Understanding Referral Patterns for Bone Mineral Density Testing among Family Physicians: A Qualitative Descriptive Study

Abstract

Introduction. Evidence of inappropriate bone mineral density (BMD) testing has been identified in terms of overtesting in low risk women and undertesting among patients at high risk. In light of these phenomena, the objective of this study was to understand the referral patterns for BMD testing among Ontario's family physicians (FPs). Methods. A qualitative descriptive approach was adopted. Twenty-two FPs took part in a semi-structured interview lasting approximately 30 minutes. An inductive thematic analysis was performed on the transcribed data in order to understand the referral patterns for BMD testing. Results. We identified a lack of clarity about screening for osteoporosis with a tendency for baseline BMD testing in healthy, postmenopausal women and a lack of clarity on the appropriate age for screening for men in particular. A lack of clarity on appropriate intervals for follow-up testing was also described. Conclusions. These findings lend support to what has been documented at the population level suggesting a tendency among FPs to refer menopausal women (at low risk). Emphasis on referral of high-risk groups as well as men and further clarification and education on the appropriate intervals for follow-up testing is warranted.

Acceptability and Feasibility of an Evidence-Based Requisition for Bone Mineral Density Testing in Clinical Practice

“…The usefulness of the RUR as a tool to remind PCPs of the CPGs, as identified in the current study, is consistent with our previous research that has demonstrated that FPs lack clarity about the 2010 Canadian CPGs on appropriate screening for osteoporosis as well as the intervals for BMD follow-up [15]. This may be due to the fact that there are multiple sources of recommendations for BMD testing which do not always agree with the 2010 guidelines [1].…”

Why do clinicians overtest? A narrative review and workshop group discussion exploring influences on clinician overtesting as possible causes of overdiagnosis

“…If you really mess things up, so that the patient switches to another doctor, that's what affects me" [37] ""So they see it as their right to have it" [46] "I guess I do it because...I want my patients to perceive that I practice good medicine...you do have to be seen to be proactive" [46] "There is a demand from patients for testing or medication or imaging that they've read about or they feel that they should get in order to be satis ed that they've been adequately cared for" [47] "Patients absolutely drive test ordering..." [47] "Patients come in and they say, 'Oh, I have this, and I want a CT scan done.' They'll tell you what they want done" [51] "If we order more tests and we make sure we have every test ordered that might possibly be needed, the patient's happy and leaves in their ED [emergency department] stay" [51] "I'll say "well you just had one two years ago, you're on treatment, it was stable from the year before, and I don't think you need one"… what does usually happen is that they usually win" [64] "Can improve relationship between patients and doctor" [65] "Check-ups are largely patient driven secondary to media/public health generated anxiety" [ "There are situations where I've ordered an echo when I otherwise would not have because guidelines mandated" [29] "I think there's more, as much as we've developed these decision rules-I think there's a lot to be said about just experience" [39] "I think people are wary of practicing not in line with that and then they have potential then for criticism" [46] "There's plenty of guidelines, but they're all different and there's nothing o cial...there's no hard and fast rule" [46] "Because I work in a teaching practice, my residents are very devoted to guidelines. A lot of them are driven by the more recent guidelines" [64] Financial incentives 20 articles "Well, often the supervisor just says to run some tests, and I just accept that without question" [3] "I recently ordered a lipase, but then the gastroenterologist called me and said: in this hospital, we always combine it with an amylase."…”

“…They'll tell you what they want done" [51] "If we order more tests and we make sure we have every test ordered that might possibly be needed, the patient's happy and leaves in their ED [emergency department] stay" [51] "I'll say "well you just had one two years ago, you're on treatment, it was stable from the year before, and I don't think you need one"… what does usually happen is that they usually win" [64] "Can improve relationship between patients and doctor" [65] "Check-ups are largely patient driven secondary to media/public health generated anxiety" [ "There are situations where I've ordered an echo when I otherwise would not have because guidelines mandated" [29] "I think there's more, as much as we've developed these decision rules-I think there's a lot to be said about just experience" [39] "I think people are wary of practicing not in line with that and then they have potential then for criticism" [46] "There's plenty of guidelines, but they're all different and there's nothing o cial...there's no hard and fast rule" [46] "Because I work in a teaching practice, my residents are very devoted to guidelines. A lot of them are driven by the more recent guidelines" [64] Financial incentives 20 articles "Well, often the supervisor just says to run some tests, and I just accept that without question" [3] "I recently ordered a lipase, but then the gastroenterologist called me and said: in this hospital, we always combine it with an amylase." [3] "If an experienced cardiology colleague says we should do another echo, I would not feel strong enough to say no" [29] "If the neurologist had written, "There's nothing the matter" ...…”

“…[37] "I think for any test if it's very, very available and it's fast and it's easy to do and it doesn't take a lot of time and there's more turnaround on the report-then we're just more likely to use it more." [39] "It would probably be valuable to make the process less convenient because the threshold is so low to order CTs" [39] Factor Articles Illustrative quotes Pre-emptive testing for subsequent care 10 articles [26,29,43,46,47,51,[63][64][65]73] "I am glad that I can refer to something… And you could describe that as medical overuse to some extent. Because we are talking about tests which were not totally urgent or rather luxurious given the speci c symptoms at that time.…”

“…But it can be really helpful to have this reference point" [43] "People are used to sort of being screened...so we're tacking this onto the discussion basically" [46] "They will tend to steer on the side of getting a test, even though it may be unnecessary, because they fear they will not be able to get the patient referred" [47] ""We order tests because we feel we have to get everything up front, because it's just too painful to do things too slow, to do things as a series" [51] "Often I'm doing [BMD tests] at menopause time in a woman's life when things sort of come up. I get a baseline maybe at menopause" [64] "You only realize the importance once you do it-the yield of signi cant results is surprising" [65] Contemporary medical practice and new technology 5 articles [7,28,29,43,77] "There is less emphasis on clinical examination. Nowadays we hear murmurs, and we try to quantify their severity which leads straight to ordering an echo… However, this can result in overuse of imaging" [29] "The greatest challenge will be to put more emphasis on history taking and physical examination again… This is the prerequisite to avoid further unnecessary investigations" [43] Following expert focus group discussion: † "medical culture" was grouped with "pressure from colleagues" ‡ "physical vulnerabilities" and "language barriers" were grouped with "time constraints"…”