UTILIZATION OF LABORATORY INVESTIGATIONS: STUDY OF KNOWLEDGE, ATTITUDE AND PRACTICE AMONG PRIMARY CARE PHYSICIANS : Journal of Family and Community Medicine

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UTILIZATION OF LABORATORY INVESTIGATIONS

STUDY OF KNOWLEDGE, ATTITUDE AND PRACTICE AMONG PRIMARY CARE PHYSICIANS

Bakarman, Marwan A. FFCM(KFU)*; Kurashi, Nabil Y. FFCM(KFU)†,; Hanif, Muhammad FSS(UK)

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Journal of Family and Community Medicine: Jul–Dec 1996 - Volume 3 - Issue 2 - p 32-40
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Abstract

INTRODUCTION

For a long time history and physical examination have been the most important part of patient's assessment.1 However, in recent years, the care of patients has become increasingly dependent on the results of laboratory investigations, and clinical laboratories have become a major component in the delivery of health care. The physicians’ knowledge, attitude and practices towards laboratory services have been investigated. Laboratory investigation in Primary health Care (PHC) centers should not be considered an isolated activity of the general practitioner. It has always been and will continue to be an integral part of clinical practice in primary health care.2

The factors which motivate physicians to request laboratory services are (i) confirmation of clinical impression; (ii) reassurance of patients or colleagues that something was being done, even if the results will not affect the diagnosis or therapy and (iii) occasionally requests are based on a desire to do a complete work-up.3 The study of Ferrier et a14 showed that women physicians tended to order more laboratory tests than male physicians, and had a higher mean monthly cost of laboratory service per patient. The physicians who are more knowledgeable and clinically skilled used fewer and more appropriate investigations and medical services57

Many educational programs such as weekly seminars, lectures, senior clinical staff reviews, computer-based systems (to detect inappropriate test usage) or educational material circulated in the form of summaries of some actual patient cases were brought to the attention of the physicians to correct improper usage. All these programs elicited a satisfactory response during the study time, or shortly after that. However, clinicians reverted to their previous patterns of test utilization after a few months. To be effective, educational programs must be continued indefinitely.811 A more promising approach, which appeals not to the economic but to scientific and clinical sense, is the introduction of agreed request protocols for the investigation of specified types of patients. Guidelines consisting of short advisory statements for the ten commonest medical emergencies (myocardial infarction, overdose, hematemesis, pneumonia, etc.) were developed by consultant staff .9 Junior staff were given copies of these guidelines and encouraged to use them. There was an immediate reduction in the average number of hematological tests (G4%) and biochemical test (64%).

Wong and Lincoln12 found that clinicians ordered laboratory tests according to an informal protocol which was a product of accumulated experience sanctioned by general use, and thus appeared to have the weight of authority. The problem of laboratory test misuse was therefore not a defect in cognitive knowledge, but primarily protocol. Thus, clinicians focus their attention on the broader issue of protocols as a form of information management in medicine.69101321

MATERIAL AND METHODS

A cross sectional study was conducted in Al-Khobar area, Eastern Province of Saudi Arabia in 1995 using a questionnaire. For this purpose, all 9 PHC centers in the Al-Khobar area were taken as population under study. A random sample of 5 PHC centers ,vas selected to study the utilization pattern of laboratory investigations. All the doctors working in these PHC centers were included in this study. There were 20 physicians, in 5 PHC centers, amounting to 33% of the total physicians in all PHC centers in AI-Khobar area. The physicians in the selected PHC centers were given the questionnaires to survey their knowledge, attitude and practice (KAP) towards laboratory investigations and factors which influenced their pattern of utilization and also to correlate their answers with their real life practice, which was explored by studying the medical records. Information regarding physicians′ practice of laboratory tests were also included while preparing the questionnaire.

The variables of interest were the physicians’ age, gender, nationality, place of graduation, postgraduate qualification, years of experience, duration of work in Kingdom of Saudi Arabia, their duration of stay in PHC centers and personal data including their professional status.

All the physicians involved were informed about the study, and their role in it was fully explained. All questionnaires were completed within 5 days. A scoring system was used to evaluate physicians′ answers of questionnaire, where 45% was allocated to knowledge, 34% to attitude and 21% to practice. The idea of using a scoring system and grading was based on work done by Marion et a110 and Pick et a1.22 After computing the scores of every part of KAP, they were graded (Table 1). For a pilot study, two PHC centers were selected in Dammam and all the doctors from these two centers were given questionnaires, relevant changes in the questionnaire were made in the light of the pilot study.

T1-4
Table 1:
Physician's grading according to KAP scoring

Of the 20 physicians, 10 were selected at random for re-interviewing to check the reliability of answers given on the KAP questionnaire. Kappa23 test of reliability was used as test-retest method and it was found that there was 73% agreement between first and second sets of answers. This indicated a high agreement between both sets of answers, hence, a high reliability. Data analysis was performed using SPSS package. All means were expressed as (mean ± SD). The method of multiple regression was applied to the study to see which factor(s) had an effect on their knowledge, attitude and practice.

RESULTS

There were 9 (45%/o) Saudi and 11 (55%) non-Saudi physicians. More than half (55%) of the sample were females. Only 3 (15%) physicians were specialists with diplomas or Master's Degree. The Master Degree was in infectious diseases, the two diploma holders were in Pediatrics and Ophthalmology and the remaining 17 (85%) physicians had only MBBS. No one was qualified in Family Medicine. The mean age of physicians was 34.5 + 6.9 years. The mean duration of experience in years was 9.0 + 7.2 and mean duration of stay in primary health centers was 4.4 + 3.9 years. All physicians indicated that laboratory services were important. Of the 20 physicians, 15% indicated that laboratory services were always important, 55% said that they were important most of the time, and 30% of them mentioned that laboratory services did not always contribute to the management of their patients. Forty percent of the physicians indicated that the quality of laboratory services was good to excellent, 30% indicated that quality of laboratory service was satisfactory, whereas 30% indicated that it was deficient. In the opinion of 65% of the physicians, the laboratory services available in PHC was inadequate, whereas 35% indicated that laboratory services were satisfactory. More than half (55"/") of the physicians indicated that their practice would be adversely affected if there were no laboratory facilities in the primary health care centers, and 45% indicated that their practice would be moderately to slightly affected. No one mentioned that his practice would remain unaffected if there were no laboratory facilities.

More than half (55%) of the physicians indicated that they would order laboratory tests for a patient who asked for a periodic check-up, 40% indicated that they would only take a history and carry out a physical examination and only 5% physicians, would do both (take history and examine, and order laboratory tests). No one would refuse to do a periodic check-tip for a patient, and none would send a patient to a hospital for these procedures.

Eight out of 20 (40%) physicians practiced medicine outside Saudi Arabia. The remaining 12 (60%) physicians were either Saudi (45%) or non-Saudi (15%) but did not practice medicine outside Saudi Arabia. Of the eight (40%) physicians who practiced medicine outside Saudi Arabia, six (75%) indicated that they carried out laboratory investigations more in Saudi Arabia. No one mentioned that he/she carried out more in his own country than Saudi Arabia. The other two (25%) physicians indicated that their laboratory use in Saudi Arabia was the same as in their own country. The reasons for the different rates of utilization, as indicated by the six (75%) physicians who used laboratory services more in Saudi Arabia are illustrated in Table 2. The fact that laboratory services were free and easily available and that patients demanded them were the most important factors in utilization differences between Saudi Arabia and other countries.

T2-4
Table 2:
Factors causing more utilization in KSA than original countries (6 physicians)

When crucial investigations needed for a patient were not available in the PHC centers, 85% of physicians would send the patient to King Fahd University Hospital for them, 10% would ask the patient to have them done in a private hospital and 5% would not do the test but would depend on his/her clinical sense to diagnose and manage the patient. Other factors such as medico-legal reasons and the need to reassure patients were less important. The style of physician practice was the least important factor.

Most physicians (60%) believed that laboratory investigations were properly utilized, 25% believed they were over-utilized, and the remaining 15% believed that they were under-utilized (Table 3). Physicians who thought that laboratory tests were over utilized were asked to indicate why they held that view. The important factors mentioned were free laboratory services, physicians’ lack of knowledge, routine Ministry of Health requirements and patients demand, early detection and management, medico-legal factors and availability of laboratory services (Table 4).

T3-4
Table 3:
Opinion about utilization of lab investigations
T4-4
Table 4:
Physicians opinion about factors causing over utilization (5 physicians)

The KAP questionnaire for every physician was evaluated and scored. There was a variety of ranges between the lowest and the highest scores in knowledge, attitude and practice. The narrowest range and the highest mean score was in knowledge. The range was much wider in attitude and practice, both of which had a lower mean score. The mean score for attitude was the lowest. The questionnaires were graded according to physicians’ knowledge, attitude and practice. Knowledge ranged from good to fair and no one had a poor score.

The attitude of most of the physicians (80%) toward laboratory services was negative, 10% were neutral, and the remaining 10% had a good attitude. Almost 60% of physicians who scored negative in attitude questions had worked for more than ten years. The overall KAP grading was fair for 50% of the physicians, whereas 20% had good grade and 30% had a poor grade (Table 5).

T5-4
Table 5:
Grading of Physicians’ KAP scores

The physicians’ characteristics, personal and professional, were studied to measure the influence of these factors on the knowledge, attitude and practice scores. The multiple regression equation with stepwise method was applied. It was found that the length of experience played a role in practice score: as the physician acquired more years of experience, his/her practice scoring regarding laboratory test utilization improved (p > .0296) with R2 = 0.237. This implies that around 24% of the variation in the physicians′ practice score, could be explained by the differences in the variables employed. None of these independent variables was significant in affecting the score in knowledge or attitude.

DISCUSSION

The proportion of Saudi physicians working in PHC centers was 45% in contrast to the BaSuliman's24 study in Dammam city (1992), where 9.5% of all physicians working in PHC centers were Saudis. This may be due to increased awareness of the importance of PHC centers for the provision of health. Another important reason could be the increase in the number of Saudi graduates from Medical Colleges and the requirement by Ministry of Health for all new Saudi graduates to work in PHC centers for at least two years before joining the hospital service or applying for postgraduate study.

The vast majority of physicians (25%) who practiced medicine outside Saudi Arabia indicated that laboratory service was utilized more in Kingdom of Saudi Arabia. This was unlike the result obtained by Willimas et a125 who surveyed a group of residents, hospital consultants and community internists in USA to determine physicians perception of the reasons for overuse of diagnostic tests. They found that different groups had different perceptions. Community physicians cited routine screening, habitual ordering of groups of tests, and were concerned about possible malpractice suit as being an important reason. Nearly all (25%) physicians had practiced medicine in developing counties with a lower economic status than in Saudi Arabia. Laboratory facilities in most of these countries were relatively deficient compared to Saudi Arabia. This was reflected by the finding that the availability of laboratory facilities was the most important factor for the higher utilization in Saudi Arabia as indicated by physicians themselves.

The attitude of most of the physicians (80%) towards laboratory service was negative. The reason may be that, 60% of them had worked for more than ten years, and had been trained in an era of medical practice not as dependent upon technology as the present time, and they were still unaccustomed to use diagnostic technology.

Patients’ demand was cited by physicians in this study as one of the important factors promoting over utilization. Unfortunately, it seems to be easier and often safer medico-legally to comply with such demands than not, even when they are totally unjustified. The wide variation among physicians in the use of ancillary services suggests that both over-utilization and under-utilization may occur. This variation in utilization was attributable to the physicians age, specialty, type of practice and experience. The physicians’ knowledge of cost and efficacy of the diagnostic tests is also likely to influence the use of tests.26 Physicians’ practice scoring indicated that the physicians’ years of experience (practice since graduation) was the only important factor in determining their utilization of laboratory tests. Several other investigators have studied the role of different physicians’ characteristics on the use of diagnostic services. Salloum and Franssen27 performed a covariant analysis to identify any trend in the use of lab tests by family physicians in Canada. They used the total number of ordered tests and the dependent variable. Independent variables were physicians’ gender, years of practice, laboratory facilities in the building, number of patients seen per day, and certification. No significant factors were found to be responsible for variations in the use of laboratory tests. Eisenberg and Nicklin28 studied the effect of physicians’ personal characteristics on the use of laboratory tests. These characteristics were the physician's age, specifically, years since graduation, graduation from private or public school, postgraduate degree, foreign or domestic graduate and urban or rural practice. They came out with the following results: (i) The use of laboratory tests was inversely related to the number of years since graduation from medical school. (ii) The age had no effect on the use of laboratory tests. (iii) There was no statistically significant difference in the use of laboratory tests between foreign and domestic graduates. (iv). Laboratory test use was not significantly different for physicians in different practice sites.

Lave and Leinhardt29 reported that older physicians order fewer tests for hospitalized patients than do younger physicians. Eisenberg and Nicklin28 quoted Rose and Abel-Smith who found that the period of time since graduation was inversely related to a physicians use of lab services, but was not statistically significant.

Pineault30 studied 34 internists practicing in prepaid group practice and suggested that physicians order fewer diagnostic tests with an increasing number of years since residency. Schroeder et a131 were unable to demonstrate a statistically significant relationship between age and lab use. Freeborn et al32 showed a tendency for younger physicians to order more tests, but were also unable to obtain am’ statistically significant difference.

Epstein et a133 in Boston correlated the use of outpatient diagnostic tests with personal characteristics of the prescribing physician, by studying the records of 351 hypertensive patients cared for by 30 physicians. They found that the pattern of test utilization was not strongly related to the number of years since graduation from medical school.

Ferrier et a14 showed that women physician tended to order more laboratory tests than men physicians, and had a higher mean monthly cost of laboratory service per patient. These differences were correlated with practice features related to physicians in their study such as the proportion of total work done in the office, the proportion of female patients aged I S to 49, and the proportion of the physicians′ practice that is psycho-therapeutic. Year of graduation, medical school, practice location and board certification had no significant contribution towards explaining the difference in laboratory ordering.

CONCLUSIONS

  1. There had been an increase in the number of Saudi physicians in PHC centers.
  2. Not a single physician had any post-graduate degree in Family Medicine or in general practice.
  3. Laboratory investigations are essential services for PHC center physicians.
  4. The quality of current laboratory services is deficient in the opinion of 30% physicians.
  5. The utilization of laboratory tests in Saudi Arabia is most probably higher than many other developing countries with less economic welfare, but this does not necessarily mean better utilization.

RECOMMENDATIONS

  1. Undergraduate curricula of Medical Colleges should include courses on health economics and cost effective decision making.
  2. Test selection and interpretation of results should be adequately taught in the Medical Colleges.
  3. A regular audit should be established to make it evident to all in the primary health care centers and laboratory clinics.
  4. Continuing medical education should be directed towards the indications, rational use and cost of investigations.
  5. It is essential to change the practice behavior of physicians.
  6. Half-day group discussions of all primary health care centers physicians and a clinical chemists should be held on a regular basis.
  7. To improve the services provided by PHC center physicians, and for better cooperation between physicians and laboratory specialists, a diagnostic center should be established to serve all PHC centers.
  8. As a part of health education, efforts should be directed at raising public awareness of the cost and benefits of laboratory investigations.
  9. Another study is required to measure the utilization vis-a-vis clinical outcome of care, and to examine the reliability of the results in PHC center laboratories.

ACKNOWLEDGMENT

We are thankful to Dr. Abdallah Dafallah, Associate Professor of King Faisal University for his invaluable help and Mr. Romeo G. Ganda for excellent type setting.

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          Keywords:

          Utilization; Knowledge; Attitude; Practice; Primary Health Care; Sampling

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