Effect of an Individualized Audit and Feedback Intervention on Rates of Musculoskeletal Diagnostic Imaging Requests by Australian General Practitioners: A Randomized Clinical Trial

O'Connor D, Gelber N, Bourne A, G. Maher C, Buchbinder R. Australian General Practitioners' Use of Diagnostic Lumbar Spine Imaging for Patients With Acute Low Back Pain: A Qualitative Study

BACKGROUND

General practitioners (GPs) use of imaging for acute low back pain (LBP) is above guideline recommendations, and the reasons for this remain under-researched. We examined the perspectives, expectations and information needs of Australian GPs requesting lumbar spine diagnostic imaging for patients presenting with acute LBP.

METHODS

We completed semi-structured interviews with 12 GPs practising in Victoria, Australia. Transcripts were thematically analysed, and themes compared according to whether or not GPs reported they regularly requested imaging for LBP.

RESULTS

We identified four themes. (1) Besides responding to 'red flags', GPs' experiences of uncovering unexpected but serious findings on imaging for LBP as well as perceived external pressures motivated their defensive imaging practices. (2) While most were reluctant to request imaging for LBP, once requested, GPs escalated through imaging modalities and focused on the diagnostic benefit of their findings. (3) GPs supported the inclusion of epidemiological data on imaging reports, but (4) largely opposed imaging reports being written in plain language, believing reports to be clinician-to-clinician communications that patients would misunderstand. All GPs were aware of the limited utility of imaging for diagnosing LBP, and themes were similar between GPs who regularly requested imaging and those who did not. Factors other than knowledge of imaging efficacy for LBP seemed to play an important role in imaging requests.

CONCLUSIONS

Our study identified key drivers of imaging use for LBP in primary care. The findings underscore that interventions targeting GPs addressing the overuse of imaging for LBP should transcend knowledge deficit models.

Dissemination and Implementation-A Primer for Accelerating "Time to Translation" in Radiation Oncology

The field of radiation oncology has achieved significant technological and scientific advancements in the 21st century. Yet uptake of new evidence-based practices has been heterogeneous, even in the presence of national and international guidelines. Addressing barriers to practice change requires a deliberate focus on developing and testing strategies tailored to improving care delivery and quality, especially for vulnerable patient populations. Implementation science provides a systematic approach to developing and testing strategies, though applications in radiation oncology remain limited. In this critical review, we aim to (1) assess the time from first evidence to widespread adoption, or "time to translation," across multiple evidence-based practices involving radiation therapy, and (2) provide a primer on the application of implementation science to radiation oncology. Specifically, we discuss potential targets for implementation research in radiation oncology, including both evidence-based practices and quality metrics, and highlight examples of studies evaluating implementation strategies. We also define key concepts and frameworks in the field of implementation science, review common study designs, including hybrid trials and cluster randomization, and discuss the interaction with related disciplines such as quality improvement and behavioral economics. Ultimately, this review aims to illustrate how a comprehensive understanding of implementation science could be used to promote equity and quality in cancer care through the development of effective, scalable, and sustainable care delivery solutions.

Audit and feedback: effects on professional practice

BACKGROUND

Audit and feedback (A&F) is a widely used strategy to improve professional practice. This is supported by prior Cochrane reviews and behavioural theories describing how healthcare professionals are prompted to modify their practice when given data showing that their clinical practice is inconsistent with a desirable target. Yet there remains uncertainty regarding the effects of A&F on improving healthcare practice and the characteristics of A&F that lead to a greater impact.

OBJECTIVES

To assess the effects of A&F on the practice of healthcare professionals and to examine factors that may explain variation in the effectiveness of A&F.

SEARCH METHODS

With the Cochrane Effective Practice and Organisation of Care (EPOC) group information scientist, we updated our search strategy to include studies published from 2010 to June 2020. Search updates were performed on 28 February 2019 and 11 June 2020. We searched MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCO), the Cochrane Library, clinicaltrials.gov (all dates to June 2020), WHO ICTRP (all dates to February Week 3 2019, no information available in 2020 due to COVID-19 pandemic). An updated search and duplicate screen was completed on February 14, 2022; studies that met inclusion criteria are included in the 'Studies awaiting classification' section.

SELECTION CRITERIA

Randomised trials, including cluster-trials and cross-over and factorial designs, featuring A&F (defined as measurement of clinical performance over a specified period of time (audit) and provision of the resulting data to clinicians or clinical teams (feedback)) in any trial arm that reported objectively measured health professional practice outcomes.

DATA COLLECTION AND ANALYSIS

For this updated review, we re-extracted data for each study arm, including theory-informed variables regarding how the A&F was conducted and behaviour change techniques for each intervention, as well as study-level characteristics including risk of bias. For each study, we extracted outcome data for every healthcare professional practice targeted by A&F. All data were extracted by a minimum of two independent review authors. For studies with dichotomous outcomes that included arms with and without A&F, we calculated risk differences (RDs) (absolute difference between arms in proportion of desired practice completed) and also odds ratios (ORs). We synthesised the median RDs and interquartile ranges (IQRs) across all trials. We then conducted meta-analyses, accounting for multiple outcomes from a given study and weighted by effective sample size, using reported (or imputed, when necessary) intra-cluster correlation coefficients. Next, we explored the role of baseline performance, co-interventions, targeted behaviour, and study design factors on the estimated effects of A&F. Finally, we conducted exploratory meta-regressions to test preselected variables that might be associated with A&F effect size: characteristics of the audit (number of indicators, aggregation of data); delivery of the feedback (multi-modal format, local champion, nature of comparator, repeated delivery); and components supporting action (facilitation, provision of specific plans for improvement, co-development of action plans).

MAIN RESULTS

We included 292 studies with 678 arms; 133 (46%) had a low risk of bias, 41 (14%) unclear, and 113 (39%) had a high risk of bias. There were 26 (9%) studies conducted in low- or middle-income countries. In most studies (237, 81%), the recipients of A&F were physicians. Professional practices most commonly targeted in the studies were prescribing (138 studies, 47%) and test-ordering (103 studies, 35%). Most studies featured multifaceted interventions: the most common co-interventions were clinician education (377 study arms, 56%) and reminders (100 study arms, 15%). Forty-eight unique behaviour change techniques were identified within the study arms (mean 5.2, standard deviation 2.8, range 1 to 29). Synthesis of 558 dichotomous outcomes measuring professional practices from 177 studies testing A&F versus control revealed a median absolute improvement in desired practice of 2.7%, with an IQR of 0.0 to 8.6. Meta-analyses of these studies, accounting for multiple outcomes from the same study and weighting by effective sample size accounting for clustering, found a mean absolute increase in desired practice of 6.2% (95% confidence interval (CI) 4.1 to 8.2; moderate-certainty evidence) and an OR of 1.47 (95% CI 1.31 to 1.64; moderate-certainty evidence). Effects were similar for pre-planned subgroup analyses focused on prescribing and test-ordering outcomes. Lower baseline performance and increased number of co-interventions were both associated with larger intervention effects. Meta-regressions comparing the presence versus absence of specific A&F components to explore heterogeneity, accounting for baseline performance and number of co-interventions, suggested that A&F effects were greater with individual-recipient-level data rather than team-level data, comparing performance to top-peers or a benchmark, involving a local champion with whom the recipient had a relationship, using interactive modalities rather than just didactic or just written format, and with facilitation to support engagement, and action plans to improve performance. The meta-regressions did not find significant effects with the number of indicators in the audit, comparison to average performance of all peers, or co-development of action plans. Contrary to expectations, repeated delivery was associated with lower effect size. Direct comparisons from head-to-head trials support the use of peer-comparisons versus no comparison at all and the use of design elements in feedback that facilitate the identification and action of high-priority clinical items.

AUTHORS' CONCLUSIONS

A&F can be effective in improving professional practice, but effects vary in size. A&F is most often delivered along with co-interventions which can contribute additive effects. A&F may be most effective when designed to help recipients prioritise and take action on high-priority clinical issues and with the following characteristics: 1. targets important performance metrics where health professionals have substantial room for improvement (audit); 2. measures the individual recipient's practice, rather than their team or organisation (audit); 3. involves a local champion with an existing relationship with the recipient (feedback); 4. includes multiple, interactive modalities such as verbal and written (feedback); 5. compares performance to top peers or a benchmark (feedback); 6. facilitates engagement with the feedback (action); 7. features an actionable plan with specific advice for improvement (action). These conclusions require further confirmatory research; future research should focus on discerning ways to optimise the effectiveness of A&F interventions.

Patterns of Imaging Requests By General Practitioners for People With Musculoskeletal Complaints: An Analysis From a Primary Care Database

OBJECTIVE

The aim of this study was to examine imaging requested by general practitioners (GPs) for patients with low back, neck, shoulder, and knee complaints over 5 years (2014-2018).

METHODS

This analysis from the Australian Population Level Analysis and Reporting database included patients presenting with a diagnosis of low back, neck, shoulder, and/or knee complaints. Eligible imaging requests included low back and neck x-ray, computed tomography (CT), and magnetic resonance imaging (MRI); knee x-ray, CT, MRI, and ultrasound; and shoulder x-ray, MRI, and ultrasound. We determined number of imaging requests and examined their timing, associated factors, and trends over time. Primary analysis included imaging requests from 2 weeks before diagnosis to 1 year after diagnosis.

RESULTS

There were 133,279 patients (57% low back, 25% knee, 20% shoulder, and 11% neck complaints). Imaging was most common among those with a shoulder (49%) complaint, followed by knee (43%), neck (34%), and low back complaints (26%). Most requests occurred simultaneously with the diagnosis. Imaging modality varied by body region and, to a lesser extent, by gender, socioeconomic status, and primary health network. For low back, there was a 1.3% (95% confidence interval [95% CI] 1.0-1.6) annual increase in proportion of MRI and a concomitant 1.3% (95% CI 0.8-1.8) decrease in CT requests. For neck, there was a 3.0% (95% CI 2.1-3.9) annual increase in proportion of MRI and a concomitant 3.1% (95% CI 2.2-4.0) decrease in x-ray requests.

CONCLUSION

GPs commonly request early diagnostic imaging for musculoskeletal complaints at odds with recommended practice. We observed a trend towards more complex imaging for neck and back complaints.

Can General Practitioner Opioid Prescribing to Compensated Workers with Low Back Pain Be Detected Using Administrative Payments Data? An Exploratory Study

BACKGROUND

Approximately one third of Australians with accepted time loss workers' compensation claims for low back pain (LBP) are dispensed opioid analgesics. Structured administrative payments data is scalable but does not directly link opioids to prescribers. We sought to determine whether opioid prescribing by general practitioners (GPs) to workers with workers' compensation claims for LBP can be detected in structured administrative payments data.

METHODS

We used a sample of workers with accepted time loss workers' compensation claims for low back pain from 2011 to 2015 from the Australian states of Victoria and South Australia. We structured administrative data to test the assumption that opioid dispenses that occurred immediately after a GP encounter in sequence and occurred on the same date as the GP encounter are likely to be related. We measured the number and proportion of opioid dispenses with a GP encounter prior and the days between a GP encounter and opioid dispense.

RESULTS

Nearly one third of workers (32.2%, N = 4,128) in our sample (n = 12,816) were dispensed opioids a median of five times (interquartile range 2, 17). There were 43,324 opioid dispenses to included workers. 30,263 (69.9%) of opioid dispenses were immediately preceded by a GP encounter. Of those dispenses, 51.0% (n = 15,443) occurred on the same day as the GP encounter.

CONCLUSION

At least one third of opioids dispensed to workers with claims for LBP can be potentially linked to GP prescribing using workers' compensation structured administrative payments data. This approach could have potential applications in supporting monitoring and audit and feedback systems. Future research should test this approach with a more diverse array of pain medicines and medical practitioners.

Theory-Informed Development of a Multicomponent Intervention to Implement Clinical Practice Guideline Recommendations in the Management of Shoulder Pain

OBJECTIVE

Suboptimal primary health care management of shoulder pain has been reported in previous studies. Implementing clinical practice guidelines (CPGs) recommendations using a theoretical approach is recommended to improve shoulder pain management. This study aims to identify determinants of implementing recommendations from shoulder CPGs to help develop an intervention based on the identified determinants.

METHODS

Family physicians and physical therapists managing patients with shoulder pain in primary care were invited to participate in a qualitative study to identify determinants to implementing recommendations from shoulder CPGs. The Theoretical Domains Framework (TDF) was used to inform the creation of the semi-structured interview guide and for deductive coding of transcriptions. The determinants were mapped to intervention functions and behavior change techniques (BCT) using the Behavior Change Wheel method and strategies for implementing CPGs recommendations were identified.

RESULTS

Interviews were conducted with 16 family physicians and 19 physical therapists. We identified 12 barriers and 6 facilitators within 7 TDF domains: knowledge, skills, beliefs about capabilities, beliefs about consequences, intentions, environmental context and resources, and social influence. We identified 6 intervention functions and 12 BCT addressing the relevant determinants. The 11 implementation strategies identified include the development and distribution of educational material, interactive educational outreach visits, and audit and feedback. Other components to consider are the identification and preparation of champions in primary care clinical settings, revision of professional roles, and creation of interdisciplinary clinical teams.

CONCLUSIONS

The identification of barriers and facilitators to implementing recommendations from shoulder CPGs allowed us to select implementation strategies at individual and organizational levels.

IMPACT

The implementation strategies will be adapted to specific primary care contexts in consultation with stakeholders and operationalized into a multicomponent implementation intervention. Implementing the intervention has the potential to improve shoulder pain management in primary care and facilitate the use of evidence-based recommendations from CPGs.

Perceptions of medical doctors and patients about imaging for people with low back pain: A qualitative study

BACKGROUND

Low-value care is the use of substitutive/ineffective/harmful strategies based on available evidence, and it is considered one of the main contributors to the burden related to low back pain in health care systems. The use of routine imaging for patients with low back pain is the main example of inappropriate care. Therefore, understanding the perceptions of medical doctors and patients from Brazil about this practice may help propose strategies to reduce imaging rates.

OBJECTIVE

To investigate the perceptions of medical doctors and patients about imaging for the diagnosis of nonspecific low back pain.

DESIGN

A qualitative study using the framework analysis method.

SETTINGS

Primary and secondary care.

PARTICIPANTS

Fifteen patients with low back pain and 15 doctors participated in this study.

DATA COLLECTION

Sociodemographic data were collected from all participants, and the interviews were performed using a set of questions created based on the literature.

MAIN RESULTS

Patients and doctors believe that the main reason for ordering imaging tests is to identify the source of pain, and imaging could be useful for tracking disease progression over time or if there is a lack of improvement after treatment. Patients' expectations and pressures play a role in the decision to order imaging tests, but clinicians believe that education is the preferred strategy to reduce imaging rates.

CONCLUSION

Identifying the source of pain, tracking the disease progression, and patients' expectations and pressures were the main drivers of imaging requests for low back pain. Educational strategies were suggested to reduce the use of routine imaging.

Effectiveness of strategies for implementing guideline-concordant care in low back pain: a systematic review and meta-analysis of randomised controlled trials

Background

International low back pain guidelines recommend providing education/advice to patients, discouraging routine imaging use, and encouraging judicious prescribing of analgesics. However, practice variation occurs and the effectiveness of implementation strategies to promote guideline-concordant care is unclear. This review aims to comprehensively evaluate the effectiveness of implementation strategies to promote guideline-concordant care for low back pain.

Methods

Five databases (including MEDLINE, Embase, CINAHL, CENTRAL and PEDro were searched from inception until 22nd August 2024. Randomised controlled trials (RCTs) that evaluated strategies to promote guideline-concordant care (providing education/advice, discouraging routine imaging use, and/or reducing analgesic use) among healthcare professionals or organisations were included. Two reviewers independently conducted screening, data extraction, and risk of bias assessments. The primary outcome was guideline-concordant care in the medium-term (>3 months but <12 months). The taxonomy recommended by the Cochrane Effective Practice and Organisation of Care (EPOC) group was used to categorise implementation strategies. Meta-analysis with a random-effects model was conducted where possible. This systematic review was prospectively registered in PROSPERO (registration number: CRD42023452969).

Findings

Twenty-seven RCTs with 32 reports were included. All strategies targeted healthcare professionals (7796 health professionals overseeing 34,890 patients with low back pain), and none targeted organisations. The most commonly used implementation strategies were educational materials (15/27) and educational meetings (14/27), although most studies (24/27) used more than one strategy ('multifaceted strategies'). In the medium-term, compared to no implementation, implementation strategies probably reduced the use of routine imaging (number of studies [N] = 7, odds ratio [OR] = 1.26, 95% confidence interval [CI]: 1.01-1.58, I 2  = 50%, moderate certainty evidence), but made no difference in reducing analgesic use (N = 4, OR = 1.05, 95% CI: 0.96-1.14, I 2  = 0%, high certainty evidence). Further, implementation strategies may make no difference to improve the rate of providing education/advice (N = 3, OR = 1.83, 95% CI: 0.87-3.87, I 2  = 95%, low certainty evidence), but this finding should be interpreted with caution because the sensitivity analysis showed a weak positive finding indicating unstable results that are likely to change with future research (N = 2, OR = 1.18, 95% CI: 1.04-1.35, I 2  = 0%, moderate certainty evidence). No difference was found when comparing one implementation strategy to another in the medium-term.

Interpretation

Implementing guideline recommendations delivered mixed effects in promoting guideline-concordant care for low back pain management.

Funding

There was no funding source for this review.

How Do Australians Manage Diagnostic Testing Risks? Focus Groups Linked to a Model of Behaviour Change

BACKGROUND

Diagnostic tests carry significant risks, and communications are needed to help lay people consider these. The development of communications has been hindered by poor knowledge about how lay people understand and negotiate testing risks. We examined lay Australians' perceptions of diagnostic testing risks and how these risks are managed.

METHOD

We completed 12 semistructured online focus groups with 61 Australian adults (18+) between April and June 2022. Participants were divided into younger/older (> 50 years) and male/female groups. Using semistructured discussion and exploring two hypothetical scenarios, we examined attitudes to diagnostic tests, their risks and how test risks were managed. Themes were identified, subanalysed to identify age and gender differences and mapped to the COM-B model of behaviour change.

RESULTS

The six themes provided detailed accounts of how participants considered themselves able, empowered and assertive when negotiating testing risks and of complex ways in which relationships with health workers, personal experiences and structural factors influenced negotiating testing risks. COM-B identified multiple opportunities for leveraging these lay beliefs in health promotion. It also identified barriers, including narrow concepts of testing risks, challenges during shared decision-making and overestimation of personal influence on testing decisions.

SIGNIFICANCE

Our findings matter because they are a novel, detailed account of testing risk beliefs, linked to a model for behaviour change. This will directly inform development of test risk/benefit communications, which are a research priority.

PUBLIC CONTRIBUTION

The study design enabled participants to influence the discussion agenda, and they could comment on the analysis. Participants contributed insights about their needs, beliefs and experiences related to medical testing, and these will be used to shape future patient-centred decision tools.

Geographic patterns of dental service use in the Child Dental Benefits Schedule: 6 years of claims in the Longitudinal Study of Australian Children

ISSUE ADDRESSED

This article explores the geographic patterns of claims within the Australian Government's Child Dental Benefits Schedule (CDBS).

BACKGROUND

The CDBS is a means-tested schedule implemented in 2014 to improve access to dental services for children. Under the schedule, eligible children receive funding to subsidise dental services.

METHODS

This study used data from the Longitudinal Study of Australian Children and linked data from the Medicare universal healthcare system, to examine dental service use amongst a subset of children aged 10 and 14 years. Dental service items were classified using Two-step Cluster Analysis, and appointments were analysed using multinomial logistic regression. Geographic characteristics were included as predictor variables.

RESULTS

The study found that the majority of dental appointments were non-operative (70.7%, n = 5808), with diagnostic, radiographic, and preventive items being the most common. There were slightly higher proportions of operative appointments (fillings and extractions) compared with non-operative appointments in remote and very remote areas, low socio-economic areas, and Queensland and Northern Territory. Cluster analysis identified eight groups of non-operative appointments and four groups of operative appointments. New South Wales had a higher proportion of 'prophylactic IV' appointments than any other State and Territory, which included debridement and topical fluoride services.

CONCLUSION

Cluster analysis identified distinct groups of non-operative and operative appointments, each with unique characteristics. The distribution of appointments varied by State/Territory and region.

SO WHAT

Further research and interventions are needed to ensure equitable access to services and a shift to preventive care for disadvantaged populations of Australian children. Exploring alternative funding models that support clinically relevant claims, rather than maximising financial benefits such as time-based renumeration models should be explored.

The use of linked administrative data in Australian randomised controlled trials: A scoping review

BACKGROUND/AIMS

The demand for simplified data collection within trials to increase efficiency and reduce costs has led to broader interest in repurposing routinely collected administrative data for use in clinical trials research. The aim of this scoping review is to describe how and why administrative data have been used in Australian randomised controlled trial conduct and analyses, specifically the advantages and limitations of their use as well as barriers and enablers to accessing administrative data for use alongside randomised controlled trials.

METHODS

Databases were searched to November 2022. Randomised controlled trials were included if they accessed one or more Australian administrative data sets, where some or all trial participants were enrolled in Australia, and where the article was published between January 2000 and November 2022. Titles and abstracts were independently screened by two reviewers, and the full texts of selected studies were assessed against the eligibility criteria by two independent reviewers. Data were extracted from included articles by two reviewers using a data extraction tool.

RESULTS

Forty-one articles from 36 randomised controlled trials were included. Trial characteristics, including the sample size, disease area, population, and intervention, were varied; however, randomised controlled trials most commonly linked to government reimbursed claims data sets, hospital admissions data sets and birth/death registries, and the most common reason for linkage was to ascertain disease outcomes or survival status, and to track health service use. The majority of randomised controlled trials were able to achieve linkage in over 90% of trial participants; however, consent and participant withdrawals were common limitations to participant linkage. Reported advantages were the reliability and accuracy of the data, the ease of long term follow-up, and the use of established data linkage units. Common reported limitations were locating participants who had moved outside the jurisdictional area, missing data where consent was not provided, and unavailability of certain healthcare data.

CONCLUSIONS

As linked administrative data are not intended for research purposes, detailed knowledge of the data sets is required by researchers, and the time delay in receiving the data is viewed as a barrier to its use. The lack of access to primary care data sets is viewed as a barrier to administrative data use; however, work to expand the number of healthcare data sets that can be linked has made it easier for researchers to access and use these data, which may have implications on how randomised controlled trials will be run in future.

Clinical care standards for the management of low back pain: a scoping review

The objective of this study is to compare and contrast the quality statements and quality indicators across clinical care standards for low back pain. Searches were performed in Medline, guideline databases, and Google searches to identify clinical care standards for the management of low back pain targeting a multidisciplinary audience. Two independent reviewers reviewed the search results and extracted relevant information from the clinical care standards. We compared the quality statements and indicators of the clinical care standards to identify the consistent messages and the discrepancies between them. Three national clinical care standards from Australia, Canada, and the United Kingdom were included. They provided from 6 to 8 quality statements and from 12 to 18 quality indicators. The three standards provide consistent recommendations in the quality statements related to imaging, and patient education/advice and self-management. In addition, the Canadian and Australian standards also provide consistent recommendations regarding comprehensive assessment, psychological support, and review and patient referral. However, the three clinical care standards differ in the statements related to psychological assessment, opioid analgesics, non-opioid analgesics, and non-pharmacological therapies. The three national clinical care standards provide consistent recommendations on imaging and patient education/advice, self-management of the condition, and two standards (Canadian and Australian) agree on recommendations regarding comprehensive assessment, psychological support, and review and patient referral. The standards differ in the quality statements related to psychological assessment, opioid prescription, non-opioid analgesics, and non-pharmacological therapies.

Audit and feedback to change diagnostic image ordering practices: A systematic review and meta-analysis

BACKGROUND

Up to 30% of diagnostic imaging (DI) tests may be unnecessary, leading to increased healthcare costs and the possibility of patient harm. The primary objective of this systematic review was to assess the effect of audit and feedback (AF) interventions directed at healthcare providers on reducing image ordering. The secondary objective was to examine the effect of AF on the appropriateness of DI ordering.

METHODS

Studies were identified using MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials and ClinicalTrials.gov registry on December 22nd, 2022. Studies were included if they were randomized control trials (RCTs), targeted healthcare professionals, and studied AF as the sole intervention or as the core component of a multi-faceted intervention. Risk of bias for each study was evaluated using the Cochrane risk of bias tool. Meta-analyses were completed using RevMan software and results were displayed in forest plots.

RESULTS

Eleven RCTs enrolling 4311 clinicians or practices were included. AF interventions resulted in 1.5 fewer image test orders per 1000 patients seen than control interventions (95% confidence interval (CI) for the difference -2.6 to -0.4, p-value = 0.009). The effect of AF on appropriateness was not statistically significant, with a 3.2% (95% CI -1.5 to 7.7%, p-value = 0.18) greater likelihood of test orders being considered appropriate with AF vs control interventions. The strength of evidence was rated as moderate for the primary objective but was very low for the appropriateness outcome because of risk of bias, inconsistency in findings, indirectness, and imprecision.

CONCLUSION

AF interventions are associated with a modest reduction in total DI ordering with moderate certainty, suggesting some benefit of AF. Individual studies document effects of AF on image order appropriateness ranging from a non-significant trend toward worsening to a highly significant improvement, but the weighted average effect size from the meta-analysis is not statistically significant with very low certainty.

Evaluating a Physician Audit and Feedback Intervention to Increase Clinical Trial Enrollment in Radiation Oncology in a Multisite Tertiary Cancer Center: A Randomized Study

PURPOSE

Clinical trial participation continues to be low, slowing new cancer therapy development. Few strategies have been prospectively tested to address barriers to enrollment. We investigated the effectiveness of a physician audit and feedback report to improve clinical trial enrollment.

METHODS AND MATERIALS

We conducted a randomized quality improvement study among radiation oncologists at a multisite tertiary cancer network. Physicians in the intervention group received quarterly audit and feedback reports comparing the physician's trial enrollments with those of their peers. The primary outcome was trial enrollments.

RESULTS

Among physicians randomized to receive the feedback report (n = 30), the median proportion of patients enrolled during the study period increased to 6.1% (IQR, 2.6%-9.3%) from 3.2% (IQR, 1.1%-10%) at baseline. Among those not receiving the feedback report (n = 29), the median proportion of patients enrolled increased to 4.1% (IQR, 1.3%-7.6%) from 1.6% (IQR, 0%-4.1%) at baseline. There was a nonsignificant change in the proportion of enrollments associated with receiving the feedback report (-0.6%; 95% CI, -3.0% to 1.8%; P = .6). Notably, there was an interaction between baseline trial accrual and receipt of feedback reports (P = .005), with enrollment declining among high accruers. There was an increase in enrollment throughout the study, regardless of study group (P = .001).

CONCLUSIONS

In this study, a positive effect of physician audit and feedback on clinical trial enrollment was not observed. Future efforts should avoid disincentivizing high accruers and might consider pairing feedback with other patient- or physician-level strategies. The increase in trial enrollment in both groups over time highlights the importance of including a comparison group in quality improvement studies to reduce confounding from secular trends.

Implementation Strategies to Promote Short-Course Radiation for Bone Metastases

Importance

For patients with nonspine bone metastases, short-course radiotherapy (RT) can reduce patient burden without sacrificing clinical benefit. However, there is great variation in uptake of short-course RT across practice settings.

Objective

To evaluate whether a set of 3 implementation strategies facilitates increased adoption of a consensus recommendation to treat nonspine bone metastases with short-course RT (ie, ≤5 fractions).

Design, Setting, and Participants

This prospective, stepped-wedge, cluster randomized quality improvement study was conducted at 3 community-based cancer centers within an existing academic-community partnership. Rollout was initiated in 3-month increments between October 2021 and May 2022. Participants included treating physicians and patients receiving RT for nonspine bone metastases. Data analysis was performed from October 2022 to May 2023.

Exposures

Three implementation strategies-(1) dissemination of published consensus guidelines, (2) personalized audit-and-feedback reports, and (3) an email-based electronic consultation platform (eConsult)-were rolled out to physicians.

Main Outcomes and Measures

The primary outcome was adherence to the consensus recommendation of short-course RT for nonspine bone metastases. Mixed-effects logistic regression at the bone metastasis level was used to model associations between the exposure of physicians to the set of strategies (preimplementation vs postimplementation) and short-course RT, while accounting for patient and physician characteristics and calendar time, with a random effect for physician. Physician surveys were administered before implementation and after implementation to assess feasibility, acceptability, and appropriateness of each strategy.

Results

Forty-five physicians treated 714 patients (median [IQR] age at treatment start, 67 [59-75] years; 343 women [48%]) with 838 unique nonspine bone metastases during the study period. Implementing the set of strategies was not associated with use of short-course RT (odds ratio, 0.78; 95% CI, 0.45-1.34; P = .40), with unadjusted adherence rates of 53% (444 lesions) preimplementation vs 56% (469 lesions) postimplementation; however, the adjusted odds of adherence increased with calendar time (odds ratio, 1.68; 95% CI, 1.20-2.36; P = .003). All 3 implementation strategies were perceived as being feasible, acceptable, and appropriate; only the perception of audit-and-feedback appropriateness changed before vs after implementation (19 of 29 physicians [66%] vs 27 of 30 physicians [90%]; P = .03, Fisher exact test), with 20 physicians (67%) preferring reports quarterly.

Conclusions and Relevance

In this quality improvement study, a multicomponent set of implementation strategies was not associated with increased use of short-course RT within an academic-community partnership. However, practice improved with time, perhaps owing to secular trends or physician awareness of the study. Audit-and-feedback was more appropriate than anticipated. Findings support the need to investigate optimal approaches for promoting evidence-based radiation practice across settings.

Process evaluation of the implementation of an evidence-based model of care for low back pain in Australian emergency departments

BACKGROUND

The Sydney Health Partners Emergency Department (SHaPED) trial targeted ED clinicians and evaluated a multifaceted strategy to implement a new model of care. The objective of this study was to investigate attitudes and experiences of ED clinicians as well as barriers and facilitators for implementation of the model of care.

DESIGN

A qualitative study.

METHODS

The EDs of three urban and one rural hospital in New South Wales, Australia participated in the trial between August and November 2018. A sample of clinicians was invited to participate in qualitative interviews via telephone and face-to-face. The data collected from the interviews were coded and grouped in themes using thematic analysis methods.

RESULTS

Non-opioid pain management strategies (i.e., patient education, simple analgesics, and heat wraps) were perceived to be the most helpful strategy for reducing opioid use by ED clinicians. However, time constraints and rotation of junior medical staff were seen as the main barriers for uptake of the model of care. Fear of missing a serious pathology and the clinicians' conviction of a need to provide something for the patient were seen as barriers to reducing lumbar imaging referrals. Other barriers to guideline endorsed care included patient's expectations and characteristics (e.g., older age and symptoms severity).

CONCLUSIONS

Improving knowledge of non-opioid pain management strategies was seen as a helpful strategy for reducing opioid use. However, clinicians also raised barriers related to the ED environment, clinicians' behaviour, and cultural aspects, which should be addressed in future implementation efforts.

Evaluating an audit and feedback intervention for reducing overuse of pathology test requesting by Australian general practitioners: protocol for a factorial cluster randomised controlled trial

INTRODUCTION

Consistent evidence shows pathology services are overused worldwide and that about one-third of testing is unnecessary. Audit and feedback (AF) is effective for improving care but few trials evaluating AF to reduce pathology test requesting in primary care have been conducted. The aim of this trial is to estimate the effectiveness of AF for reducing requests for commonly overused pathology test combinations by high-requesting Australian general practitioners (GPs) compared with no intervention control. A secondary aim is to evaluate which forms of AF are most effective.

METHODS AND ANALYSIS

This is a factorial cluster randomised trial conducted in Australian general practice. It uses routinely collected Medicare Benefits Schedule data to identify the study population, apply eligibility criteria, generate the interventions and analyse outcomes. On 12 May 2022, all eligible GPs were simultaneously randomised to either no intervention control or to one of eight intervention groups. GPs allocated to an intervention group received individualised AF on their rate of requesting of pathology test combinations compared with their GP peers. Three separate elements of the AF intervention will be evaluated when outcome data become available on 11 August 2023: (1) invitation to participate in continuing professional development-accredited education on appropriate pathology requesting, (2) provision of cost information on pathology test combinations and (3) format of feedback. The primary outcome is the overall rate of requesting of any of the displayed combinations of pathology tests of GPs over 6 months following intervention delivery. With 3371 clusters, assuming no interaction and similar effects for each intervention, we anticipate over 95% power to detect a difference of 4.4 requests in the mean rate of pathology test combination requests between the control and intervention groups.

ETHICS AND DISSEMINATION

Ethics approval was received from the Bond University Human Research Ethics Committee (#JH03507; approved 30 November 2021). The results of this study will be published in a peer-reviewed journal and presented at conferences. Reporting will adhere to Consolidated Standards of Reporting Trials.

TRIAL REGISTRATION NUMBER

ACTRN12622000566730.

Use of Decision-Analytic Modelling to Assess the Cost-Effectiveness of Diagnostic Imaging of the Spine, Shoulder, and Knee: A Scoping Review

BACKGROUND

Limited evidence is available on the cost-effectiveness of diagnostic imaging for back, neck, knee, and shoulder complaints. Decision analytic modelling may be an appropriate method to synthesise evidence from multiple sources, and overcomes issues with trial-based economic evaluations.

OBJECTIVE

The aim was to describe the reporting of methods and objectives utilised in existing decision analytic modelling studies that assess the cost-effectiveness of diagnostic imaging for back, neck, knee, and shoulder complaints.

METHODS

Decision analytic modelling studies investigating the use of any imaging modality for people of any age with back, neck, knee, or shoulder complaints were included. No restrictions on comparators were applied, and included studies were required to estimate both costs and benefits. A systematic search (5 January 2023) of four databases was conducted with no date limits imposed. Methodological and knowledge gaps were identified through a narrative summary.

RESULTS

Eighteen studies were included. Methodological issues were identified relating to the poor reporting of methods, and measures of effectiveness did not incorporate changes in quantity and/or quality of life (cost-utility analysis in only ten of 18 studies). Included studies, particularly those investigating back or neck complaints, focused on conditions that were of low prevalence but have a serious impact on health (i.e. cervical spine trauma, cancer-related back pain).

CONCLUSIONS

Future models should pay particular attention to the identified methodological and knowledge gaps. Investment in the health technology assessment of these commonly utilised diagnostic imaging services is needed to justify the current level of utilisation and ensure that these services represent value for money.

Prevalence and characteristics of musculoskeletal complaints in primary care: an analysis from the population level and analysis reporting (POLAR) database

BACKGROUND

Electronic health record datasets have been used to determine the prevalence of musculoskeletal complaints in general practice but not to examine the associated characteristics and healthcare utilisation at the primary care level.

AIM

To describe the prevalence and characteristics of patients presenting to general practitioners with musculoskeletal complaints.

DESIGN AND SETTING

A five-year analysis within three Primary Health Networks (PHNs) in Victoria, Australia.

METHOD

We included patients with at least one face-to-face consultation 2014 to 2018 inclusive and a low back (≥ 18 years), and/or neck, shoulder or knee (≥ 45 years) complaint determined by SNOMED codes derived from diagnostic text within the medical record. We determined prevalence, socio-demographic characteristics and diagnostic codes for patients with an eligible diagnosis; and number of consultations within one year of diagnosis.

RESULTS

324,793/1,294,021 (25%) presented with at least one musculoskeletal diagnosis, of whom 41% (n = 133,279) fulfilled our inclusion criteria. There were slightly more females (n = 73,428, 55%), two-thirds (n = 88,043) were of working age (18-64 years) and 83,816 (63%) had at least one comorbidity. Over half had a low back diagnosis (n = 76,504, 57%) followed by knee (n = 33,438, 25%), shoulder (n = 26,335, 20%) and neck (n = 14,492, 11%). Most codes included 'pain' and/or 'ache' (low back: 58%, neck: 41%, shoulder: 32%, knee 26%). Median (IQR) all-cause consultations per patient within one year of diagnosis was 7 (4-12).

CONCLUSION

The burden of MSK complaints at the primary care level is high as evidenced by the prevalence of people with musculoskeletal complaints presenting to a general practitioner, the preponderance of comorbidities and the numerous consultations per year. Identification and evaluation of strategies to reduce this burden are needed.