What methods are being used to create an evidence base underlying chronic disease monitoring in primary care? A scoping review
Around 50% of laboratory testing in primary care is for monitoring chronic conditions. Substantial variation in test ordering between GP practices and regions suggests that many tests are being over- and under-used, which can cause harm to patients and increase healthcare costs. Current guidelines on testing lack a solid evidence base. There is currently no framework for evaluating optimal testing strategies and no guidance on how to generate this much needed evidence.
The aims of this scoping review were to map the extent, range and nature of research that provides evidence on optimal chronic diseases monitoring in primary care, and to identify research gaps in the existing literature. EMBASE, MEDLINE, and CINAHL were searched from inception to April 2019. We used the following eligibility criteria: studies of adult patients with chronic disease in a primary care setting that evaluated laboratory tests and aimed to optimise testing, find the best test or testing interval, show patient harms, costs, or variation related to testing. We used standard scoping review methods, including standardised data abstraction forms and data charting.
Of 94 included papers, 36% aimed to investigate test performance and 40% to describe the variation in monitoring. Most studies focused on diabetes (51%), followed by hypertension (11%), and rheumatoid arthritis (10%). The most frequently studied laboratory tests were renal function tests (35%), followed by HbA1c (23%). A retrospective cohort design, using routinely collected data, was the most commonly used study design (49%). A large proportion of studies only used descriptive statistics to analyse the data (28%). We identified gaps in evidence on establishing optimal testing intervals; strategies to optimise testing that improve patient outcomes; and harms to patients due to over-testing.
Future studies need to address the identified gaps in the literature. Development of methodologies and reporting guidelines for research evaluating the use of tests for monitoring could improve the rigor, transparency, and reproducibility of future research in this area, and help researchers, peer reviewers, authors, and readers to determine the trustworthiness of the findings.In the absence of clear evidence, decisions around testing should be based on current guidelines, however these guideline recommendations should feed into, rather than override, patients’ personal preferences and views.