Improving Test Ordering in Primary Care: The Added Value of a Small-Group Quality Improvement Strategy Compared With Classic Feedback Only

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Figure 1.
Structure of the 90-minute small-group quality improvement meeting.
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Figure 2.
Flow of randomized trial. PCP = primary care physician.
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Figure 3.
Baseline and follow-up measurements in mean total numbers of tests per 6 months at aggregated local practice group level for the 13 intervention and the 14 feedback local practice groups.

Table 1.

Clinical Problems and Associated Tests Used in the Trial

Clinical Problems	Tests
BUN = blood urea nitrogen; ECG = electrocardiogram; ALT = alanine aminotransferase; AST = aspartate aminotransferase; LDH = lactic dehydrogenase.
*Tests that are inappropriate according to national evidence-based guidelines on upper abdominal complaints (see Supplemental Appendix).
Cardiovascular conditions	Cholesterol, subfractions, potassium, sodium, creatinine, BUN, ECG (exercise)
Lower abdominal complaints	Prostate-specific antigen, C-reactive protein, ultrasound scan of the kidney, intravenous pyelogram, double-contrast barium enema, sigmoidoscopy
Upper abdominal complaints	ALT, AST,* LDH, amylase, γ-glutamyltrans- ferase, bilirubin,* alkaline phosphatase,* ultrasound scan of hepatobiliary tract

Table 2.

Study Population Characteristics at Individual Primary Care Physician Level

Characteristic	Intervention Arm	Feedback Arm
* Total practice population for whom the primary care physician is responsible. † Working time factor, full time = 100% = 5 days; each half-day = 10%, so a physician with a part-time factor of 70% works 7 half-day periods.
Number of physicians	85	109
Age, mean (SD), y	46.2 (6.6)	46.2 (6.6)
Female, No. (%)	14 (16)	11 (10)
Patients per physician, mean No. (SD)*	2,587 (641)	2,444 (416)
Patients >65 y, mean % (SD)	15 (6.8)	15 (6.5)
Working time factor, % (SD)^†	91 (15)	92 (12)
Physicians with a solo practice, No. (%)	43 (51)	44 (40)
Physicians who use computerized registration system, No. (%)	66 (78)	75 (69)

Table 3.

Effects of Strategy on the Mean (SD) Number of Tests and the Coefficient of Variance, per Primary Care Physician and per 6 Months

	Intervention Arm				Feedback Arm
Study Subjects	Baseline Mean (SD)	CV*	Follow-up Mean (SD)	CV*	Baseline Mean (SD)	CV*	Follow-up Mean (SD)	CV*	β^†	SE β	95% CI	P
Note: analysis of covariance adjusted for baseline number of tests and the regions.
CV = coefficient of variance; CI = confidence interval.
* CV = SD / mean.
† β = intervention effect = the total change between baseline and follow-up of mean numbers of tests in Intervention arm less the total change of numbers between baseline and follow-up of mean numbers of tests in the feedback arm.
Total number of tests	478 (309)	0.65	422 (235)	0.56	541 (337)	0.62	535 (309)	0.58	−51	17.94	−87 to −16	.005
Cardiovascular conditions	293 (189)	0.65	276 (157)	0.57	322 (214)	0.66	333 (205)	0.62	−25	13.08	−51 to 1	.056
Lower abdominal complaints	20 (20)	1.00	18 (19)	1.06	30 (40)	1.43	30 (27)	0.90	−6	2.18	−10 to −2	.008
Upper abdominal complaints	165 (125)	0.76	128 (82)	0.64	188 (143)	0.76	171(117)	0.68	−24	7.98	−40 to −8	.003
Inappropriate upper abdominal tests	55 (60)	1.09	39 (32)	0.82	60 (63)	1.05	56 (54)	0.96	−13	4.1	−22 to −5.2	.002

Supplemental Appendix and Figure

Supplemental Appendix. Upper Abdominal Complaints; Supplemental figure. An Example of a Feedback Report.

Files in this Data Supplement:

Supplemental data: Appendix - PDF file, 1 page, 46 KB
Supplemental data: Figure - PDF file, 1 page, 41 KB
The Article in Brief

Physicians who participate in specially designed meetings with their peers order fewer diagnostic tests than physicians who receive only written reports about test ordering. The small-group meetings were held among primary care physicians in the Netherlands to discuss tests they ordered for patients with cardiovascular conditions (such as high cholesterol levels) and upper and lower abdominal complaints, and to review national guidelines on those topics. Meeting participants ordered fewer tests than physicians who received only written feedback about their test-ordering behavior. This strategy may be an effective way to reduce unnecessary test ordering and is being implemented throughout the Netherlands.