Upsala J Med Sci 95: 225-227, 1990 

Comments. Which Tests Should Be Decentralized to the 
Primary Health Care? 

Nils Tryding 
Department of Clinical Chemistry, Central Hospital, Kristianstad and Department of 

Community Helath Sciences, University of L u n d ,  Dalby, Sweden 

In order to find out the need for laboratory investigations to 
be performed locally or sent to the central hospital we have 
regular contacts with physicians in primary care. Since 25 years 
we have registered their ordering habits. After discussions we 
have decided which investigations we at present think are 
meningful in different clinical situations. With respect to the 
techniques available today we have suggested which tests that are 
suitable for local analyses and which should be sent to the 
hospital laboratory. Continuous re-evaluations are made during 
meetings with local district physicians and during 5-day 
postgraduate courses for primary health care doctors and clinical 
chemists which have taken place every half year since 15 years. 

The present list of laboratory tests physicians would like to 
have performed locally according to clinical needs includes: 

B-Erythrocyte sedimentation rate (B-ESR) 
B-Hemoglobin (B-Hb) 
U-Albumin, U-Glucose (teststrips) 
(U-Hemoglobin, U-Acetoacetate, U-Nitrite teststrips) 
B-Glucose 
B-, U-Cells, microscopy 
B-Coagulation factors (Prothrombin complex) 
Pt-Bleeding time 
S-Potassium 
S-C-reactive protein (CRP) 
S-Creatinine 
S-ALAT, S-GT,S-ALP, S-Bilirubin, S-Amylase, S-Cat S-CKMB 
S-Cholesterol, fS-Triglycerides, B-HbAlc, S-Theophylline 
U-Dens ity 

15 - 908573 225 



U-A 1 bumi n 
U-Human Chorionic gonadotropin (U-hCG) 
F-Hemoglobin 

The list reflects present Swedish practice but varies locally. 
Some of these tests are not needed for immediate action. However, 
some physicians in health care want e.g. serum cholesterol or GT 
because they want to discuss the test results directly with the 
patient. 

Factors like distance to the central laboratory, communica- 
tions, number of analyses, training of personnel etc are 
important. 

In order to give room for the new analyses we decided to reduce 
the number of tests with limited value, e.g. blood leucocyte 
counting. Other laboratory investigations that were substantially 
diminished in number were B-ESR, urine microscopy, S-ASAT, S -  
Bilirubin, S-Urate and S-Sodium. In fact the total number of 
tests ordered by the physicians on two health centres was reduced 
by 30-50 per cent after my information and discussions concerning 
optimal use of clinical chemistry. The format for ordering tests 
has an impact. There are also very great differences between 
physicians. Continuous, practically oriented education and 
information from clinical chemists are necessary. 

We have asked patients and physicians about how soon they want 
to know the test results. The advantage of the new techniques is 
the offering of immediate answers when the physician and the 
patient are in personal contact. The laboratory test results can 
be evaluated immediately, together with other medical informa- 
tion. After further questions and investigations diagnostic 
decisions can be made without delay. The patients are saved 
travelling time. The personnel is saved work with specimen 
handling for postal transport. The secretaries are saved clerical 
work. The physicians have the opportunity to make a final 
decision without extra communication by telephone or letter. 
Undoubtedly all types of people concerned are willing to pay well 
for this service. However, money is invested well only when the 

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information obtained is clinically relevant and reliable. 
llClinicalll comes from the Greek word kline which means bed. Thus 
literally clinical chemistry means bedside chemistry. Thanks to 
new techniques this is now a reality. 
There is no definite answer to the question "Which tests should 

be decentralized to the primary health care?" We have here 
discussed some factors that must be considered. The clinical need 
for nearer patient testing is definitely the most important. The 
clinical chemist must take the responsibility for the evaluation 
of the effects of the new techniques. Continuous discussions 
between clinical chemists and physicians are necessary. There is 
a great need for education of the personnel in primary health 
care and regular quality control systems must be established. 

In summary: The goal must be to do correct tests as well as to 
do tests correctly. 

Correspondence: 
Professor Nils Tryding, 
Department of Clinical Chemistry, 
Central Hospital, 
S-29185 Kristianstad 
and Department of Community Health Sciences, 
University of Lund, 
5-24010 Dalby, Sweden 

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