Abstract
BackgroundMedical tests provide important information to guide clinical management. Overtesting, however, may cause harm to patients and the healthcare system, including through misdiagnosis, false positives, false negatives and overdiagnosis. Clinicians are ultimately responsible for test requests, and are therefore ideally positioned to prevent overtesting and its unintended consequences. Through this narrative literature review and workshop discussion with experts at the Preventing Overdiagnosis Conference (Sydney, 2019), we aimed to identify and establish a thematic framework of factors that influence clinicians to request non-recommended and unnecessary tests.MethodsArticles exploring factors affecting clinician test ordering behaviour were identified through a systematic search of MedLine in April 2019, forward and backward citation searches and content experts. Two authors screened abstract titles and abstracts, and two authors screened full text for inclusion. Identified factors were categorised into a preliminary framework which was subsequently presented at the PODC for iterative development.ResultsThe MedLine search yielded 542 articles; 55 were included. Another 10 articles identified by forward-backward citation and content experts were included, resulting in 65 articles in total. Following small group discussion with workshop participants, a revised thematic framework of factors was developed:“Intrapersonal” – fear of malpractice and litigation; clinician knowledge and understanding; intolerance of uncertainty and risk aversion; cognitive biases and experiences; sense of medical obligation“Interpersonal” – pressure from patients and doctor-patient relationship; pressure from colleagues and medical culture;“Environment/context” – guidelines, protocols and policies; financial incentives and ownership of tests; time constraints, physical vulnerabilities and language barriers; availability and ease of access to tests; pre-emptive testing to facilitate subsequent care; contemporary medical practice and new technologyConclusionThis thematic framework may raise awareness of overtesting and prompt clinicians to change their test request behaviour. The development of a scale to assess clinician knowledge, attitudes and practices is planned to allow evaluation of clinician-targeted interventions to reduce overtesting.
Highlights
Medical tests provide important information to guide clinical management
Overtesting of screening and diagnostic tests may occur where there is an unfavourable balance of benefits to harms [13] and where there would be little or there would be no consequences to the patient from not performing the test [12]
There has been no systematic synthesis of published evidence exploring factors that influence clinicians to overtest. In this narrative literature review and workshop discussion with experts at the Preventing Overdiagnosis Conference 2019, we aimed to identify and create a thematic framework of important factors that may influence clinicians to overtest
Summary
Medical tests provide important information to guide clinical management. Overtesting, may cause harm to patients and the healthcare system, including through misdiagnosis, false positives, false negatives and overdiagnosis. Clinicians are responsible for test requests, and are ideally positioned to prevent overtesting and its unintended consequences. With the overall aim of healthcare being to prevent premature morbidity and mortality [10], it follows that the value and rationale for performing tests lies in their ability to improve patient health outcomes [11] through detection and/or monitoring of disease and subsequent treatment. These health outcomes may be clinical, emotional, social, cognitive or behavioural [10]. Overtesting of monitoring tests may occur where the tests have poor measurement properties, and/or are done overly frequently (low signal: noise ratio) [14]
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