Abstract
Recently Barlow published the results of a survey among local general practitioners (GPs) and nurse practitioners (NPs) 1,2 in which he analysed whether adding or incorporating clinical interpretative comments on biochemistry results (also called reflective testing) was found to be helpful. It was concluded that there was overwhelming support for this activity. We have made a similar observation in the Netherlands. 3,4
The practice of reflective testing by laboratory staff was introduced to 155 local GPs in June 2006. In a first study GPs received a questionnaire describing 10 fictitious patient cases, each involving the possible addition of a specific test. Four possible options could be chosen: (1) add on (a) test(s); (2) telephone the GP and discuss the case; (3) add a comment without further testing; or (4) no further action by the laboratory. Seventy questionnaires were returned (response rate 45%). Most GPs (91%) were in favour of adding on tests for diagnosis of anaemia, γ-glutamyltransferase (79%), lipid profile (65%), troponin (67%), tests for studying renal impairment (63%), thyroid peroxidase antibodies (56%) and serum protein electrophoresis (56%) in the given scenarios. On the contrary, only 25% and 39% respectively would have wanted a pregnancy test or prostate-specific antigen (PSA) added without prior consultation. These results are comparable with those of a similar study in the UK. 5
In addition, the effect of adding on tests and comments to laboratory reports on the diagnostic and therapeutic process was evaluated. Part of this study was published previously. 4 GPs received 200 historical laboratory reports from their own patients to which additional tests and comments had been added. In an accompanying questionnaire they were asked to indicate whether reflective testing had had a positive, negative or neutral influence on management of the specific patient. In cases of a positive influence, this could be further elaborated as earlier diagnosis/treatment, adjustment of medication, additional diagnostic tests initiated (i.e. echo of the liver at suspicion on steatosis), no further need for additional diagnostic tests, earlier referral to a medical specialist, or otherwise. In cases where the GP felt there was no influence on patient management, they were asked to indicate whether the additional information had been useful or not. In cases of a negative influence they were asked to give further details. The response rate of this part of the study was 78% (156/200); 150 of the questionnaires could be used for analysis. The results showed that 53% of the GPs indicated a positive influence of adding tests and comments on patient management. Overall, this was expressed in an earlier diagnosis/treatment (38%, particularly in case of anaemia, thyroid disease or renal disease), earlier referral to a medical specialist (29%, anaemia or renal disease), adjustment of medication (18%, thyroid disease), additional diagnostics (16%, steatosis) or no further need for additional diagnostics (5%, Gilbert syndrome). Only 1% reported a negative influence on patient management, with 46% reporting no influence of reflective testing. Overall, 99% of the GPs indicated that the given information had been useful.
Our study confirms the results of Barlow 1,2 and emphasizes that additional support by means of adding on tests and comments to pathology results by the laboratory staff is appreciated by GPs. Moreover, it leads to an improvement of the diagnostic and therapeutic process of patients in the majority of cases.
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