Article Figures & Data
Figures
- Figure 1. Document screening and selection processes
- Figure 2. Final programme theory illustrating overarching context–mechanism–outcome configurations (CMOCs). ETTO = Efficiency–Thoroughness Trade-Off. Figure legend: single line oval = context, double line oval = mechanism, rectangle = outcome.
Tables
- Table 1. Summary of interventions and outcomes assessed in studies included in existing systematic reviews
Interventions prioritisingefficiency Interventions prioritising thoroughness Review Test-ordering outcome(s) Process changes (including computer systems) Guidelines and/or protocols Education Audit and feedback Financial incentives Solomon et al 199814 Reduction in test-ordering volumeReduction in test expenditure x x x x x Main et al 201015 Changes in test-ordering volume‘Appropriateness’ of testing x Smellie 201216 Reduction in test-ordering volumeReduction in test expenditure‘Appropriateness’ of testing x x x x x Cadogan et al 201517 Reduction in test-ordering volume x x x x Kobewka et al 201518 Reduction in test-ordering volume x x x x Thomas et al 201519 Reduction in test-ordering volume x x x Thomas et al 201620 Change in test-ordering volume x x x Zhelev et al 201621 Reduction in test-ordering volumeChanges in test expenditure‘Appropriateness’ of testingChanges in testing patterns x x x x x Delvaux et al 201722 ‘Appropriateness’ of testingChanges in test expenditureClinical outcomes x Maillet et al 201823 Changes in test ordering‘Appropriateness’ of testingWorkload x Step 1Initial programme theory (IPT) development An IPT is a first attempt to develop an understanding of the research question. To develop the IPT for this review, two scoping searches were run of the literature to identify: (a) existing theoretical perspectives; and (b) common intervention designs in relation to test-ordering practice. Full details of the search strategies are provided in supplementary Table S2. The IPT was further developed via the input of the stakeholder group and is presented in full in supplementary Figure S1. Step 2Searching for evidence The main search for evidence was undertaken with the aim of assembling a body of relevant data that could be used to develop and refine the programme theory. A broad range of sources were searched (n = 15) to ensure that literature across multiple disciplines was considered. Full details of the main search strategy are provided in supplementary Table S3.Additional documents were identified via supplementary search methods such as citation tracking (snowballing) and via personal contacts and networks.69,70Further searches were undertaken later to identify relevant substantive theory to act as a theoretical lens through which to understand the review’s overall findings.71 The search strategies employed are provided in supplementary Table S4. Step 3Selection and appraisal Document selection was based on an assessment of relevance (whether or not documents contained data that could be used to develop theoretical explanations [‘programme theory’]) and rigour (whether data were considered credible in relation to their role in contributing to the theory).26,72Included documents provided data on important contexts, mechanisms, and outcomes related to clinician decision making in relation to laboratory test ordering in primary care settings, or provided data related to analogous settings or decisions, or relevant theoretical perspectives. More details on data selection processes are provided in supplementary Table S1. Step 4Data extraction and organisation Included documents were read closely and coded in NVivo (version 12 Pro) to organise the data and identify important concepts that could inform the realist analysis. The characteristics of included documents (n = 145) are provided in supplementary Table S5. Step 5Analysis and synthesis Analysis and synthesis of included data involved the iterative development of realist ‘context–mechanism–outcome configurations’ (CMOCs).These are theoretical causal explanations describing how important contexts trigger the mechanisms that generate observed outcomes. Members of the stakeholder group provided feedback on the relevance and resonance of the developing theories. CMOC development and refinement continued until the reviewers agreed theoretical saturation was reached.A ‘final programme theory’ (FPT) was developed after consideration of the full set of CMOCs and drawing on theoretical literature.Full details of the CMOCs developed and illustrative data excerpts are provided in supplementary Tables S6–S8. Overarching CMOCs Illustrative examples of underpinning CMOCs When laboratory tests are perceived to be relatively trivial (C1), and cognitive resources are limited (C2), clinicians prioritise efficiency over thoroughness for test-ordering decisions, directing their cognitive resources to other clinical decisions (M) so decisions about testing will be based on heuristics or routines (O). When clinicians have incomplete technical knowledge about laboratory medicine and/or diagnostic reasoning (C), they rely on ‘gist’ understanding (M) to develop decision-making heuristics for test ordering (O) [CMOC 1b].In the presence of diagnostic uncertainty (C), clinicians may apply a heuristic of 'more testing is better' (O1) or 'rule out the worst case' (O2) as they seek to minimise the risk of missing a diagnosis (M) [CMOCs 2a–2b].When a test or condition is 'in fashion', and there is high awareness among clinicians and/or the public (C), the use of this test may be incorporated into testing heuristics (O) owing to increased awareness (‘salience’) (M) [CMOC 3g]. When laboratory tests are perceived to be relatively trivial (C1), and cognitive resources are limited (C2), clinicians prioritise efficiency over thoroughness for test-ordering decisions, and direct their cognitive resources to other clinical decisions (M) and so tests may be used to fulfil social and strategic functions (O). In the presence of diagnostic uncertainty (C), clinicians may demonstrate care (M1), attempt to reassure (M2), or exert control via ‘doing something’ for their patients (M3) by ordering tests (O) [CMOCs 5a–5c].When clinicians anticipate a 'difficult' interaction with a patient (C), they may use the offer of a laboratory test (O) as a strategy to help manage the consultation (M) [CMOC 6c].When clinicians anticipate disagreement with a patient about their proposed management plan (C), they may acquiesce to patient requests or expectations and order tests (O) to avoid having to explain why they are inappropriate (M1) or avoid conflict in the consultation (M2) [CMOCs 7b–7c]. When laboratory tests are perceived to be relatively trivial (C1), and cognitive resources are limited (C2), clinicians will prioritise efficiency over thoroughness in test-ordering decisions, and direct their cognitive resources to other clinical decisions (M) so decisions about testing will be open to wider system influences (O). When responsibility for patient care is shifted from secondary to primary care (C), clinicians in primary care settings comply with testing expectations and requests (M) received from secondary care and take on responsibility for associated testing (O) [CMOC 9c].In the absence of disincentives for inappropriate testing (C), clinicians and laboratory managers will not prioritise concerns about under/overtesting (M) and so will not take action to address these problems (O) [CMOC 10b].When tests are available to order as part of profiles or panels (C), clinicians may try to save time and cognitive energy (M) by ordering full panels instead of individual tests (O) [CMOC 11b]. C = context; M = mechanism; O = outcome
Supplementary Data
- bjgpopen20X101146.pdf -
Supplementary material is not copyedited or typeset, and is published as supplied by the author(s). The author(s) retain(s) responsibility for its accuracy.
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Efficiency over thoroughness in laboratory testing decision making in primary care: findings from a realist review
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