Talk is cheap for tackling wasteful emergency diagnostics

An intervention as simple as a staff discussion during a general meeting results in a large reduction in the number of unnecessary diagnostic tests ordered by emergency physicians, say Brazilian researchers.

The test, in this case, was for C-reactive protein (CRP). Itamar de Souza Santos (University of São Paulo Medical School) and team saw a large increase in the use of this test in their institution between 2007 and 2009, and a large proportion of the orders for the test came from the emergency department (ED). The number of tests ordered rose from 5.1 to 28.7 per 1000 ED consultations during this period, representing 24.8% and 38.6% of all orders, respectively.

"It is reasonable to think that non-specific information such as CRP levels may benefit doctors in the [intensive care unit], but not those working in the ED," say de Souza Santos et al.

The researchers had no way of determining to what extent CRP tests influenced emergency physicians' treatment decisions, and the resulting outcomes. But they say: "The medical literature does not currently support the use of CRP testing in decision-making processes in the ED."

The issue was therefore raised at a general meeting, attended by ED staff among others. The researchers presented published evidence for the role of CRP testing, highlighted the rising use of the test in their hospital, and invited discussion. "There was broad consensus that the test was over-solicited," they say.

During the months that followed, medical staff discussed the issue with new intakes of medical students and residents, to ensure that all ED workers avoided unnecessary CRP tests.

This led directly to a 48% reduction in the number of CRP tests ordered in the ED during 2010, to 14.8 per 1000 consultations, the team reports in the Emergency Medicine Journal.

The largest decline came during the 4 months immediately after the staff meeting, with CRP test orders falling by an average 24.2% per month. During the rest of the year there was a nonsignificant 3.7% monthly increase in orders.

Before the meeting, use of CRP tests had been increasing in all professional subgroups - students, residents, and staff - and all groups reduced their use of the tests after the meeting. But the largest annual decline was seen among students, at 61.3%, compared with 39.9% among medical residents and 47.6% for medical staff.

The researchers stress that their intervention was based purely on behavior change, with no actual restrictions placed on use of CRP tests. "Based on our data, medical students may be especially responsive to such interventions," they say.

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