Decision-making in general practice: the importance of laboratory analyses when choosing medical actions

Presenter: Siri Fauli Munkerud, Norwegian Medical Association, NOKLUS, HERO

Abstract

Background: Laboratory analyses are widely used in diagnostic work-up and monitoring of patients in primary care. Getting the correct treatment at an early stage may in turn decrease the patient’s likelihood of developing a more severe form of the illness that requires more complex and costly care. Thus, the economic consequences for laboratory analyses may amount to a substantial proportion of health service costs. In Norway GPs are reimbursed for use of several near patient tests, and the less impact of test results, the less motivation it is for the government to spend money on reimbursement. There is a lack of studies on the impact of test results in clinical practice.

Objectives: Our main purpose is to develop a model to study the impact of a near patient test result with regard to medical actions taken in general practice. We also study the effect of characteristics of the GP and the practice on the medical actions chosen. Information about what factors influence the medical actions chosen in general practice is important for implementing strategies to be able to secure rational use of near patient tests.

Methods: Blood sample based tests to detect the bacterium Helicobacter Pylori (HP) are useful in diagnosing peptic ulcer, and suitable to illustrate the model.

A clinical vignette, describing a young woman with dyspepsia, was surveyed to GPs in Norway. GPs who requested the H. Pylori rapid test (HPRT) in response to the vignette were asked to suggest actions related to either a negative or a positive result of the test (HPRT). These actions were then categorised into three management strategies for initial handling of the patient i.e. only symptomatic treatment to ease the dyspepsia, referral for upper endoscopy, or medication to eradicate H. pylori, so-called triple therapy. In addition, we obtained information on the socio-economic characteristics of the GPs. Discrete choice analysis with multinomial logit models with normally distributed effects was used to analyse the choice of medical actions.

Results: We find that the result of the HPRT has a major influence on actions suggested, and in particular for the management strategies symptomatic treatment and triple therapy. In addition, travelling time needed to have upper endoscopy, whether or not the GP recommends sick leave, and whether or not the GP makes a follow-up appointment with the patient all have significant effects on the choice of medical actions.

Conclusion: Since HPRT- results seem to have a major influence on the GPs’ choice of medical actions, an important prerequisite for reimbursing near patient tests is fulfilled. Further, the analytical quality of test results is likely to affect patients’ health and social costs.