Steep Rise in GP-Ordered Tests

Peter Russell

November 29, 2018

Growing workload pressure in general practice can partly be explained by a growth in the number of tests being ordered as GPs take on more services previously provided by hospitals, a study found.

A research team led by the Nuffield Department of Primary Care Health Sciences at the University of Oxford found there had been a 3.3-fold increase in diagnostic tests ordered by GPs over a 15-year period.

They said patients in 2015-16 had on average five tests each year, compared with 1.5 in 2000-2001.

Workload Pressures for GPs

Writing in The BMJ , the researchers said that tests were costing the NHS in excess of £2.8 billion a year, and that ordering and reviewing their results had increased workload pressure in primary care.

The observational study used electronic health record data from patients

registered with general practices which contribute to the Clinical Practice Research Datalink (CPRD) from 1 April 2000 to 31 March 2016. The anonymised data contains electronic health records of primary care patients covering about 7% of the UK population.

Total test numbers increased markedly over time, in both sexes, across all age groups, test types (laboratory, imaging, and miscellaneous), and for 40 of 44 tests specifically studied.

The researchers found that the increase in the number of tests ordered was slightly greater in men (3.4-fold increase) than in women (3.3-fold increase).

Elderly patients had the greatest increase – a 4.6-fold increase for those aged more than 85.

The average annual percentage increase in the rate of tests over the 15-year period was:

  • 8.7% for laboratory testing

  • 5.5% for imaging tests

  • 6.3% for miscellaneous tests

NHS Service Changes

The researchers suggested that the increased testing might be partly due to changes to NHS service provision under which GPs' ability to order diagnostic tests, particularly imaging, has expanded.

Also, many services were diverted from secondary to primary care during this period with the introduction of the Quality and Outcomes Framework incentivising GPs to monitor chronic diseases using laboratory tests.

The increase could also be "a direct response to the increasing number and duration of consultations with general practitioners, with tests reportedly being used for 'strategic, nonmedical reasons,' such as reassuring patients and ending consultations," the authors said.

Also, patients may demand more tests as they become more informed, and are encouraged to participate in decisions about their care.

The authors point out that the nature of their observational study meant that no firm conclusions could be drawn about cause and effect.

Nevertheless, they say whatever factors contributed to increased test use, it had major implications for general practitioners' workload and the NHS budget.
 

'Difficult' Situation for GPs

Commenting on the research, Professor Helen Stokes-Lampard, chair of the Royal College of GPs, said: "GPs are in an incredibly difficult position when it comes to making referrals or ordering blood tests and other investigations, in that we get criticised when we do, and criticised when we don't. Ultimately, our priority is to our patients and we will work in their best interests.

"This research looks at the increase of number of requests for tests GPs make, but not the reasons why and whether they were appropriate – and both of those must be key when making a judgement about whether an increase is positive, or not.

"The fact that the last 15 years have seen more varied and more accurate diagnostic tests become available in the NHS is a good thing – but these do come at a cost. It’s obviously important to consider NHS resources when deciding to make a request for a test, but GPs and their teams don’t take the decision lightly, or if they don’t think they will genuinely help in narrowing down what might be wrong with a patient.

"We’re now serving a growing and ageing population, and where many patients are living with multi-morbidities, so, as this report shows, there will be a completely appropriate increase in the number of tests being carried out in the community as these conditions and the medications used to treat them are monitored. We would argue that GPs and our teams need far better access to diagnostic tests in the community, so that we can make a more informed decision about requesting more specialised tests or making a referral to a hospital colleague."

Temporal trends in use of tests in UK primary care, 2000-15: retrospective analysis of 250 million tests. BMJ 2018; 363 doi: https://doi.org/10.1136/bmj.k4666 (Published 28 November 2018). BMJ 2018;363:k4666. Abstract.

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