Effect of a practice-based strategy on test ordering performance of primary care physicians: a randomized trial.
BACKGROUND
Numbers of diagnostic tests ordered by primary care physicians are growing and many of these tests seem to be unnecessary according to established, evidence-based guidelines. An innovative strategy that focused on clinical problems and associated tests was developed.


OBJECTIVE
To determine the effects of a multifaceted strategy aimed at improving the performance of primary care physicians' test ordering.


METHODS
Multicenter, randomized controlled trial with a balanced, incomplete block design and randomization at group level. Thirteen groups of primary care physicians underwent the strategy for 3 clinical problems (arm A; cardiovascular topics, upper and lower abdominal complaints), while 13 other groups underwent the strategy for 3 other clinical problems (arm B; chronic obstructive pulmonary disease and asthma, general complaints, degenerative joint complaints). Each arm acted as a control for the other.


METHODS
Primary care physician groups in 5 regions in the Netherlands with diagnostic centers recruited from May to September 1998.


METHODS
Twenty-six primary care physician groups, including 174 primary care physicians.


METHODS
During the 6 months of intervention, physicians discussed 3 consecutive, personal feedback reports in 3 small group meetings, related them to 3 evidence-based clinical guidelines, and made plans for change.


METHODS
According to existing national, evidence-based guidelines, a decrease in the total numbers of tests ordered per clinical problem, and of some defined inappropriate tests, is considered a quality improvement.


RESULTS
For clinical problems allocated to arm A, the mean total number of requested tests per 6 months per physician was reduced from baseline to follow-up by 12% among physicians in the arm A intervention, but was unchanged in the arm B control, with a mean reduction of 67 more tests per physician per 6 months in arm A than in arm B (P =.01). For clinical problems allocated to arm B, the mean total number of requested tests per 6 months per physician was reduced from baseline to follow-up by 8% among physicians in the arm B intervention, and by 3% in the arm A control, with a mean reduction of 28 more tests per physician per 6 months in arm B than in arm A (P =.22). Physicians in arm A had a significant reduction in mean total number of inappropriate tests ordered for problems allocated to arm A, whereas the reduction in inappropriate test ordered physicians in arm B for problems allocated to arm B was not statistically significant.


CONCLUSIONS
In this study, a practice-based, multifaceted strategy using guidelines, feedback, and social interaction resulted in modest improvements in test ordering by primary care physicians.
Center for Quality of Care Research, Department of General Practice, Maastricht University, Maastricht, The Netherlands. wim.verstappen@hag.unimass.nl
Wim H J M
WH
Verstappen
Trudy
T
van der Weijden
Jildou
J
Sijbrandij
Ivo
I
Smeele
Jan
J
Hermsen
Jeremy
J
Grimshaw
Richard P T M
RP
Grol
D003955:Diagnostic Tests, Routine / Q000592:standards / Q000706:statistics & numerical data*; D019317:Evidence-Based Medicine; D017144:Focus Groups; D006801:Humans; D009426:Netherlands; D010821:Physicians, Family / Q000592:standards*; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000592:standards / Q000706:statistics & numerical data*; D011320:Primary Health Care / Q000592:standards*; D011786:Quality Control; D017749:Total Quality Management / Q000379:methods*; D019564:Unnecessary Procedures / Q000706:statistics & numerical data