'I'm fishing really'--inflammatory marker testing in primary care: a qualitative study

Abstract

Background: Inflammatory markers can be helpful as part of the diagnostic workup for specific diseases or for monitoring disease activity. A third use is as a screening and/or triage tool to differentiate between the presence or absence of disease. Most research into inflammatory markers looks at diagnosis of specific diseases and comes from secondary care. Qualitative studies to explore when and why clinicians use these tests in primary care are lacking.

Aim: To identify clinicians' approaches to inflammatory marker testing in primary care.

Design and setting: Qualitative study with 26 GPs and nurse practitioners.

Method: Interviews were conducted using a semi-structured topic guide. Clinicians reviewed recent cases of inflammatory marker testing in their pathology inbox. Interviews were audiorecorded and transcribed. Qualitative analysis was conducted by two of the authors.

Results: Clinicians are uncertain about the appropriate use of inflammatory markers and differ in their approach to testing patients with undifferentiated symptoms. Normal or significantly elevated inflammatory markers are seen as helpful, but mildly raised inflammatory markers in the context of non-specific symptoms are difficult to interpret. Clinicians describe a tension between not wanting to 'miss anything' and, on the other hand, being wary of picking up borderline abnormalities that can lead to cascades of further tests. Diagnostic uncertainty is a common reason for inflammatory marker testing, with the aim to reassure; however, paradoxically, inconclusive results can generate a cycle of uncertainty and anxiety.

Conclusion: Further research is needed to define when inflammatory marker testing is useful in primary care and how to interpret results.

Keywords: C-reactive protein; acute-phase proteins; diagnosis; general practice; primary health care; qualitative research.

Figure 1.

Cycle of uncertainty and anxiety in inflammatory marker testing. Uncertainty about diagnosis can lead to increased testing rates. This increases the chance of borderline test results, which may cause more uncertainty and anxiety.