Laboratory Utilization: Knowledge, Attitudes, and Strategies



good morning my name is Janet crane I'm the manager of knowledge mobilization at cadiz welcome to today's webinar laboratory utilization knowledge attitudes and strategies for today's online presentation we have approximately 170 participants questions and discussion will occur at the end of the presentation however online participants should feel free to enter their questions at any time they may submit their question at the bottom left hand of the screen please identify yourself and the organization you represent with your question to begin the webinar and pleased to introduce Gabriel Zimmerman Thank You Janet and thank you all for joining us this morning my name is Gabriel Zimmerman and i am the Alberta liaison officer for Academy and for those of you that are not familiar with caddis also known as the Canadian agency for drugs and technologies and health where we are an independent not-for-profit agency responsible for providing Canada's health care decision makers with objective evidence to help make important decisions about the appropriate use of drugs medical devices diagnostics and procedures in our health system over the past couple of years we've witnessed an increased interest in the appropriate use of laboratory tests kadith has supported decision making in this area through the production of a number of studies such as troponin point-of-care testing for inr factor 5 Leiden and prothrombin mutation testing and others what we are very interested in now is in contributing to the conversation about laboratory test optimization and encouraging it to continue this session like the eight other sessions we are co-hosting across the country is designed to meet your specific needs we know that a one-size-fits-all approach when it comes to lab test optimization does it work so we are doing what we can to help individual groups meet their goals on March 23rd will share the results of these customized customized events broadly to carry on the conversation and also introduce the opportunity for and collaboration across the laboratory test communities in Canada we are really pleased to have this opportunity to work with you today and now it's my pleasure to introduce your speakers this morning we have dr. Chris naw blur the zone clinical section chief general pathology and section had laboratory informatics with calgary laboratory services he's also an associate professor with the departments of pathology and laboratory medicine and family medicine at the University of Calgary dr. Roger Thomas is a professor of family medicine and Cochrane Collaboration coordinating coordinator also at the University of Calgary thank you thanks very much Gabrielle so we'll be sharing the podium this morning I'm going to go first I think this conflict of interest statement would apply to equally to both of us we have no relevant conflicts of interest to declare so for an outline this morning as I said two parts the first I'll be discussing brief description of landscape of test ordering in Calgary and giving you some preliminary results of a survey of knowledge and attitudes of primary care physicians towards laboratory utilization and i will just re-emphasize that the the focus this morning is on family physician ordering and then dr. thomas is going to talk about some systematic reviews we've recently completed but I'll leave that to him so part one so the first thing I'm going to show you is some detailed information on the lab testing environment in Calgary we have about 3,500 physicians who are ordering tests from Calgary lab services we're kind of unique I think in the country and that there's one laboratory that services the entire population so we essentially have the entire testing history for the whole city within our lab information system of those 3,500 physicians are both 1500 primary care physicians in total for 12 months of testing the last year was 23 million tests and these are again our clinical laboratory tests additional tests with Plato pathology anatomic pathology so these are just clinical lab so what we did for the first part of this is we looked at 12 months of testing so it was calendar year 2013 and we converted the tests into cost per position and cost per specialty we did this to try to get a better idea of the landscape of overall testing the second part i'm going to show you was a survey to primary care physicians in alberta and we grateful to have the help of the Alberta Medical Association in promoting the survey I think we've had close to 175 responses so far and we will be closing that survey off today because I'm going to present the results and don't want to bias things so we'll go on to this slide and I think I have ability to use the pointer here so we looked at at 35 different specialties within Calgary and we looked at we as i said we broke into individual physicians into specialty group we want to see how much was the relative spanned of each of each specialty group so I know these may be hard to read along the bottom I think the important one to point out here is primary care which is about 68 million dollars out of a total of about 200 million for our lab budget and this represents about fifty eight percent of lab expenditures in Calgary so it's clear that family physicians primary care physicians are by far the most powerful group in terms of ordering laboratory tests and they actually dwarf any other specialty group the next largest group is internal medicine which is here at just over 10 million dollars that's about nine percent of of the expenditures so fifty-eight percent is again a huge number compared to any other group if we break it down into expenditures per physician we see primary cares actually fall somewhere in the middle it's about forty four thousand dollars as an average number per position there are groups that are more expensive their groups that are less expensive so on an individual basis prime very care is is is near the center of the pack this next slide shows if we break it down this is just family dog fever break it down into laboratory cost per physician and the numbers at the bottom here I'll just explain they may be a little hard to see most of the physicians the largest group rather is actually spending ten thousand dollars or less per year on lab tests and then we see this long tail where we have a very small number of physicians at the end of the tail here that are actually spending very large amounts of money on lab tests and so there's actually 18 physicians who spent greater than two hundred thousand dollars in that year on lab tests and so if we break this down into physicians or rather break it down into percentages we actually have twenty percent of lab tests by costs that are ordered by four point seven percent of primary care physicians so I want to go on a little bit talk about the utilization survey that I described earlier so there's a few questions through just five questions i believe here that i'm going to show you we first question we asked is how important do you consider the issue of laboratory tests over use and ninety-five percent of respondents thought it was important or very important very few of the responding physicians thought it was unimportant next we asked of all lab tests combined please estimate the percentage of tests ordered without clinical indications and this is just mean mode and median they're all about the same but thirty percent of was the estimate from primary care Doc's of tests ordered without clinical education that's probably very close to the literature values between twenty and thirty percent would be the common values from the literature unnecessarily repeated lab tests the the average estimate for that was twenty five percent we found in previous studies now berta it's probably closer to twenty percent but it's still still a pretty accurate estimate we asked what's the proportion of lab tests not ordered in situations where indicated and the average response was about fifteen percent to know how accurate that is probably a little bit on the low side and finally we asked what percentage of lab tests represent false positives and the average response was fifteen percent that's probably a little bit high lab tests by definition have about a five percent false positive rate that's your your two standard deviations but all in all we found that the physicians responded were pretty well informed in terms of of lab testing next we asked who's responsible for addressing issues regarding appropriate lab utilization and the options were individual family doctor individual medical doctors and ninety-seven percent thought it was responsibility of individual physicians to address appropriate lab utilization Alberta Medical Association 67% Alberta Health Services or other provincial agencies 71 percent laboratories themselves seventy-nine percent and patients fifty-eight percent and the last slide on the survey is a little more busy I'll just walk you through a few of the salient points which of the following are acceptable approaches to improving the quality of lab testing and we gave this list to choose from the first one was was education and ninety-eight percent thought this was an acceptable approach to trying to improve lab testing audit and feedback so called report cards which are used in a number of jurisdictions was the next most common strategy at eighty-four percent and then below that they all fall in the fifty percent range or less so user pay fifty percent restricting certain tests to specialist groups thirty-eight percent specialized tests requisitions forty-five percent modifying test requisitions 51% restricting test frequency 56% pathologist approval which is something we use fairly commonly in Calgary thirty-six percent and we asked about positive incentives or in quotes gainsharing for changes in test rating practices this was actually the least the least positive response among this group of physicians who responded so conclusions I think we can draw from these are number one primary care physicians are by far the mo important group with regards to lab tests utilization utilization rates are highly uneven among physicians and despite this there's a very high level of awareness of lab utilization issues among primary care physicians and there is a very strong opinion from the survey that physicians themselves are responsible for addressing problems so I think the final takeaway message that I'll leave you with is that at least from the survey work we've done and comparing with the actual test patterns there seems to be a gap between knowledge and action among primary care physicians that's one of the one of the issues were hoping to to address later on today so with that I'll turn things over to dr. Thomas right so since this is all about numbers we'll start off with a couple of jokes so as a mathematical group called themselves solving for function and just like here in the hotel they rang up to get their annual meeting and the response of the hotel keepers was we do not cater for functions if somebody tells you before I was 25 I dated a number of supermodels and won a number of Nobel prizes you have to remember that 0 is also a number so what do you Alan said some people drink deeply of the river of knowledge and others merely gargle so I'm going to present sir be a systematic review so far of what we've done in finding interventions to change test ordering and you or judge the depth of the river you just put a stick in is it deep or not Marcus is online and Turin is actually lecturing on the advanced epidemiology Khorasani he'll be here so we searched all these databases and when we done it we put every relevant study which is my favorite approach into PubMed single citation matcher what it'll do you put the study in it'll find 1500 400 related studies you chase those up see if their spot on then some of those you put them in single citation matcher so we've done that we may find more studies and we're going through extensive series of reviews that we found so far we found 22 randomized control trials about educating physicians and you can see the Dutch have been working about this for a long time so the studies there are three from Canada involving more of the 3000 family doctors so one of the things I'm going to tell you is that they're extremely heterogeneous every institution tested their an intervention for the problem that worried them there are no replications at all in different environments and nobody has ever taken their study and improved it or dents somebody else 18 out of the 22 studies the follow-up was a year or less so you've got tremendous variation in the number of tests targeted sometimes it's one sometimes it's several there's a fair amount of variation and risk of bias so the cochrane risk of biases did use strong method randomized did you conceal the allocation from the researchers do you have blinding do you have attrition we're going to do that right at the end some of the more recent studies actually performed rather well on these criteria others of them before 2000 before the consort statement didn't do so well so I'm going to talk about 14 randomized control trials as positive singer there so you can't talk about them all so just doing a selection and there are three kinds or so automated reminders which is I set something up on your computer I go away audit and feedback and one that you're really enjoyed by car delayed testing wait for a month and use the tincture of time to see if the patient gets better and so you see that some of these are really quite complex so quite a lot of focus on chronic illness diabetics are always a front of the pack in these studies so this is a pretty automatic thing every time the electronic medical record was opened up algorithm checked if the patient had received care according to 50 dance-based guideline reminders for diabetes and for for coronary artery disease you've got reminders displayed within your electronic medical record with medication problem lists I mean that's pretty thorough now the puzzle is intervention group got more annual cholesterol exams for diabetics but there's no change in hemoglobin a1c ordering or cholesterol exams for coronary artery disease this is a theme i will bring out we don't know why these things work nobody actually bother to find out why it worked or didn't white work by focus groups are internet or interviews afterwards now here's a 1 by flaw top in Norway and you'll find quite often they do one thing with one group of practice is one group with another so if I'm in one group I'd have got a guideline at a computerized decision support a system and reminders about urinary tract infections and Chris would have got the same for sore throat and we will be the control group for each other so I mean 16,000 consultations for sore throat hit one physician didn't do them all now what's odd you get a three point six percent decrease in lab tests for your and retract infection no differences for sore throat me there's been a tremendous amount of discussion about sore throat MacIsaac poor criteria are guessing if they got strep throat so that's really odd and we're going to go on to now one by Holbrook from canada on diabetics now this sounds pretty good doesn't it there's a compete diabetes tracker monitored 13 variables and set targets from Canadian American Diabetes Association guidelines I told you I'm going to be focusing on dimensions because I want you to think what you'd do there was an automated telephone system for patients and patients have access to the web tracker and they got a color-coded track of four times then you take it to your physician I gather in France if the patient owns the x-rays and they come to you say doctor what are you going to do about this and monthly reminders for laboratory and physician visits now we know for studies with residents that the more work it is to look something up they don't do it so often you know they don't need a five percent would look out something in a computer system this looks like a pretty thorough system doesn't it now what was interesting is through no statistical differences after all this effort in hemoglobin a1c LDL albuminuria testing and there was a cholesterol mean level with point2 lower so shows they go from 7.41 let's say total cholesterol would go from six to five point eight not a big difference in terms of process aight process measures for looking after the diabetics they would there was an overall improvement going to stop for a minute I've given you some flavor of what's going on I'd like to take a piece of paper out and write down the change you would like to see if you were the Minister of Health for a province or whoever and the three interventions you use would you like to do that just for about a minute its intervention you would like what change you'd like to see and the intervention and we'll see if somebody has tried it for you or you could do it in your ped just a minute one you do that and choose the top three methods okay we'll carry on now here's a study from Canada about punching and this I think would be of great interest to laboratory directors they got hold of the family physicians who ordered the most live or actually tests in a year these are the outliers that Chris is detected and they got three visits by lab reps over two years with educational material that's a huge investment of time to get in your car gps would beam present than yet and so their personal laboratory utilization was presented discuss compared with beers and they got a relation reduction of seven point nine percent in tests which is very effective an absolute reduction of point two two tests per visit so this actually works its audit and feedback what is in feedback is one of the most preferred methods so that worked here's a study in Belgium and there been a huge number of studies of how well can we organize our anticoagulation services sixty percent of most patients on warfarin are within the therapeutic limits and that's actually the comparator groups for most of the new anticoagulants debate get around actually compared to warfarin so what they did they organize them into four groups so everybody got education on oral anticoagulation they got the UK guidelines they got patient information booklets feedback every two months which is quite intense on their practice performance compared to everybody else and then second group got personal intervention feedback every two months about how well I'm doing and then number 3 o's given a tester to use in my office and the fourth group got all the others plus a computer to advise them now what was interesting is all four groups improved from forty nine point five percent of baseline which actually a low level to sixty percent were within north point five of an inr from the preferred but no differences between the groups so the intensity of the intervention didn't seem to make any difference so that the mildest one worked as well as the others so you can see that we're building up a lot of puzzles aren't we there's no particularly predictable way of getting doctors to change or figuring out which intervention automatically produces a change now here's an interesting study suppose I get up my game and I actually offer you a patient recall system I give you audit and I arrange for all the patients who should be getting the new intervention to come back this worked very well actually so they looked at patients with coronary heart disease so Group one the feedback was to the primary healthcare team could be five doctors 20 doctors nurses and then they recalled for the GP set up a disease register and I will organize a recall of patients number three was nurse they have quite a few what it called nurse-led clinics have written set up disease register systematic records a nurse-led clinic so let's see what happened so really dramatic increases so the audit group where the practice got it cholesterol jumped from forty two percent at baseline to sixty-seven percent and they were very interested obviously in smoking Costantini as a measure whether you're telling the truth about smoking a big jump their GP recall group also big increases and the nursery core also big increases and the nurse have been recalled to the nurse was better than just audit to the practice thirty-three percent recordings the GP was better than audit by twenty three percent and the nurses when nine percent better than GPS but it wasn't a distinctly significant so this is one that worked with three different groups and it seems that making it personal to the physician or personal to the nurse is better than to the group as a whole so there's something of interest now something also that lab directors will like this is a study in the United Kingdom so for senior lab clinician said my laboratory tests have limited value so let's see what we can do about getting rid of them so they gave feedback every three months and color graphs of every practices test rate group to got feedback and they got fifty percent got educational messages or brief educational reminders automatically added to the test results or both so they had several levels of intervention so they're really telling you very very clearly what's going on here and it was effective so the practice of its receive the enhanced feedback reduced orders for all nine tests and four of them were statistically significant autoantibody screens f sh t sh vitamin b12 practice we've got the brief educational reminders also reduced orders rate tests and so really about a 13-percent to eleven percent difference but what's interesting Chris showed you how variable or doctors were the variability didn't change that seems to be the hardest thing to change is the is the variability among doctors the outliers and the in liars now this is a really fun study in the Netherlands a very inventive group Holland is called the country of randomized control trials compared to Germany which doesn't do so many so unexplained fatigue doctor I'm tired you know this is not going to be a short visit because there are many many possibilities so group while the physicians were told you may order blood tests if you deem it appropriate and they were given two sets Chris will love this only four tests hemoglobin sedimentation rate which is obviously out of date now you wouldn't do that a glucose and a TSH or you can have a complaint list specific list of 20 tests or group two were told ok tincture of time wait a month then you can order the tests they gave three got the same plus a systemically developed quality improvement strategy so the complaint doctor I am tired is dreaded by most family doctors because it's a tricky one so what was interesting the 26 of the GPS randomized to order blood tests immediately ordered tests 146 of 158 patients the reflex to get the pen art came right out the GPS said you can only order tests after four weeks only ordered tests on 27 of the 138 and what did it all add up to for the whole 325 patients testing established diagnosis only in an 11 out of 325 for diabetics 3 anemia 110 new cases one hyperthyroid one fallacy Mia one vitamin B deficiency and three illness is not by testing what was interesting few patients in the delay group re consulted the GP within four weeks then what it meant don't know whether they didn't enjoy the visit and then he was going anywhere doctor didn't listen or they got better and the expanded fatigue set of 13 tests resulted more false positives than a limited set of four tests so what Chris was emphasizing before tests have a certain false positive rate the more tests to expose people to the more false positives you're going to get so though this is really a quite fascinating study and took us a long way in the analysis of fatigue we don't know what happened to the patients so we don't know where their fatigue got better we just focused on test ordering now we're going to look at eight that had no significant effect and if you can figure out why they're didn't work and the others did it will give you a gold medal so we can same concept automated reminders and audit and feedback so Eccles 31 practices 3,000 patients another one of these way you get one set of practices to do the angina guidelines and another set of practice nearly 5,000 patients gasma guidelines and they were randomized to computerize guidelines after 12 months no differences this is a beautifully set up randomized control trial Jeremy Grimshaw who's head of collaboration Cochran Canada was involved in the setup of it Stream amount of effort went into this no difference at all and they couldn't explain why and as I said nobody ever bothers to set it up afterwards to figure out why things work or why things don't another one in Norway so they had GPS and diabetic patients so they got them to participate in seminar in risk intervention diabetes and hypertension and gave them a computer based decision support system and GPS in another another 5 500 diabetics at all well as usual stuff interesting no difference is at all in hemoglobin a1c of cholesterol no explanation why so very often the approaches I will lay an intervention on you if it works great if not I will scratch my head but nobody actually figures out or plans ahead of time to find out why it works why it doesn't white works with some doctors and patients why doesn't work with others now here's one in the States nearly 23,000 patients in Georgia 123 rural counties a classic Qi organization feedback every six months they were told also all about diabetes care glycemic control diabetic nephropathy patient education clinical practice guidelines practice aids to implement guidelines this is what happened so both the intervention the control group improved isn't that interesting they rural Georgia is pretty big state and there was no difference pretty low levels of hemoglobin a1c in terms of urine protein very few differences very very tiny rates so this massive effort resulted in improvements in both the intervention and control group no explanation why now here's a study in Leicester and again the two practices the lab sent guidelines encouraging fewer urine and more serum lipid tests there was a prime minister of a foreign country who used to say I drink my own urine and somebody held up a sign outside the parliament buildings that said less risky more whiskey so one of the members of population had a great deal of humor anyway so it was an encouragement of fewer urine and more serum lipid tests then feedback at three-month intervals for a year and the lead GP convened the meeting so probably everybody else was snoozing while the DGP talked then another group of practices got feedback about the thyroid tests rheumatoid factor tests in urine cultures then another set of GPS got feedback about lipid and plasma viscosity tests as well this Foster's were very popular in and at one time interesting you know changing numbers of tests per thousand tests orders for anything no effect of feedback you figure nobody bothered to figure out or could figure out why it didn't work at this massive effort now here's a study that's really interesting by kefir and it's 3000 Medicare diabetes patients in a care quality improvement project in Alabama so the physicians were randomized to receive chart review physician specific feedback achievable venture art feedback compared to achieve all benchmark feedback and chart review and keith has done this actually for influenza vaccination and he actually made a difference so the idea is let's say Chris is among the top best performing doctors in terms of getting people vaccinated so it's advertised this is the benchmark you must achieve what Chris has done they may not tensioning to suppose his name and all the rest of us think right I'll show you I'll do just as well as you know statistically significant differences at all even you know they've had actually the vaccine one sort of had placards up in this in the waiting room this is how we're doing this is how dr. Chris is doing compared to dr. Roger look he's got far more have you vaccinated and you know the doctors go and look around and say no country get can't you help me get my numbers up so open naked us competition we worked with influenza vaccine doesn't work with this go figure now we come on to a subject that will alert the laboratory deck directors sitting there obvious with a wave of a mouse they can prevent people doing things that see how it works this is an interesting study in Netherlands way back in nineteen ninety two so they said okay you can only have fifteen hematological chemical tests and I love this some urine and feces tests whatever that means and a book that is explaining the essential features of the tests and very interesting quite sophisticated samples of prior and posterior probabilities and if you wrote in a test you are required to say is it to confirm our hypothesis check your own disorder spree no no risk factors or the patient asked you to and in the experimental group the number of tests 4,000 patients from one pre-intervention 72 and a half after the invention an eighteen percent reduction and then they reintroduce the standard form and guess what they back to their old level so that I guess probably need a format size of a postage stamp and here's some others bailing the youkai decided they just removed for tests and fantastic rates of decline for ldh seventy-nine percent calcium sixty-two percent CRP thirty percent rheumatoid factor twenty-seven percent and in Israel Israel has very large health maintenance organizations called planet in the south and they don't grow b12 folic acid and ferreting group together and labeled anemia so just separated them and they got sixty percent decreases in folic acid fifty percent in ferreting forty percent in b12 and a two percent decrease in iron so you can sit as i said to you some of these groups do very small numbers of tests and some very large groups and this had an effect but none of the went on foot I've only about 40 that went on for more than a year so we don't know what happened after that now here's one in the States and they said okay if I practice in the States and Medicare is a formidable organization that is very punitive if you do any more than you should so they said okay you can only do medicare-approved panels and if there's a cascade will explain it in detail so really no statistically difference in the tests for seven months after the intervention with a very restricted list okay so why did that work don't know so the conclusions randomized control trials to educate family physicians in evidence-based testing extremely heterogeneous in the design the populations the number of tests targeted 22 individual interventions outcome measures the duration of intervention 1422 got significant results aight didn't in terms of the laboratory directors four out of five by laboratory directors achieved significant reductions there are no qualitative observational interview or focus group studies to understand why some interventions work why some don't why some have a large effect why sell have a small effect so the question is do we need a national evidence-based laboratory form that groups could adopt we do experiments on it conclusions part two should we focus on the interventions we've got lots of those should it be the intervenors so i'm the author of a 30 a cochrane review on interventions in schools to prevent smoking by children we did 135 randomized control trials it took about 18 months to analyze them all so a lot of these actually did a very good job at checking that the intervention was delivered according to protocol according to manual they go in the classrooms make sure the teachers gave the intervention so we can phone a focus on the intervenors the big issue that we talked about as a group last night is buy-in and ownership why should I do this why should i buy in and then how frequent should feed back the watch form should feed back take so I've also done a systematic review of interventions in families to prevent children smoking 27 systematic reviews 22 different interventions one replicated by 21 replicated by three so it's very very common for people to use their own individual intervention just because it's part of their course it's their local thing I systematic review of interventions to teach undergraduates suturing techniques techniques for emerged techniques are ICU the suturing studies often never look to what other people did just kicked off did their own thing quite sophisticated you know three surgeons observing I was asked to review a study of German surgeons in quite a lot of reviews searchable methods and there was a lot of variation between surgeons but also with insurgents certainly use different techniques no explanation why so I think we're very very short and explanations why things work so my proposal would be a national level form we perform experiments we figure out why things work and don't thank you very much so equal to one we have about 20 minutes for four questions so there's a couple of questions from the phone I will start off with the first is we have an inherent weakness in not being able to measure appropriateness rather than test volume so this is an excellent question i think so how do we know what's appropriate or inappropriate so there's been some reviews written entirely addressing this topic sometimes i think we can define appropriate or inappropriate if there's a specific guideline so for instance of vitamin d testing is the one that's commonly brought up some of the other screening tests have guidelines that folks can follow or not fall but to the vast majority of tests there isn't a guideline or a gold standard to say you know when is it appropriate to order CBC and you're not going to find a clinical practice guideline that tells you so that the another approach to that is to look at unexplained practice very and look for outliers which is an approach we've taken in in Alberta there's some problems with us in that you need to define your your peer group very carefully so you're comparing apples and apples but that's another way that's used more commonly maybe in in clinical medicine rather than in lab in the lab world I think it has some some merit in terms of looking at practice variants as a proxy for for appropriateness there's an another question but you have anything to add to that Roger yes the guidelines for a wide range of diseases often give no advice about frequency of testing particularly true for chronic diseases particularly true for combinations of chronic diseases recorded is in the audience was involved in a project looking at all of the guidelines for coronary artery disease and chronic disease and tried Boyle done Rick can you shout out the numbers of total guidelines and the number the attraction managed to reduce it to way too many but did you reduce it to about 89 siege guidelines but yes yeah you know we have brought the other large numbers and I think the take-home messages up to try for our staff my position to try to follow guidelines space they would spend 24 hours they just doing guidelines based investigation not at any time for acute care so it's a huge problem in terms of digesting bring out of court number know that answers your question but yes it does so Chris and I were talking about deliverables that we should aim for so certainly one is to publish our systematic reviews and make all these available and secondly to make sure that there's a very handy concise evidence-based review of testing frequency inappropriate it's very difficult to do that's certainly something that is essential to move forward so for those in the phone if you couldn't hear the response i think the gist of it was there's way too many clinical practice guidelines for family physicians to realistically follow or you would do nothing but follow guidelines all day and not actually do any acute care so the next question is are along the same lines our clinical practice guidelines a problem in driving excessive in quotes mindless testing when individual patient circumstances don't need it and i think i think we've we've maybe partly answered that question is an interesting question because it's kind of a double-edged sword I mean you need some standards in most cases to to to hold up as as a comparator to individual practice but our people just mindlessly going through and taking off lists I what I do it feelings on that Roger we don't know we don't know what people are doing so I think it is it really is kind of a double-edged sword but also also an unknown be interesting to look at when there's a clear new guideline cut that comes in you know before and after tests orders that are mentioned as something we should probably look at look at doing so next question concerns choosing wisely Canada and the question is is there any hope for choosing wisely Canada to make an impact so this is something that you know we've discussed recently I think choosing wisely Canada and I will admit some bias because I've been involved with that with that program nationally choosing wisely Canada itself is not offering interventions or direction to individual labs or physician groups I think part of its impact is to raise awareness to identify areas that should be looked at and so really until we start to do some analysis on when it when a guideline when a recommendation comes out is there any change in practice and we actually do have some of those projects underway but for my from my point of view I think it's it's a very good initiative for raising awareness for a rallying point for physicians and labs and health system payers but is it actually going to make an impact I don't know well hungry has a unique laboratory database and probably a deliverable we need to aim for is to look at the guidelines and see what change in the patient status is observed by monitoring patients for particular tests and the interval we don't really have us data on and benefit from the patient data so we probably what we should do is scrutinize the guidelines in great detail and see how evidence-based they are about the testing component yeah I want there's any other questions from the phone I will just make a comment regarding the removal of tests from requisitions it's interesting to see that there was a big reduction in that one study we've got some some data from Alberta as well and I've had a chance to discuss this with some other lab directors across Canada in the last couple of weeks we we had the experience of a few years ago where we took a full laid off of our requisitions single test and it actually resulted in an eighty percent reduction in in folate orders we've recently been doing a trial where we've had a greatly simplified requisition where we took about half or two-thirds of the tests off not as a shortened a list as say bc or ontario has but when we took a whole bunch of tests off we actually saw no change in test ordering so there seems to be you know maybe it's sort of anecdotal but maybe there's some some level there's some psychologic factor there that a few things are kind of oda cited of mine but if you make a radical change it actually people just start get the pano to start writing so something I think that that warrants maybe some additional study so another question from the phone is it more effective to target patients than providers to improve test utilization have you come across any studies on that Roger I haven't come across anything in the literature certainly that addresses that I think in our internal discussions in Alberta the the consensus is we probably need to do both even though we don't know what the relative impact is going to be certainly patients are not commonly involved in these discussions and if they are it's often more of a token involvement rather than through engagement so I think we just don't know what the effect would be if you have if you have real a deep public or patient engagement patients should pull the love I mean occasion so there's a question from from the group here in in Calgary and the question was regarding the survey we did where we asked family physicians whose responsibility is to be engaged in utilization the question is if happy what possible ways could patients be be involved so it's an excellent an excellent question so one of the things we don't understand well is how many tests are ordered because of patient pressure so how many patients go in and you know I need a vitamin D test and I'm not going to leave until I get it and it's easier to write the to make a tick box on the wreck so I think some that would be one way that patients could be more engaged is actually taking a more active involvement in their care and and realizing you know what's an appropriate level of testing for them what do they really need what do they not need but besides that I think you know it's still it's still an open question there's another question from from the phone what are the key benefits for physicians ie in their practice to be part of an exercise for utilization of diagnostic tests as being optimized so I think the question is what's in it for for the physicians I have an opinion you want to start the Roger you go ahead Chris okay so you know it's there's a couple of ways you could address this question one is I think it's its key just to the sustainability of our health care system to be to be better stewards of our resources so the maybe the more altruistic answer is is that it's it's unnecessary I think going forward in order to to be able to pay for the services for patients another issue that we commonly raised with medical students when we talked about this is ordering tests that aren't necessary is not risk-free you know we've all in the lab side and I'm sure many of you who are practicing physicians have seen negative outcomes from false positive test result so biopsies that didn't need to be done radiologic procedures so if we realize that about 5% of lab tests are going to be sort of ink wotus false positives the social stress to patients of having being labeled with potential illness that they don't have so there is some I think demonstrable negative effects to 22 patients by being over tested in addition to the health system I impact it was a group last night and we discussed a wide range of topics Oh certainly one is that Alberta has net care so every laboratory test is on that can you should be able to look it up but you have to get a little forward little computer which sinks for the main computer in Edmonton and Chris tells me the rate of people actually getting fobs is quite low so Alberta has a high rate of using electronic medical records compared to the other provinces because the government subsidized the use of computers and actually provided a lot of management expertise introducing them into practices because many family doctors are still paper the data would have to come from the laboratories so the laboratory's need to have a buy-in and they would need to either do it because they wanted to or they have to explore financial incentives for them because they would be the ones who would have to provide the data to the how many doctors and some might only be able to communicate by fax if they're not on electronic medical records that's the first thing laboratories would need to be motivated secondly in terms of physicians we're wondering how government could be bought in government a motivated one of my colleagues was telling the government just impose cuts David here and they just impose oh well impose a forty percent cut you did thirty percent are shared will just do it no discussion so we in a time of financial stringency we're wondering how governments can be involved in innovative ideas so one if one concept firmly physicians is the idea of the medical home so you go there there is a respiratory technologist for your asthma there's a dietitian of extremely popular our clinic for your weight problems diet problems and VG's problems there's a counselor for your psychiatric problems what would be really popular as a physiotherapist for all the injuries people do to themselves so within this framework of providing comprehensive care the government would say okay if you reduce unnecessary tests we will provide more money for you to hire a physiotherapist in other words the practice would be a better practice very attractive to patients that's one concept should you make it attractive to the patients and the doctors as a group as a whole and the government or should you reward doctors for doing fewer tests as I said there's one study that shows you can actually pay doctors in the States for doing influenza vaccinations that's easy just a vaccination you send in the billing that's a very very simple intervention so we've been grappling with the idea is how do you entice government what is the motivator for doctors and patients probably with patients I think patients the ones who are very responsible and would wish to be educated say no I don't want another hemoglobin test mine was fine six months ago and I don't feel any different my weights the same blah blah blah and there are those who have very very anxious so I think we need to get out a lot of data for patients to show them why we do tests and why there's no point repeating test frequently so we've been struggling with ideas ready to how to get major buy-in from government don't know so another question from from a four when is decapitation systems seem to have an impact on test utilization now we did have a discussion on this last night that someone had raised an example is does someone remember that in the room of a system where that there's basically capitation meaning the physicians given a sum of money to spend on their patients for the for the following year and if they have some leftover presumably they keep some or all of it this is it might be analogous to fund holders in the UK Roger do you have any i I don't I haven't read any direct literature on that at all of you have right so the way it works in the UK family doctors are paid for knowing about their patients knowing and recording the blood pressure recording where they've had a pap smear recording where they have a colonoscopy and they get a separate set of payments for having a blog posts within range and having the cholesterol within range and the hemoglobin a1c in range and actually the family doctors about three years ago done so much of this they got a massive increase in the income much the surprise of the government because they got it all recorded the other side of this is that practices in the UK have far more IT support within the practice collecting all this information so there's a problem for Canada we have very little IT support in practices to collect this detailed information probably in the larger practices the as I say the sort of medical home where there's a focus on delivering a wide set of services to patients one of the things will be to put more itn and gather support and perhaps one of the bargains could be to the practice as a whole you would have fewer unnecessary tests then we finance a physio for you to be very attractive idea for most practices so I guess another point to raise what that is I kind of now there is sort of a de facto capitation system in most labs in Canada but it's not at the level of the physician it's at the level of the laboratory so labs are given a bucket funding to see them through the following year but the actual decisions aren't being made within the lab they're being made within physician offices so I think that this caller was may be wondering about is there any evidence if you that that funding to actually physicians whether it it makes any change in ordering and I guess the answer is we just don't know well we know that surgery in England because one certain groups had exceeded their money to doing surgery they say well we can't do anymore and that's not very popular to get to october veto we can't do any more lab tests so it requires great prudence on the part of everybody to space out the money month by month so we've got couple questions from the room here just a couple of comments on the capitation side and we're going to capitated practice certainly utilization in terms of physician visits just go down in that system the second is that I think the what's in it for me question is is critical because you know reflecting on my own practice as a family physician when the patient is there in front of unit it takes nanoseconds to order a test it takes minutes to explain why not order a custom so there really is no intrinsic incentive and same thing with looking up net care which camp very complex process in terms of doing other security clearances just takes time so what's in it for me yeah so just repeat that for folks on the phone if you couldn't hear one of the primary care physicians in the room here had was commenting that they do work in a capitated system and they do see at least a reduction in visits from that the second comment was concerning the what's in it for me and the point was made that that's a really key question to try to answer because it's much more difficult to try to look up an old test result electronically or have a discussion with the patient in terms of why they don't need it rather than the nanosecond it takes to make a tick mark on on the on the test requisition I was I was going to give you a story of capitation experiment that we did implementing a new test into an ER service we asked the physicians ahead of time how many patients do you think would need this test they gave us that and I'm or during an evaluation period we confirmed that the number they gave us was the right number so when we implemented we told them they would have that number of tests per month and if they ran out of tests by the 28th of the month of the 22nd of the month there would be no more till the start of the next month we monitored this for two and a half years in the only one month did they go over their volume thank you that was dr. Jim Lee Sandberg the medical director for lab sent in Alberta sober so I think we've we've used our time up this morning and it was a very useful discussion I thank everyone for their attention and for the very interesting questions that were sent in you

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