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November 5, 2003

Strategies to Improve Test Ordering in Primary Care—Reply

Author Affiliations

Letters Section Editor: Stephen J. Lurie, MD, PhD, Senior Editor.

JAMA. 2003;290(17):2253. doi:10.1001/jama.290.17.2253-a

To the Editor: Dr Verstappen and colleagues1 found that a practice-based, multifaceted strategy using guidelines, feedback, and social interaction resulted in modest improvements in the quality of test ordering by Dutch primary care physicians. In the intervention, physicians received 3 personal feedback reports on 3 different clinical problems, discussed these in small group meetings, related them to evidence-based guidelines, and made plans for change. Such multifaceted interventions are time consuming, and therefore difficult to implement for the large spectrum of clinical problems that primary care physicians face. Furthermore, many studies have found that the effects of information and feedback are limited, and the effects may disappear soon after the end of intervention.2 In their literature review, for instance, Wensing et al3 concluded that some, but not all, multifaceted interventions are effective, but that information linked to performance generally was not effective. Large-scale interventions, related to sustained change in all possible test-ordering situations, are likely to be ineffective. Thus, I wonder if this is the way to proceed in improving test-ordering behavior.

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