Clinical management
Around a quarter of blood tests potentially unnecessary
A retrospective audit explored who requests blood tests, why and the outcomes of testing in UK primary care. Data was collected from 2,572 patients across 57 GP practices regarding blood tests performed in April 2021 by members of the Primary Care Academic CollaboraTive (PACT).
Abnormal/borderline results were common. 26.6% had normal test results. Around a quarter of tests were thought to be partially or fully unnecessary when reviewed retrospectively by a clinical colleague. 6.2% of tests led to a new diagnosis or confirmation of a diagnosis.
WiseGP Approach
Do you over-investigate with blood tests? Consider if you or your team would benefit from a retrospective audit of the blood tests they request and time to reflect on outcomes during a practice clinical meeting.
Do you consider how you can reduce the burden of blood tests on patients, including how you communicate expected outcomes?
Consider if there is a group your practice could target where over-investigation with blood tests is a problem, for example, in nursing home residents.
Read more here:
https://bjgp.org/content/early/2023/07/26/BJGP.2023.0191
X-Rays in Osteoarthritis
A cross-sectional study examined the association between hip pain and radiographic osteoarthritis (ROA) in a Dutch cohort.
The difference in hip ROA prevalence between painful and pain-free hips was only modest. The prevalence of definite ROA in painful hips was 13.3% (n = 105/789) and in pain-free hips 9.5% (n = 113/1193). Therefore, radiographs provide GPs with little assistance to aid GPs in the identification of patients with hip OA.
In hips that fulfil the clinical criteria of hip OA, GPs should consider starting the patient on guideline-recommended conservative OA treatments, without radiographic confirmation.
WiseGP actions:
NICE guidelines recommend adults aged ≥ 45 can be diagnosed with OA clinically without investigation if they have activity-related joint pain and either no morning stiffness or morning stiffness lasting ≤ 30 minutes. Could your GP registrar consider this as an audit topic, to see if x-rays are being over-used as a diagnostic tool for knee and hip OA in your practice?
Could your practice physiotherapist lead a clinical education session on initial OA management, including discussion of evidence regarding radiographic investigation?
Read more about the evidence informing this GEM here: https://bjgp.org/content/72/723/e722
Think twice before requesting inflammatory marker tests
Testing multiple inflammatory markers simultaneously doesn’t increase your ability to rule out disease and should generally be avoided. CRP has marginally superior diagnostic accuracy for infections, and is equivalent for autoimmune conditions and cancers, so should generally be the first-line test. Cancer should be considered in patients with raised inflammatory markers, though as inflammatory markers have a poor sensitivity for cancer they are not useful as ‘rule-out’ test.
WiseGP actions:
1. Next time you request inflammatory markers reflect on how the results would influence your next management steps and whether those blood tests would be necessary. If inflammatory marker testing is indicated, would CRP alone be sufficient?
Read more about the research informing these recommendations here:
Reaching a shared understanding about blood test investigations
An increasing number of blood tests are being performed to aid diagnosis and offer reassurance or validation to patients. However, patients often don’t understand the reason for testing or the meaning of results, leading to them experiencing frustration, anxiety and uncertainty. Shared decision-making is recommended as best practice, though it doesn’t reflect the reality in this context.
WiseGP actions:
1. Reflect on whether you involve patients in decisions about blood tests and discuss the possible outcomes, including the possibility of them not providing an answer to someone’s presenting concern (eg. fatigue).
2. Do you have an established way of informing patients about results to avoid confusion? This will be more relevant in the context of increased patient access to health records. Consider establishing a practice wide system to avoid confusion and improve patient safety.
Read more about the research informing these recommendations here: https://research-information.bris.ac.uk/en/publications/blood-tests-in-primary-care-a-qualitative-study-of-communication-
Ambulatory rather than home blood pressure monitoring
Since the pandemic, home blood pressure monitoring (HBPM) is used more frequently than ambulatory blood pressure monitoring (ABPM). However, HBPM doesn’t measure night time BP. Patients whose night time BP doesn’t dip or rises have poorer cardiovascular outcomes. Therefore, hypertension may be missed if ABPM isn’t used.
WiseGP actions:
1. Consider using ABPM when assessing for patients with hypertension in your practice. A practice pharmacist could take lead responsibility for reviewing results from measurements.
Read more about the research informing these recommendations here: https://bjgp.org/content/early/2022/08/26/BJGP.2022.0160
