A laboratory based intervention to improve appropriateness of lipid tests and audit cholesterol lowering in primary care

Diagnostic triage and the role of natriuretic peptide testing and echocardiography for suspected heart failure: an appropriateness ratings evaluation by UK GPs

BACKGROUND

Some UK GPs are acquiring access to natriuretic peptide (NP) testing or echocardiography as diagnostic tests for heart failure. This study developed appropriateness ratings for the diagnostic application of these tests in routine general practice.

AIM

To develop appropriateness ratings for the diagnostic application of NP testing or echocardiography for heart failure in general practice.

DESIGN AND SETTING

An appropriateness ratings evaluation in UK general practice.

METHOD

Four presenting symptoms (cough, bilateral ankle swelling, dyspnoea, fatigue), three levels of risk of cardiovascular disease (low, intermediate, high), and dichotomous categorisations of cardiovascular/chest examination and electrocardiogram result, were used to create 540 appropriateness scenarios for patients in whom NP testing or echocardiography might be considered. These were rated by a 10-person expert panel, consisting of GPs and GPs with specialist interests in cardiology, in a two-round RAND Appropriateness Method.

RESULTS

Onward referral for NP testing or echocardiography was rated as an appropriate next step in 217 (40.2%) of the 540 scenarios; in 194 (35.9%) it was rated inappropriate. The ratings also show where NP testing or echocardiography were ranked as equivalent next steps and when one test was seen as the more appropriate than the other.

CONCLUSION

NP testing should be the routine test for suspected heart failure where referral for diagnostic testing is considered appropriate. An abnormal electrocardiogram status makes referral to echocardiography an accompanying, or more appropriate, next step alongside NP testing, especially in the presence of dyspnoea. Abnormal NP testing should subsequently be followed up with referral for echocardiography.

Interactive workshops increase chlamydia testing in primary care--a controlled study

BACKGROUND

Primary care clinicians suggest that staff education is needed to increase chlamydia testing appropriately.

OBJECTIVES

To determine if interactive workshops and modified laboratory request forms could increase testing and case detection.

STUDY DESIGN

Prospective cluster randomized controlled study, using modified Zelen's design, examining the effect of workshops and modified request forms on primary care clinicians' chlamydia specimen submission and case positivity rate.

STUDY POPULATION

82 general practices in six geographical clusters within five primary care trusts (PCTs) in Gloucestershire and County Durham and Darlington.

INTERVENTION

Practices within geographical clusters were randomly assigned to workshops on chlamydia or a control consisting of comparable workshops on the management of urinary symptoms, held in PCT-protected learning time. Half the practices were randomized to receive modified laboratory request forms. Staff were unaware that they were part of a study.

RESULTS

Interactive workshops increased chlamydia testing in 16- to 24-year-old women by 33% in intervention practices compared to controls with effect persisting at 10 months (P = 0.003). No associated rise in the number of chlamydia infections was detected (P = 0.91), suggesting that increased testing may have occurred in a lower risk population. Modified forms did not change test submission (P = 0.75).

CONCLUSIONS

Interactive workshops for general practices can be used to successfully increase chlamydia-testing rates. Chlamydia detection rates will need to be monitored as this type of educational programme may not increase absolute numbers of chlamydia infections detected, if patients at lower risk of infection are inappropriately tested. Other interventions may need to be combined with the workshops, to reach sufficiently high chlamydia screening rates to significantly reduce prevalence of chlamydial infection.

Improving the appropriateness of laboratory submissions for urinalysis from general practice

BACKGROUND

Urine is the most common microbiology laboratory specimen. Submissions increase annually by 5-10%, and many specimens may be unnecessary.

OBJECTIVES

To assess the impact of guidance, implemented by interactive workshops and reinforced with modified request forms, on specimen submission.

METHODS

This was a prospective randomized controlled study with modified Zelen design. The study population comprised five primary care trusts (PCTs) in Gloucestershire/County Durham/Darlington, containing 82 general practices in six geographical clusters. The six clusters were randomly assigned to urine workshop covering submission in the elderly, adults and children or a control workshop. Within these groups, half the practices were randomized to receive modified laboratory forms emphasizing the workshop messages. Practices were not aware of the study.

RESULTS

Workshops lead to a 12% reduction in urine submissions from 16- to 64-year olds, which persisted for the 15 months but had no effect on bacteriuria rate. Workshops had no significant effect in the elderly or children. Modified forms were not associated with any reduction in submissions but were associated with an 11% reduction in detection of significant bacteriuria in 16- to 64-year olds.

CONCLUSIONS

The 12% decrease in urine submissions from 16- to 64-year olds, attained with workshops, may help counter relentlessly rising test submissions. Modified forms are currently not worth pursuing. When educational workshops are used across PCTs to change practice, the change in test submission is smaller than attained in educational initiatives involving volunteers. Workshops may be more effective if they also discuss urine submissions from asymptomatic patients and are directed at high testing practices and care homes.

Hypertriglyceridaemia in diabetes

Mild hypertriglyceridaemia is common in diabetes, but patients with newly presenting or poorly controlled diabetes may have a quantitatively different syndrome of gross hypertriglyceridaemia, which should be treated by optimising glycaemic control before use of lipid lowering drugs.

Best practice in primary care pathology: review 3

This best practice review examines four series of common primary care questions in laboratory medicine: (i) "minor" blood platelet count and haemoglobin abnormalities; (ii) diagnosis and monitoring of anaemia caused by iron deficiency; (iii) secondary hyperlipidaemia and hypertriglyceridaemia; and (iv) glycated haemoglobin and microalbumin use in diabetes. The review is presented in question-answer format, referenced for each question series. The recommendations represent a précis of guidance found using a standardised literature search of national and international guidance notes, consensus statements, health policy documents and evidence-based medicine reviews, supplemented by Medline Embase searches to identify relevant primary research documents. They are not standards, but form a guide to be set in the clinical context. Most of the recommendations are based on consensus rather than evidence. They will be updated periodically to take account of new information.

Change of pathology request forms can reduce unwanted requests and tests

BACKGROUND

Developments in clinical and laboratory medical practice have resulted in a large increase in laboratory workload, with considerable financial implications. It has been shown that the design of laboratory request cards can influence patterns of test ordering and possibly reduce inappropriate requests.

AIMS/METHODS

To redesign pathology request cards with a view to reducing inappropriate test requesting.

RESULTS

A redesign of the request cards used by general practitioners in the Bradford area led to a significant reduction in the ordering of specific investigations.

CONCLUSIONS

The redesigning of pathology request cards can have a beneficial effect on test requesting.

Évolution de la prescription des examens de biologie après la diffusion de recommandations médicales sur les dyslipidémies

BACKGROUND

Guidelines for screening and treatment of dyslipidemia were disseminated in September and October 2000 by the National Agency of Accreditation and of Evaluation in Health (ANAES) and the French Agency of Medical Safety of the Products of Health (AFSSAPS). It was confirmed that the specific biological test was the measurement of LDL Cholestérol.

OBJECTIVE

To study changes in biological test practices after diffusion of guidelines among patients on statin therapy, using Health Insurance database on reimbursement of patients living in Ile-de-France region (8,534,623 social insurance contributors).

METHODS

Two groups of patients were defined in the database from the codes for medication refunds during one month (March 2000 and March 2002). The first group named "new users" included patients starting statin therapy in March, in order to follow the biological test for screening. The second group named "long term users" included patients who had been treated by statin therapy for one year or more, in order to examine the biological follow-up of treatment. All lipid biological tests were recorded during one year, before March 2000 and March 2002. Changes in medical practices were noted as the percentage of the biological tests for "exploration of a lipidic anomaly" (EAL) with determination of LDL cholesterol.

RESULTS

For new users the percentage of patients having had at least one EAL for screening purposes increased by 13.5 (39.9% in 2000 and 53.4% en 2002). For long term users the change was + 21.1 (38.3% in 2000 and 59.4% in 2002) during follow-up.

CONCLUSION

An improvement in biological testing practices was noted after diffusion of guidelines.