Is clinical practice variability the major reason for differences in pathology requesting patterns in general practice?

Abstract

Aims: To examine whether variations in pathology test requesting between different general practices can be accounted for by sociodemographic or other descriptive indicators of the practice. Method: This was a comparative analysis of requesting patterns across a range of pathology tests representing 95% of those requested in general practice, in 22 general practices in a single district, serving a population of 165 000. Spearman correlation coefficients were calculated and both the top and bottom fifths of activity were displayed graphically to detect trends at the extremes of the ranges. Results: The proportion of women of childbearing age, median practice Townsend scores, or the existence of specialist miniclinics within the practice did not have a demonstrable impact on requesting patterns. A weak correlation was found between the proportion of elderly patients and creatinine/electrolyte testing but not for the other two tests examined for this patient group. Conclusions: The large differences observed in general practice pathology requesting probably result mostly from individual variation in clinical practice and are therefore potentially amenable to change.A lthough the relation between sociodemographic parameters, morbidity rates, and the use of medical services on a large scale is well established, 1 2 we are not aware of similar reports for the use of pathology services, either on a broad population basis or within individual health localities. Clinical practice is often assumed to account for differences in the use of pathology tests, but there is little published evidence to support this.Recently, we have published details of a simple model that may be used to monitor test requesting activity in general practice across different tests in pathology.3 This model produced stable results over time, and showed considerable differences between the test requesting activity of 22 general practices. In a context of primary care groups being able to use this type of model in a clinical governance setting, it is important to exclude potential confounding variables that could explain these differences, to provide credibility for any intervention designed to change practice."Clinical practice is often assumed to account for differences in the use of pathology tests, but there is little published evidence to support this"To examine whether these variations could be explained by differences in the general practices themselves, or in the general practice catchment area, we have considered several individual factors in the cohort of 22 general practices studied.We had previously shown that adjusting the overall rankings of requesting numbers for age and sex to produce standardised requesting ratios for each practice did not alter the unadjusted rankings of request activity.3 However, most practices in these distributions lie within a broad modal band of requesting, and it is possible that age and sex adjustment of overall activities may not detect particular extremes of activity for certain tests. Therefore, we set ou...

Preanalytical quality improvement. In pursuit of harmony, on behalf of European Federation for Clinical Chemistry and Laboratory Medicine (EFLM) Working group for Preanalytical Phase (WG-PRE)

“…Definitions of appropriateness vary from tests which are manifestly not necessary, to those producing normal results which nevertheless may be entirely appropriate in the clinical context. However, comparative benchmarking of activity shows differences between primary care test submissions of up to 2000% between top and bottom deciles of requesting activity for some tests, which suggests that something more should be done [14]. Even when taking into account assorted patient demographics, specific practice subspecialist interests and social depravation indices, these differences still remain, thus suggesting that the main driving force is clinical decision-making.…”

Temporal growth and geographic variation in the use of laboratory tests by NHS general practices: using routine data to identify research priorities

“…23 Furthermore, during preliminary analysis of selected tests (C-reactive protein, folate level, glycosylated haemoglobin (HbA1c), thyroid stimulating hormone, serum creatinine, blood glucose, calcium, alkaline phosphatase), it was found that the proportion of tests with numerical results Several UK-based and international studies have concluded that regional variation exists in primary care test-ordering behaviour. [6][7][8][9][10][11] One of these studies observed large differences, probably driven by clinical practice variation, 10 in the patterns of pathology test requests of 22 UK general practices. Some studies have investigated variations at the clinician 8 or practice 9,10 level; however, individual practices or practitioners could not be identified within the present study.…”

“…[6][7][8][9][10][11] One of these studies observed large differences, probably driven by clinical practice variation, 10 in the patterns of pathology test requests of 22 UK general practices. Some studies have investigated variations at the clinician 8 or practice 9,10 level; however, individual practices or practitioners could not be identified within the present study.…”

“…1 Concerns that many laboratory tests requested by GPs are unnecessary 4,5 may be supported by considerable regional variation, both in the UK and worldwide. [6][7][8][9][10][11] Wennberg's 'professional uncertainty hypothesis' suggests that some geographic variation occurs because of regional differences in physicians', or a regional opinion leader's, beliefs about the value of the test or treatment, rather than geographic variations in patients' need. 12 Inappropriate test use has also been attributed to factors such as patient pressure and the use of 'defensive' diagnostic testing to reduce malpractice liability.…”

Appropriateness of test use in pathology: a new era or reinventing the wheel?

“…1), 8 and these di¡erences are not accounted for by di¡erences in practice-list demographics, deprivation indices or organizational features of the practices (type of mini-clinics, number of partners) themselves. 20 A similar study of di¡er-ences between 174 general practices in the North-East and South-West of England, each covering a population of 1.1 million, has revealed even greater di¡er-ences for a range of microbiology tests. These have shown a 10-fold or greater di¡erence between the top and bottom quartiles of GP activity.…”