Ron Winkens

Evidence base of clinical diagnosis: Rational, cost effective use of investigations in clinical practice

Investigations such as blood tests and radiography are important tools for the making correct diagnoses. The use of diagnostic resources is growing steadily—in the Netherlands, for example, nationwide expenditure on diagnostic tests is growing at the rate of 7% a year. Unfortunately, health status is not improving similarly, which suggests that investigations are being overused. The ordering of tests seems not to be influenced by the fact that their diagnostic accuracy is often disappointing. Considerations other than strict scientific indications seem to be involved, and we may ask whether new knowledge and research findings are adequately reflected in daily practice. Several factors may be responsible for the increasing use of investigations, such as the increasing demand for care (due to ageing of the population and increasing numbers of chronically ill people); the fact that they are available, which in itself leads to ordering; and the urge to make use of new technology. Once an abnormal test result is found, doctors may order further investigations, not realising that on average 5% of test results are outside their reference ranges, and a cascade of testing may result. Furthermore, higher standards of care, the guidelines for which often recommend additional testing, and defensive behaviour have led to more investigations. Unfortunately, when guidelines on selective and rational ordering of investigations are introduced, numerous motives for ignoring evidence based recommendations, such as fear of litigation, or procrastination on the part of the doctor, come into play in daily practice and are difficult to influence. Overuse of investigations—and there is reason to believe that some requests are illogical—leads to overloading of the diagnostic services and overexpenditure: more efficient usage is therefore needed. Interventions focusing on overt examples of inappropriate testing might reduce costs while simultaneously improving quality of care. #### Summary points Intervention is needed to reduce the often …

Use of out of hours services: a comparison between two organisations

Objectives: To investigate differences in numbers and characteristics of patients using primary or emergency care because of differences in organisation of out of hours care. Background: Increasing numbers of self referrals at the accident and emergency (A&E) department cause overcrowding, while a substantial number of these patients exhibit minor injuries that can be treated by a general practitioner (GP). Methods: Two different organisations of out of hours care in two Dutch cities (Heerlen and Maastricht) were investigated. Important differences between the two organisations are the accessibility and the location of primary care facility (GP cooperative). The Heerlen GP cooperative is situated in the centre of the city and is respectively 5 km and 9 km away from the two A&E departments situated in the area of Heerlen. This GP cooperative can only be visited by appointment. The Maastricht GP cooperative has free access and is located within the local A&E department. During a three week period all registration forms of patient contacts with out of hours care (GP cooperative and A&E department) were collected and with respect to the primary care patients a random sample of one third was analysed. Results: For the Heerlen and Maastricht GP cooperative the annual contact rate, as extrapolated from our data, per 1000 inhabitants per year is 238 and 279 respectively (χ2(1df)=4.385, p=0.036). The contact rate at the A&E departments of Heerlen (n=66) and Maastricht (n=52) is not different (χ2(1df)=1.765, p=0.184). Some 51.7% of the patients attending the A&E department in Heerlen during out of hours were self referred, compared with 15.9% in Maastricht (χ2(1df)=203.13, p<0.001). Conclusions: The organisation of out of hours care in Maastricht has optimised the GP’s gatekeeper function and thereby led to fewer self referrals at the A&E department, compared with Heerlen.

Effect of feedback on test ordering behaviour of general practitioners.

OBJECTIVE--To assess the effect of feedback on the test ordering behaviour of general practitioners. DESIGN--Comparison of requests at two diagnostic centres, and internal comparison between tests which were discussed in feedback and tests which were not. SETTING--A diagnostic centre in Maastricht giving feedback and another elsewhere in the Netherlands (laboratory A) not giving feedback. SUBJECTS--All 85 general practitioners in the region of Maastricht, and all general practitioners in the region of laboratory A. MAIN OUTCOME MEASURES--Numbers of tests requested by general practitioners. RESULTS--Requests at the Maastricht diagnostic centre decreased soon after the onset of feedback whereas there was a persistent increase in requests at laboratory A. Tests that were discussed showed the strongest decrease (maximum 40%), though tests that were not discussed decreased as well (maximum 27%). CONCLUSIONS--Feedback on diagnostic requests may exert a strong influence on request behaviour. Four years after the onset of feedback the effects were still noticeable.

Quality of clinical aspects of call handling at Dutch out of hours centres : cross sectional national study

Objective To assess the quality of telephone triage by following the consecutive phases of its care process and the quality of the clinical questions asked about the patient’s clinical condition, of the triage outcome, of the content of the home management advice, and of the safety net advice given at out of hours centres. Design Cross sectional national study using telephone incognito standardised patients. Setting The Netherlands. Participants 17 out of hours centres. Main outcome measures Percentages of clinical obligatory questions asked and items within home management and safety net advice, both in relation to pre-agreed standards, and of care advice given in relation to the required care advice. Results The telephone incognito standardised patients presented seven clinical cases three times each over a period of 12 months, making a total of 357 calls. The mean percentage of obligatory questions asked compared with the standard was 21%. Answers to questions about the clinical condition were not always correctly evaluated from a clinical viewpoint, either by triagists or by general practitioners. The quality of information on home management and safety net advice varied, but it was consistently poor for all cases and for all out of hours centres. Triagists achieved the appropriate triage outcome in 58% of calls. Conclusion In determining the outcome of the care process, triagists often reached a conclusion after asking a minimal number of questions. By analysing the quality of different phases within the process of telephone triage, evaluation of whether an appropriate triage outcome has been arrived at by means of good clinical reasoning or by an educated guess is possible. In terms of enhancing the overall clinical safety of telephone triage, apart from obtaining an appropriate clinical history, adequate home management and safety net advice must also be given.

The Impact of a Primary Care Physician Cooperative on the Caseload of an Emergency Department: The Maastricht Integrated Out-of-Hours Service

AbstractOBJECTIVE: To determine the effect of an out-of-hours primary care physician (PCP) cooperative on the caseload at the emergency department (ED) and to study characteristics of patients utilizing out-of-hours care. DESIGN: A pre-post intervention design was used. During a 3-week period before and a 3-week period after establishing the PCP cooperative, all patient records with out-of-hours primary and emergency care were analyzed. SETTING: Primary care in Maastricht (the Netherlands) is delivered by 59 PCPs. Primary care physicians formerly organized out-of-hours care in small locum groups. In January 2000, out-of-hours primary care was reorganized, and a PCP cooperative was established. This cooperative is located at the ED of the University Hospital Maastricht, the city’s only hospital, which has no emergency medicine specialists. MAIN OUTCOME MEASURES: The number of patients utilizing out-of-hours care, their age and sex, diagnoses, post-ED care, and serious adverse events. RESULTS. After establishing the PCP cooperative, the proportion of patients utilizing emergency care decreased by 53%, and the proportion of patients utilizing primary care increased by 25%. The shift was the largest for patients with musculoskeletal disorders or skin problems. There were fewer hospital admissions, and fewer subsequent referrals to the patient’s own PCP and medical specialists. No substantial change in new outpatient visits at the hospital or in mortality occurred. CONCLUSIONS: In the city of Maastricht, the Netherlands, the PCP cooperative reduced the use of hospital emergency care during out-of-hours care.

Adherence to professional guidelines for patients with urinary incontinence by general practitioners: a cross-sectional study.

BACKGROUND Urinary incontinence is a common problem, affecting quality of life and leading to high costs. There is doubt about the use of clinical practice guidelines on urinary incontinence in primary care. OBJECTIVE To assess adherence levels and reasons for (non)adherence to the Guideline on Urinary Incontinence of the Dutch College of General Practitioners. Design, setting and participants A postal survey among Dutch general practitioners (GPs). MAIN OUTCOME MEASURE Adherence of GPs to the guideline. RESULTS We analysed 264 questionnaires. Almost all GPs adhered to the guideline when diagnosing the type of urinary incontinence. A bladder diary is not often used (35%). Adherence to therapeutic procedures was only high for mild/moderate stress urinary incontinence: most GPs (82.6%) used adequate advice on bladder retraining and pelvic floor muscle training. One out of four GPs agreed that adhering to the guideline is difficult, mainly owing to lack of time, staff, diagnostic tools, competences to provide this care and low motivation of patients. CONCLUSIONS Dutch GPs follow the guideline only partially: compliance with diagnostic advices is fairly good; compliance with treatment advices is low. Further research should focus on solutions how to support GPs to tackle major barriers to facilitate the adherence to guidelines (substitution of tasks to specialized nurses, reducing the threshold for referral and concentrating expertise in integrated continence care services).

Does a joint development and dissemination of multidisciplinary guidelines improve prescribing behaviour: a pre/post study with concurrent control group and a randomised trial

BackgroundIt is difficult to keep control over prescribing behaviour in general practices. The purpose of this study was to assess the effects of a dissemination strategy of multidisciplinary guidelines on the volume of drug prescribing.MethodsThe study included two designs, a quasi-experimental pre/post study with concurrent control group and a random sample of GPs within the intervention group. The intervention area with 53 GPs was compared with a control group of 54 randomly selected GPs in the south and centre of the Netherlands. Additionally, a randomisation was executed in the intervention group to create two arms with 27 GPs who were more intensively involved in the development of the guideline and 26 GPs in the control group.A multidisciplinary committee developed prescription guidelines. Subsequently these guidelines were disseminated to all GPs in the intervention region. Additional effects were studied in the subgroup trial in which GPs were invited to be more intensively involved in the guideline development procedure. The guidelines contained 14 recommendations on antibiotics, asthma/COPD drugs and cholesterol drugsThe main outcome measures were prescription data of a three-year period (one year before and 2 years after guideline dissemination) and proportion of change according to recommendations.ResultsSignificant short-term improvements were seen for one recommendation: mupirocin. Long-term changes were found for cholesterol drug prescriptions. No additional changes were seen for the randomised controlled study in the subgroup. GPs did not take up the invitation for involvement.ConclusionDisseminating multidisciplinary guidelines that were developed within a region, has no clear effect on prescribing behaviour even though GPs and specialists were involved more intensively in their development. Apparently, more effort is needed to bring about change.

Feasibility and acceptability of a computerised system with automated reminders for prescribing behaviour in primary care

OBJECTIVE To evaluate the feasibility and acceptability of a computer reminder system (CRS) to improve prescribing behaviour in general practice and to explore the strengths and weaknesses of a reminder system. One group of GPs received reminders on cholesterol lowering drugs, the other group on antibiotics, asthma and COPD drugs. METHODS Process evaluation of the computer reminder system being used by 53 GPs in 20 practices, by means of an analysis of the research database of the CRS. In addition, a questionnaire and semi-structured face-to-face interview were conducted with all GP practices, two project leaders, and one technical consultant. RESULTS The strategy was largely carried out as planned, although the development period for the CRS had to be extended. Nine percent of the GPs dropped out. We found a significant learning curve without extinguishing effect (p=0.03) for the antibiotics reminders. The questionnaire showed that, in general, GPs were satisfied with the user-friendliness and the content of the different types of reminders, but less satisfied with certain specific technical performance issues of the system. The GPs reported mixed feelings towards the CRS in the interviews. They were generally positive about the guidelines themselves, but negative regarding to the organisational context and the method of implementing the CRS. GPs stated that they sometimes manipulated the system to bypass reminders. Interviews with the project leaders and technical consultant revealed barriers to cooperation and miscommunication between the different parties, and technical problems with multiple updates of the GP information system and the operating system. CONCLUSIONS This process evaluation demonstrated that the implementation of the CRS was mainly carried out as planned, but the subjective experience of working with the CRS was not only positive. Participating GPs had mixed feelings, and quite a number of barriers need to be addressed to facilitate large-scale implementation of the CRS. Costs cannot be neglected, so it is important to analyse the balance between costs and effects.

Out-of-hours primary care. Implications of organisation on costs

BackgroundTo perform out-of-hours primary care, Dutch general practitioners (GPs) have organised themselves in large-scale GP cooperatives. Roughly, two models of out-of-hours care can be distinguished; GP cooperatives working separate from the hospital emergency department (ED) and GP cooperatives integrated with the hospital ED. Research has shown differences in care utilisation between these two models; a significant shift in the integrated model from utilisation of ED care to primary care. These differences may have implications on costs, however, until now this has not been investigated. This study was performed to provide insight in costs of these two different models of out-of-hours care.MethodsAnnual reports of two GP cooperatives (one separate from and one integrated with a hospital emergency department) in 2003 were analysed on costs and use of out-of-hours care. Costs were calculated per capita. Comparisons were made between the two cooperatives. In addition, a comparison was made between the costs of the hospital ED of the integrated model before and after the set up of the GP cooperative were analysed.ResultsCosts per capita of the GP cooperative in the integrated model were slightly higher than in the separate model (ε 11.47 and ε 10.54 respectively). Differences were mainly caused by personnel and other costs, including transportation, interest, cleaning, computers and overhead. Despite a significant reduction in patients utilising ED care as a result of the introduction of the GP cooperative integrated within the ED, the costs of the ED remained the same.ConclusionThe study results show that the costs of primary care appear to be more dependent on the size of the population the cooperative covers than on the way the GP cooperative is organised, i.e. separated versus integrated. In addition, despite the substantial reduction of patients, locating the GP cooperative at the same site as the ED was found to have little effect on costs of the ED. Sharing more facilities and personnel between the ED and the GP cooperative may improve cost-efficiency.

Routine individual feedback on requests for diagnostic tests : an economic evaluation

The authors assessed the economic consequences of routine individual feedback on test requests provided to 85 family physicians in a region with 187,000 inhabitants. In a retrospective study as part of a quasi-experiment, cost trends in a region where feedback was provided over a seven-year period were compared with cost trends elsewhere in The Netherlands without feedback. Data on variable costs were obtained for 400 individual tests that accounted for 90% of all requests. Differences in request trends thus were transformed to savings in costs of diagnostic testing, taking account of the extra costs of providing the feedback. Expenditures for diagnostic testing de clined after the start of the feedback, despite the costs of providing the feedback. The savings increased as the feedback continued. Compared with the trend elsewhere without feedback, over seven years a total net sum of 1.4 million U.S. dollars was saved. Routine individual feedback is therefore economically worthwhile. Key words: economic evaluation; feedback; diagnostic testing; quality assurance; cost contain ment. (Med Decis Making 1996;16:309-314)