ArticlesEffect of audit and feedback, and reminder messages on primary-care radiology referrals: a randomised trial
Introduction
General practitioners (GPs) can overuse radiological tests, particularly lumbar spine1, 2 and knee radiographs.3 Such tests are frequently of little clinical use. Guidelines for use of these investigations are in the UK Royal College of Radiologists' publication Making the best use of a radiology department.4 However, few studies have been done of interventions designed to change GPs' behaviour. Although these studies showed that GPs altered their use of radiological tests, they were badly designed,5, 6 used inappropriate analysis,7 had short duration of follow-up,8 or omitted cost considerations.9 Grol10 and Lomas11 have summarised the theory of how to change doctors' behaviour, and Oxman and colleagues12 have reviewed the effectiveness of interventions. Specific prompts at the time of consultation are a powerful strategy13 and have been shown to alter GPs' behaviour— eg, when referring patients for infertility investigations14—but the effect of the widely-used strategy of audit and feedback is not so certain.15, 16
We assessed two methods (audit and feedback, and educational messages) of reducing GPs' requests for radiological tests in accordance with the UK Royal College of Radiologists' guidelines. Our hypothesis was that either intervention alone would be more effective than a control and that both interventions together would be more effective than either alone.
Section snippets
Study design
The study was based in six radiology departments in the north-east of England and Scotland and in GPs' surgeries (practices) that referred patients exclusively to them. The study was a before-and-after, pragmatic, cluster randomised controlled trial, with a 2·2 factorial design—practices were the units of randomisation and analysis.17 Randomisation, stratified by radiology department and practice size, was done by the study statistician (NS) with computer-generated random-number tables. The
Results
247 practices were enrolled, three of which dropped out (figure, table 1). To assess concordance with the guidelines, data were abstracted from 1693 patients' records of 162 GPs in 48 practices. The audit and feedback intervention was delivered to all eligible GPs according to study design. Attachment rate of educational reminder messages was close to 100%, or was 100%, in departments in which messages were attached electronically; was 100% in departments in which messages were attached by
Discussion
Our results have shown that the routine attachment of educational reminder messages to radiographs can reduce the number requested by 20%. Any department of radiology that takes referrals from primary care could deliver this intervention. 6-monthly feedback of audit data does not reduce radiograph requests.
Educational reminder messages are a response to information overload, and are easy to deliver21 and help to implement guidelines.22 Tierney and McDonald,23 looking at delivering preventive
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2022, CJC OpenCitation Excerpt :To the best of our knowledge, this study is the first to describe the use of an audit and feedback process as a strategy to encourage uptake of approaches for preventing CA-AKI. Numerous prior studies have described the development of audit and feedback interventions to improve the delivery of many other aspects of clinical care.22,47-55 Similar to our work, these studies have typically described the design of an audit and feedback process based on its content and presentation, and the manner in which audit information and feedback are reported to end-users.
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2022, eClinicalMedicineCitation Excerpt :To date, this has been limited to interventions seeking to optimise imaging in LBP, which have tended to demonstrate greater effect sizes. A cluster RCT16 showed that guideline-based reminder messages attached to lumbar spine radiology reports reduced requests by 30-37% (2·17 to 3·07 percentage points). Moreover, prospective28,31 and retrospective40 interrupted time series studies have observed that checklist computer systems prior to referral28 and fewer options for referral reasons to radiology31,40 reduce imaging referral rates from 23%28 to 47%.31
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