
Ethical approval: Due to being a “quality study”, an Ethical Committee permission was not required.

References

1. Cadamuro, J, Ibarz, M, Cornes, M, Nybo, M, Haschke-Becher, E, von Meyer, A, et al.. Managing inappropriate utilization of laboratory resources. Diagnosis (Berl) 2018;26:5–13.10.1515/dx-2018-0029Search in Google Scholar PubMed

2. Yeh, DD. A clinician’s perspective on laboratory utilization management. Clin Chim Acta 2014;427:145–50. https://doi.org/10.1016/j.cca.2013.09.023.Search in Google Scholar PubMed

3. Zhi, M, Ding, EL, Theisen-Toupal, J, Whelan, J, Arnaout, R. The landscape of inappropriate laboratory testing: a 15-year meta-analysis. PLoS ONE 2013;8:e78962. https://doi.org/10.1371/journal.pone.0078962.Search in Google Scholar PubMed PubMed Central

4. Huck, A, Lewandrowski, K. Utilization management in the clinical laboratory: an introduction and overview of the literature. Clin Chim Acta 2014;427:111–7. https://doi.org/10.1016/j.cca.2013.09.021.Search in Google Scholar PubMed

5. Freedman, DB. Towards better test utilization – strategies to improve physician ordering and their impact on patient outcomes. EJIFCC 2015;26:15–30.Search in Google Scholar

6. Lillo, S, Larsen, TR, Pennerup, L, Antonsen, S. The impact of interventions applied in primary care to optimize the use of laboratory tests: a systematic review. Clin Chem Lab Med 2021;59:1336–52. https://doi.org/10.1515/cclm-2020-1734.Search in Google Scholar PubMed

7. Kobewka, DM, Ronksley, PE, McKay, JA, Forster, AJ, Van Walraven, C. Influence of educational, audit and feedback, system based, and incentive and penalty interventions to reduce laboratory test utilization: a systematic review. Clin Chem Lab Med 2015;53:157–83. https://doi.org/10.1515/cclm-2014-0778.Search in Google Scholar PubMed

8. Bindraban, RS, Ten Berg, MJ, Naaktgeboren, CA, Kramer, MHH, Van Solinge, WW, Nanayakkara, PWB. Reducing test utilization in hospital settings: a narrative review. Ann Lab Med 2018;38:402–12. https://doi.org/10.3343/alm.2018.38.5.402.Search in Google Scholar PubMed PubMed Central

9. Christine Brot, PD. Sundhedsstyrelsens anbefalinger vedrørende forebyggelse, diagnostik og behandling af D-vitaminmangel Rationel Farmakoterapi, nr. 6; 2010. Available from: https://www.sst.dk/da/udgivelser/2010/rationel-farmakoterapi-6-2010/sundhedsstyrelsens-anbefalinger-vedroerende-forebyggelse-diagnostik-og-behandling-af-d-vitaminmangel.Search in Google Scholar

10. Available from: www.gdpr.eu.Search in Google Scholar

11. Available from: www.sundhed.dk. https://www.sundhed.dk/sundhedsfaglig/laegehaandbogen/endokrinologi/tilstande-og-sygdomme/knoglevaev-og-vitamin-d/d-vitamin-mangel/. 2021.Search in Google Scholar

12. StataCorp. Stata Statistical Software: Release 17. College Station TSL: StataCorp; 2021.Search in Google Scholar

13. Verstappen, WH, van der Weijden, T, Sijbrandij, J, Smeele, I, Hermsen, J, Grimshaw, J, et al.. Effect of a practice-based strategy on test ordering performance of primary care physicians: a randomized trial. JAMA 2003;289:2407–12. https://doi.org/10.1001/jama.289.18.2407.Search in Google Scholar PubMed

14. Camerotto, A, Pozzato, A, Truppo, V, Bedendo, S, Angiolelli, G, Lucchiari, A, et al.. The software GOELM as an innovative way of knowledge management and prescription of laboratory tests: the experience of two Local Healthcare Units (ULSS). Biochim Clin 2012;36:98–106.Search in Google Scholar

15. Munk, JK, Bathum, L, Jørgensen, HL, Lind, BS. A compulsory pop-up form reduces the number of vitamin D requests from general practitioners by 25 percent. Scand J Prim Health Care 2020;38:308–14. https://doi.org/10.1080/02813432.2020.1794399.Search in Google Scholar PubMed PubMed Central

16. Kimlin, MG. Geographic location and vitamin D synthesis. Mol Aspects Med 2008;29:453–61. https://doi.org/10.1016/j.mam.2008.08.005.Search in Google Scholar PubMed

17. Webb, AR, Kline, L, Holick, MF. Influence of season and latitude on the cutaneous synthesis of vitamin D3: exposure to winter sunlight in Boston and Edmonton will not promote vitamin D3 synthesis in human skin. J Clin Endocrinol Metab 1988;67:373–8. https://doi.org/10.1210/jcem-67-2-373.Search in Google Scholar PubMed

Supplementary Material

The online version of this article offers supplementary material (https://doi.org/10.1515/cclm-2021-1138).

Received: 2021-10-25

Accepted: 2021-12-07

Published Online: 2021-12-16

Published in Print: 2022-02-23

You are currently not able to access this content.

Articles in the same Issue

https://doi.org/10.1515/cclm-2021-1138

Keywords for this article

interventions; optimization; primary care; vitamin D