Towards cost-effective use of blood tests in children with persistent fatigue presenting in general practice from the perspective of child, parents and general practitioner

RELEVANCE

Currently, there are no guidelines for blood tests in children with persistent fatigue in general practice. In two thirds of these children GPs order several blood tests, but we do not know whether this is cost-effective. It is often assumed that parents demand blood tests. Different expectations among GPs, children and parents lead to frustration, fear and uncertainty.

OBJECTIVE

The main aim of this study is to provide insight into the cascade of blood test ordering in children 4 to 18 years presenting with persistent fatigue in general practice. For common and acceptable test strategies (e.g. ‘a limited strategy’) we will evaluate the impact on costs, missed or falsely diagnosed somatic conditions, and quality of life and whether these test strategies have the potential to be cost-effective. In addition, our aim is to evaluate communication and decision making of ordering blood tests in various test strategies.

APPROACH

Our methods derive from the framework for early-Cost Effectiveness Analysis (CEA) of medical test of Buisman et al. 2016. The first step is to narrow down the scope and to determine the application, population, current strategies, clinical care, and outcomes. Therefore, we will use routine primary care data to evaluate current practice of blood test ordering in children with persistent fatigue. In addition, we will evaluate experiences, preferences and shared understanding of blood tests of GPs and child or parents using semi-structured interviews to determine which test strategies of blood tests are most common and acceptable in clinical practice. The second and third steps are to develop decision trees of these test strategies and to find available evidence from literature and guidelines on diagnostic accuracy, costs and health outcomes of the test strategies. The fourth step is to determine the potential impact on costs, missed and falsely diagnosed somatic conditions, and quality of life for each strategy and evaluate whether the test strategies have to potential to be cost effective. In the fifth step we will provide recommendations and will analyze opportunities of improvement and knowledge gaps for the test strategies and communication with child and parents.

IMPACT

Evaluation of the cost-effectiveness of blood tests in children with persistent fatigue in primary care is listed among top 10 priorities in the domain childhood of the 2018 Dutch national research agenda for primary care. Based on the results of this project we can provide recommendations for potential cost-effective test strategies of blood tests ordering in children with persistent fatigue including communication guidelines for explaining and interpreting the blood test ordering and test results to child and parents. These recommendations could be tested in future intervention studies to determine the actual diagnostic accuracy and cost-effectiveness of blood tests ordering in potential cost-effective test strategies and thereby answering the research question of the Dutch national research agenda for primary care. This could result in an adopted LESA-guideline. In general practice, this might help the GP in careful consideration of the decision to order blood tests and in clear communication to child and parents.