Comparing Cost Effects of Two Quality Strategies to Improve Test Ordering in Primary Care: a Randomized Trial

Objective: To determine the costs and cost reductions of an innovative strategy aimed at improving test ordering routines of primary care physicians, compared with a traditional strategy.

Design: Multicenter randomized controlled trial with randomization at the local primary care physicians group level.

Setting: Primary care: local primary care physicians groups in five regions of the Netherlands with diagnostic centers.

Study Participants: Twenty-seven existing local primary care physicians groups, including 194 primary care physicians.

Intervention: The test ordering strategy was developed systematically, and combined feedback, education on guidelines, and quality improvement sessions in small groups. In regular quality meetings in local groups, primary care physicians discussed each others' test ordering behavior, related it to guidelines, and made individual and/or group plans for change. Thirteen groups engaged in the entire strategy (complete intervention arm), while 14 groups received feedback only (feedback arm).

Main Outcome Measure: Running costs, development costs, and research costs were calculated for the intervention period per primary care physician per 6 months. The mean costs of tests ordered per primary care physician per 6 months were assessed at baseline and follow-up.

Results: The new strategy was found to cost 702.00, while the feedback strategy cost 58.00. When including running costs only, the intervention was found to cost 554.70, compared with 17.10 per primary care physician per 6 months in the feedback arm. When excluding opportunity costs for the physicians' time spent, the intervention was found to cost 92.70 per physician per 6 months in the complete intervention arm. The mean costs reduction that physicians in that arm achieved by reducing unnecessary tests was 144 larger per physician per 6 months than the physicians in the feedback arm (P = 0.048).

Conclusion: On the basis of our findings, including the expected non-monetary benefits, we recommend further long-term effect and cost-effect studies on the implementation of the quality strategy.