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Education And Debate Evidence base of clinical diagnosis

Rational, cost effective use of investigations in clinical practice

BMJ 2002; 324 doi: (Published 30 March 2002) Cite this as: BMJ 2002;324:783
  1. Ron Winkens, associate professor of research at the interface between primary and secondary care (,
  2. Geert-Jan Dinant, professor of effectiveness research in general practiceb
  1. a Department of General Practice and Transmural Care Unit, University Hospital, 6200 MD Maastricht, Netherlands
  2. b Department of General Practice, Maastricht University, 6200 MD Maastricht, Netherlands
  1. Correspondence to: R A G Winkens

    Investigations such as blood tests and radiography are important tools for the making correct diagnoses. The use of diagnostic resources is growing steadily—in the Netherlands, for example, nationwide expenditure on diagnostic tests is growing at the rate of 7% a year. Unfortunately, health status is not improving similarly, which suggests that investigations are being overused. The ordering of tests seems not to be influenced by the fact that their diagnostic accuracy is often disappointing. Considerations other than strict scientific indications seem to be involved, and we may ask whether new knowledge and research findings are adequately reflected in daily practice.

    Several factors may be responsible for the increasing use of investigations, such as the increasing demand for care (due to ageing of the population and increasing numbers of chronically ill people); the fact that they are available, which in itself leads to ordering; and the urge to make use of new technology. Once an abnormal test result is found, doctors may order further investigations, not realising that on average 5% of test results are outside their reference ranges, and a cascade of testing may result. Furthermore, higher standards of care, the guidelines for which often recommend additional testing, and defensive behaviour have led to more investigations. Unfortunately, when guidelines on selective and rational ordering of investigations are introduced, numerous motives for ignoring evidence based recommendations, such as fear of litigation, or procrastination on the part of the doctor, come into play in daily practice and are difficult to influence.

    Overuse of investigations—and there is reason to believe that some requests are illogical—leads to overloading of the diagnostic services and overexpenditure: more efficient usage is therefore needed. Interventions focusing on overt examples of inappropriate testing might reduce costs while simultaneously improving quality of care.

    Summary points

    Intervention is needed to reduce the often …

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