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.
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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
References (30)
Radiology for back pain
Clin Radiol
(1989)- et al.
The effect of radiology guidelines for general practitioners in Plymouth
Clin Radiol
(1990) - et al.
Chest radiography guidelines for general practitioners: a practical approach
Clin Radiol
(1994) - et al.
Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations
Lancet
(1993) - et al.
Multicentre trial of four strategies to reduce use of a radiological test
Lancet
(1986) - et al.
Implementation of guidelines for the use of skull radiographs in patients with head injuries
Lancet
(1984) - et al.
Chronic low back pain in primary care: a prospective study on the management and course
Fam Pract
(1998) - et al.
An audit of knee radiographs performed for general practitioners
Br J Radiol
(1997) Making the best use of a department of clinical radiology: guidelines for doctors
(1998)Influence of Royal College of Radiologists' guidelines on referral from general practice
BMJ
(1993)