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Key Points Question What is the association of a multifaceted intervention aimed at changing the mindset of caregivers with the amount of unnecessary laboratory testing? Findings In this before-after quality improvement study conducted in the internal medicine departments of 4 large teaching hospitals in the Netherlands, the volume of laboratory tests ordered per patient contact was reduced in all 4 departments by 11.4% overall. In contrast, volume increased by 2.4% in 19 comparable hospitals in the Netherlands. Meaning The approach used in this study can be used as a framework for future projects aiming to reduce unnecessary laboratory diagnostic tests in routine clinical practice.

Rationale Extensive research has been conducted on clinical reasoning to gain better understanding of this process. Clinical reasoning has been defined as the process of thinking critically about the diagnosis and patient management. However, most research has focused on the process of diagnostic reasoning. Because of the lack of understanding regarding therapeutic reasoning, education in patient management decisions lacks a solid theoretical basis. Aims and objective To improve medical education, training and refresher courses with regard to therapeutic decision making. Methods A search on the literature about clinical reasoning has been conducted. Based on this literature a hypothetical model of therapeutic reasoning is developed. Results It is assumed on the literature about diagnostic and therapeutic reasoning that after the diagnosis has been formulated, the process of determining the therapy is initiated by a concept called the therapy script. Patient cases unconsciously elicit such scripts and they consist of relevant treatments, knowledge and clinical experiences. Analytical and non-analytical processes determine the final choice of therapy. Subsequently, these processes adapt the therapy script continuously. Conclusions A hypothetical model of therapeutic reasoning has been developed in order to improve medical education, training and refresher courses with regard to therapeutic decision making. Future research should empirically test the validity of this hypothetical model in different phases of the medical education continuum.

BackgroundAppropriate use of diagnostic laboratory tests is challenging, and estimates of 20% for overutilization and 45% for underutilization have been reported. Introducing effective and sustainable solutions to stimulate optimal use of laboratory testing in clinical practice is a challenge. A recent pilot study from our group, focusing on increasing the awareness about appropriate laboratory testing with the aim of changing the mindset of health care workers, has shown promising results. In this project, we aim to extend this multistep intervention to the internal medicine departments of 4 large Dutch hospitals. We aim to reduce unnecessary laboratory testing by 5%.ObjectiveOur primary objective is to determine the effect of our intervention on diagnostic laboratory test order volume. Our secondary objectives are to determine the effect of our intervention on laboratory expenditure and order volumes, expenditures for other diagnostic modalities, and clinical patient outcomes. We will also analyze the barriers and facilitators for deimplementation of unnecessary laboratory testing.MethodsThe main interventions of this before-after study will be an intensified supervision of residents by experienced physicians regarding test ordering, creating awareness through education and monthly feedback on ordering patterns, and changes in (computerized) order entry systems.ResultsAt the time of publication of this protocol, the project is in the phase of data collection. We expect to present data on reduction early in the fourth quarter of 2018.ConclusionsIn this project, we aim to reduce the unnecessary diagnostic testing in the internal medicine departments of 4 teaching hospitals. Although the main interventions will be similar, each clinic is given the opportunity to focus on the specific facets of the interventions as deemed useful according to the local situation. If effective, the study provides a framework for a nationwide initiative for reducing inappropriate laboratory testing.Registered Report IdentifierRR1-10.2106/10473

In one-third of preoperatively screened patients, an MEA was found. The number of medications and respiratory comorbidities are risk factors for MEA in preoperatively screened patients.