Abstract
In a recent article in this journal 1 I surveyed my local general practitioners (GPs) and Nurse Practitioners (NPs) to ask whether they found interpretative commenting useful, and I had overwhelming positive feedback in this regard.
However, I did not ask our users whether such comments actually influenced patient management. Given that there is little evidence in the literature that clinical commenting does indeed affect patient management, I decided to repeat the exercise, asking once again whether our users found comments helpful and also specifically whether the comments affected management.
I also decided to ask a supplementary question about whether our users approved of us ‘adding-on’ tests to the original request if this was considered by the laboratory to provide additional value to the original request; as this is considered to be a rewarding and fulfilling aspect of senior laboratory staffs' work. I decided to specifically ask this question as this practice has been debated extensively in the UK (and elsewhere across the globe) and has actually been considered potentially unethical 2,3 by some. Moreover, few studies have reported on its success or approval of it by service users. However, a study with respect to undertaking additional iron and Vitamin D studies has recently been reported 4 and another study of reflective testing of free triiodothyronine, γ-glutamyltransferase, lipid profiles, thyroid peroxidase antibodies and other tests showed that both hospital and general practitioner (GP) users generally approved of this activity. 5
A brief and simple ‘tick box’, 5 level Likert type, questionnaire was drafted asking GPs and NPs whether they found comments helpful or not, whether the comments influenced patient management and whether they approved of laboratory staff doing ‘add-on’ tests.
Notably, they were asked whether comments on the following groups of tests: follicle-stimulating hormone (FSH)/luteinizing hormone (LH), oestradiol, testosterone, prolactin, progesterone and cortisol, thyroid function test (TFT) and glucose tolerance test (GTTs) were very helpful, helpful, slightly helpful, neither helpful nor unhelpful, or unhelpful and whether they found such comments help/influence patient management, very frequently, frequently, occasionally, very rarely or never.
Comments are added manually by the author, a single-handed Consultant, and are a mixture of ‘canned’ (coded on the computer) or free text comments and generally have a consistent style and length. In the authors' absence, colleagues in PathLinks, the Lincolnshire-wide managed Pathology network will fulfil this role to ensure continuity in reporting practice/service.
They were also asked whether they strongly approved, approved, neither approved or disapproved, disapproved or strongly disapproved of laboratory doing ‘add-on’ or reflective tests. However, it should be emphasized that controversial or potentially unethical ‘add-ons’ such as tumour markers (except serum electrophoresis), haemoglobin electrophoresis, Hepatitis screening, etc., are not added without prior discussion with the requesting GP or nurse.
The questionnaire was sent to our entire group of 161 GPs and 26 NPs across our local Primary Care Trusts that use our laboratory. The survey was undertaken in February 2008.
Replies to the questionnaire were received from 107 out of 161 GPs (66.5%) and 21 of our 26 NPs (80.8%). The overall return rate was 68.4%. The results were analysed in the two separate practitioner groups and also combined to give overall percentage responses. Ninety-four percent of GPs and 86% of NPs found the comments on FSH/LH, etc., either very helpful or helpful (93% overall) and 78% of GPs and 67% of NPs indicated that these comments very frequently or frequently helped/influenced patient management (76% overall).
Eighty-four percent of GPs and 91% of NPs found the comments on TFTs, either very helpful or helpful (85% overall) and 73% of GPs and 91% of NPs indicated that these comments very frequently or frequently helped/influenced patient management (76% overall). Eighty-six percent of GPs and 86% of NPs found the comments on GTTs either very helpful or helpful (86% overall) and 79% of GPs and 86% of NPs indicated that these comments very frequently or frequently helped/influenced patient management (80% overall). One hundred percent of GPs and NPs either strongly approved or approved of the laboratory ‘adding-on’ tests to their initial requests. Overall, 78% strongly approved of this activity.
Therefore, in summary, in at least 75% cases our comments either help or influence patient management; a figure which is very close to the 70% figure which is often quoted as the proportion of patients' diagnoses or management decisions that are aided/guided by pathology investigations. This is very encouraging as it justifies the time and effort that senior laboratory staff across the UK, put into this time-consuming activity. It also highlights the importance of participation, by relevant laboratory staff, in the UKNEQAS interpretive comments QA scheme thus helping ensure that any comments that we, as laborotarians make, are ‘accurate’ and do indeed add clinical value to the laboratory request.
Finally, there has been considerable debate about whether laboratory staff should undertake reflective, or ‘add-on’ testing but this survey has clearly shown that there is overwhelming (100%) support for this practice among our local GPs and NPs. This is very reassuring and in my view dispels any ethical arguments that might be made against it.