The design, implementation and evaluation of a laboratory based intervention to optimise serum immunoglobulin use in primary care

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Cadogan, Sharon L.
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University College Cork
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Background Laboratory testing plays a fundamental role in the screening, diagnoses and monitoring of many conditions. Given the increased pressures on the Irish health service, improving inefficiencies and reducing waste, while maintaining the quality of care is at the forefront of healthcare planning. Promoting optimal laboratory service utilisation could play a key role in reducing health expenditure, in particular by preventing the unnecessary use of costly downstream services that often arise as a result of testing. Aims and objectives The overall aim of this thesis was to design, implement and evaluate a behaviour change intervention for optimising serum immunoglobulin test use in primary care. The thesis objectives were as follows: 1. To conduct a systematic review of the existing literature on the effectiveness of previous interventions targeting primary care test use. 2. Identify the barriers and enablers of improving test ordering for serum immunoglobulins among General Practitioners (GPs), using semi-structured interviews. 3. Identify the intervention components (behaviour change techniques and mode(s) of delivery) that could overcome the modifiable barriers and enhance the enablers. 4. Determine which GP and practice characteristics are associated with higher serum immunoglobulin test ordering patterns in the South of Ireland. 5. To implement and evaluate a behaviour change intervention targeting GP serum immunoglobulin test use in the Cork-Kerry region. Structure and Methods The published literature to date was synthesised in a systematic review (Chapter 3). This review was conducted in accordance with the Effective Practice and Organisation of Care (EPOC) guidelines and quality appraised using the Cochrane Collaboration risk of bias tool. A theory-based paper identifying the modifiable barriers and enablers to test ordering behaviour change and the selection of intervention components to overcome these is presented in Chapter 4. This involved using a combination of behaviour change models including the Theoretical Domains Framework (TDF), the behaviour change wheel constructs; capabilities, opportunities, motivations of behaviour (COM-B) and Behaviour Change Techniques (BCTs) to identify intervention functions best suited to targeting GP test ordering behaviour. The GP and practice characteristics associated with higher test ordering patterns are described in Chapter 5. These were identified by performing a multi-level analysis of all GP test orders in the studied region for a one-year time period, using routine laboratory data. The design of the intervention material and details on the implementation plans are provided in Chapter 6. Results of the effect of the intervention using nine-month follow up data are described in Chapter 7. This was performed using interrupted time-series with segmented Poisson regression models to assess the pre-and xxi post-intervention trend for serum immunoglobulin testing among GPs in the Cork-Kerry region of Ireland. Finally, a discussion of the key findings, strengths and limitations of the thesis and recommendations for future research are addressed (Chapter 8). Key Findings A number of different interventions were of variable efficacy at changing GP test ordering behaviour. However, generalisability across tests and methodological weakness were identified in these studies (Chapter 3). GP factors contributing to higher immunoglobulin test ordering in our sample included female gender and fewer years of clinical experience (Chapter 5). The lack of clear guidelines and knowledge on how to interpret the test results posed greatest problems for GPs. Four key intervention functions were identified for overcoming these modifiable barriers to effective test use; education, persuasion, enablement and environmental restructuring (Chapter 4). Following the introduction of a guideline and education-based strategy targeting the two key issues (by incorporating the four functions), test orders for serum immunoglobulins dropped significantly. A nine-month evaluation of the effectiveness of this intervention found a statistically significant 1.5% reduction in the fortnight-to-fortnight test ordering trend for serum immunoglobulins (Chapter 7). Conclusions This research provides an important overview of the behavioural factors influencing laboratory testing among GPs. The incorporation of behavioural theory, specifically the COM-B, TDF and BCT taxonomy, has supported the identification of factors such as xxii knowledge and the social and environmental context, which are key for understanding testing behaviours. Combining these context specific "mechanisms of change" with international evidence on what has previously worked, assisted in the development of an effective behaviour change intervention targeting serum immunoglobulin test use in primary care.
Behaviour change intervention , Laboratory medicine , Health services research , Primary care
Cadogan, S. L. 2016. The design, implementation and evaluation of a laboratory based intervention to optimise serum immunoglobulin use in primary care. PhD Thesis, University College Cork.