Influence of postal distribution of the Royal College of Radiologists' guidelines, together with feedback on radiological referral rates, on X-ray referrals from general practice: a randomized controlled trial

Comparison of clinical estimations and radiological measurements in the context of paediatric cervical masses: How accurate are we?

OBJECTIVES

Cervical masses represent a common presentation to the paediatric ENT outpatient clinic. Despite their high prevalence, few represent an underlying malignant pathology. Currently, there is no universally accepted algorithm for management of such cases in the United Kingdom. Local guidance often centres around clinical interpretation of size when determining the need for investigation. With such emphasis placed on size, the authors sought to investigate the accuracy of physician palpation and in turn explore the validity of common referral pathways.

METHODS

A retrospective methodology was used to address the research objective. All paediatric ultrasound scans conducted during a 24-month period were reviewed to compare the clinical and radiological assessments of diameter. A 2 tailed paired student's t-test was selected to evaluate the differences between the two measurements and ultimately assess clinician accuracy.

RESULTS

753 paediatric cervical ultrasound scans were conducted during the 2-year period. Initial analysis identified three discrete ultrasonographically diagnostic groups: lymph nodes (n = 532), non-lymph node masses (n = 162) and normal anatomy (n = 59). Further analysis of clinical estimation and radiological measurement demonstrated a statistically significant difference (p < 0.02) for the lymph-node group. A statistically significant difference was not demonstrated within the non-lymph node group (p = 0.66). When clinician assessment resulted in a value outside of what was considered accurate, lymph node sizes were predominantly overestimated (62/91, 68%). Conversely, non-lymph node masses where the clinical measurement was not within 5 mm of the ultrasound measurement were more commonly underestimated in size (11/45, 55%) but this was not statistically significant.

CONCLUSIONS

Our study demonstrates a statistically significant tendency for clinicians to overestimate paediatric cervical lymphadenopathy. Calliper measurement may further improve accuracy of assessment.

Interventions for promoting evidence-based guideline-consistent surgery in low back pain: a systematic review and meta-analysis of randomised controlled trials

PURPOSE

Examine the effectiveness of interventions to approach guideline-adherent surgical referrals for low back pain assessed via systematic review and meta-analysis.

METHODS

Five databases (10 September 2021), Google Scholar, reference lists of relevant systematic reviews were searched and forward and backward citation tracking of included studies were implemented. Randomised controlled/clinical trials in adults with low back pain of interventions to optimise surgery rates or referrals to surgery or secondary referral were included. Bias was assessed using the Cochrane ROB2 tool and evidence certainty via Grading of Recommendations Assessment, Development and Evaluation (GRADE). A random effects meta-analysis with a Paule Mandel estimator plus Hartung-Knapp-Sidik-Jonkman method was used to calculate the odds ratio and 95% confidence interval, respectively.

RESULTS

Of 886 records, 6 studies were included (N = 258,329) participants; cluster sizes ranged from 4 to 54. Five studies were rated as low risk of bias and one as having some concerns. Two studies reporting spine surgery referral or rates could only be pooled via combination of p values and gave evidence for a reduction (p = 0.021, Fisher's method, risk of bias: low). This did not persist with sensitivity analysis (p = 0.053). For secondary referral, meta-analysis revealed a non-significant odds ratio of 1.07 (95% CI [0.55, 2.06], I2 = 73.0%, n = 4 studies, Grading of Recommendations Assessment, Development and Evaluation [GRADE] evidence certainty: very low).

CONCLUSION

Few RCTs exist for interventions to improve guideline-adherent spine surgery rates or referral. Clinician education in isolation may not be effective. Future RCTs should consider organisational and/or policy level interventions.

PROSPERO REGISTRATION

CRD42020215137.

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

IMPORTANCE

Audit and feedback can improve professional practice, but few trials have evaluated its effectiveness in reducing potential overuse of musculoskeletal diagnostic imaging in general practice.

OBJECTIVE

To evaluate the effectiveness of audit and feedback for reducing musculoskeletal imaging by high-requesting Australian general practitioners (GPs).

DESIGN, SETTING, AND PARTICIPANTS

This factorial cluster-randomized clinical trial included 2271 general practices with at least 1 GP who was in the top 20% of referrers for 11 imaging tests (of the lumbosacral or cervical spine, shoulder, hip, knee, and ankle/hind foot) and for at least 4 individual tests between January and December 2018. Only high-requesting GPs within participating practices were included. The trial was conducted between November 2019 and May 2021, with final follow-up on May 8, 2021.

INTERVENTIONS

Eligible practices were randomized in a 1:1:1:1:1 ratio to 1 of 4 different individualized written audit and feedback interventions (n = 3055 GPs) that varied factorially by (1) frequency of feedback (once vs twice) and (2) visual display (standard vs enhanced display highlighting highly requested tests) or to a control condition of no intervention (n = 764 GPs). Participants were not masked.

MAIN OUTCOMES AND MEASURES

The primary outcome was the overall rate of requests for the 11 targeted imaging tests per 1000 patient consultations over 12 months, assessed using routinely collected administrative data. Primary analyses included all randomized GPs who had at least 1 patient consultation during the study period and were performed by statisticians masked to group allocation.

RESULTS

A total of 3819 high-requesting GPs from 2271 practices were randomized, and 3660 GPs (95.8%; n = 727 control, n = 2933 intervention) were included in the primary analysis. Audit and feedback led to a statistically significant reduction in the overall rate of imaging requests per 1000 consultations compared with control over 12 months (adjusted mean, 27.7 [95% CI, 27.5-28.0] vs 30.4 [95% CI, 29.8-30.9], respectively; adjusted mean difference, -2.66 [95% CI, -3.24 to -2.07]; P < .001).

CONCLUSIONS AND RELEVANCE

Among Australian general practitioners known to frequently request musculoskeletal diagnostic imaging, an individualized audit and feedback intervention, compared with no intervention, significantly decreased the rate of targeted musculoskeletal imaging tests ordered over 12 months.

TRIAL REGISTRATION

ANZCTR Identifier: ACTRN12619001503112.

Reducing Low-Value Imaging for Low Back Pain: Systematic Review With Meta-analysis

OBJECTIVE

To examine the effectiveness of implementing interventions to improve guideline-recommended imaging referrals in low back pain.

DESIGN

Systematic review with meta-analysis.

LITERATURE SEARCH

We searched MEDLINE, EMBASE, the Cumulative Index to Nursing and Allied Health Literature, Web of Science Core Collection, and the Cochrane Central Register of Controlled Trials from inception to June 14, 2021, as well as Google Scholar and reference lists of relevant systematic reviews published in the last 10 years. We conducted forward and backward citation tracking.

STUDY SELECTION CRITERIA

Randomized controlled or clinical trials in adults with low back pain to improve imaging referrals.

DATA SYNTHESIS

Bias was assessed using the Cochrane Risk of Bias 2 tool. Data were synthesized using narrative synthesis and random-effects meta-analysis (Hartung-Knapp-Sidik-Jonkman method). We assessed the certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation approach.

RESULTS

Of the 2719 identified records, 8 trials were included, with 6 studies eligible for meta-analysis (participants: N = 170 460). All trials incorporated clinician education; 4 included audit and/or feedback components. Comparators were no-intervention control and passive dissemination of guidelines. Five trials were rated as low risk of bias, and 2 trials were rated as having some concerns. There was low-certainty evidence that implementing interventions to improve guideline-recommended imaging referrals had no effect (odds ratio [95% confidence interval]: 0.87 [0.72, 1.05]; I² = 0%; studies: n = 6). The main finding was robust to sensitivity analyses.

CONCLUSION

We found low-certainty evidence that interventions to reduce imaging referrals or use in low back pain had no effect. Education interventions are unlikely to be effective. Organizational- and policy-level interventions are more likely to be effective. J Orthop Sports Phys Ther 2022;52(4):175-191. Epub 05 Feb 2022. doi:10.2519/jospt.2022.10731.

The justification of non-obstetric ultrasound referrals: A safe and effective practice

INTRODUCTION

In 2015 the British Medical Ultrasound Society released a referral justification document for rejection of inappropriate ultrasound referrals to help manage increasing demand and ensure correct utilisation of diagnostic imaging tests. In our trust, referrals that were not aligned with the guidance were cancelled and returned to general practitioners, providing reasons for cancellation and advising other diagnostic tests if appropriate.Methodology: In total, 1000 cases cancelled between April and August 2019 were retrospectively audited by a team of clinical specialist sonographers. Interoperator agreement against BMUS justification guidelines and safety of this cancellation process were established. Duplicate imaging referrals, referrals made that should have been placed on management pathways or referrals cancelled by the patient directly were excluded in the safety assessment.

RESULTS

There was strong agreement amongst sonographers regarding cancellations. After exclusions, 389 cases were included for review. The majority (90.5%) required no onward imaging and were therefore deemed cancelled appropriately. There were 37 patients found with pathology on subsequent imaging, two of which were found to have cancer and the remainder with benign pathology.

CONCLUSIONS

Overall, we found the cancellation process to be safe and the justification document easy to utilise in practice. This process has ensured a minimal waiting time for ultrasound imaging is maintained and that demand can be managed to meet the available capacity.

Clinician education unlikely effective for guideline-adherent medication prescription in low back pain: systematic review and meta-analysis of RCTs

BACKGROUND

Effectiveness of implementing interventions to optimise guideline-recommended medical prescription in low back pain is not well established.

METHODS

A systematic review and random-effects meta-analyses for dichotomous outcomes with a Paule-Mandel estimator. Five databases and reference lists were searched from inception to 4^th August 2021. Randomised controlled/clinical trials in adults with low back pain to optimise medication prescription were included. Cochrane Risk of Bias 2 tool and GRADE were implemented. The review was registered prospectively with PROSPERO (CRD42020219767).

FINDINGS

Of 3352 unique records identified in the search, seven studies were included and five were eligible for meta-analysis (N=11339 participants). Six of seven studies incorporated clinician education, three studies included audit/feedback components and one study implemented changes in medical records systems. Via meta-analysis, we estimated a non-significant odds-ratio of 0·94 (95% CI (0·77; 1.16), I² = 0%; n=5 studies, GRADE: low) in favour of the intervention group. The main finding was robust to sensitivity analyses.

INTERPRETATION

There is low quality evidence that existing interventions to optimise medication prescription or usage in back pain had no impact. Peer-to-peer education alone does not appear to lead to behaviour change. Organisational and policy interventions may be more effective.

FUNDING

This work was supported by internal institutional funding only.

What behaviour change techniques have been used to improve adherence to evidence-based low back pain imaging?

Background

Despite international guideline recommendations, low back pain (LBP) imaging rates have been increasing over the last 20 years. Previous systematic reviews report limited effectiveness of implementation interventions aimed at reducing unnecessary LBP imaging. No previous reviews have analysed these implementation interventions to ascertain what behaviour change techniques (BCTs) have been used in this field. Understanding what techniques have been implemented in this field is an essential first step before exploring intervention effectiveness.

Methods

We searched EMBASE, Ovid (Medline), CINAHL and Cochrane CENTRAL from inception to February 1, 2021, as well as and hand-searched 6 relevant systematic reviews and conducted citation tracking of included studies. Two authors independently screened titles, abstracts, and full texts for eligibility and extracted data on study and intervention characteristics. Study interventions were qualitatively analysed by three coders to identify BCTs, which were mapped to mechanisms of action from the theoretical domains framework (TDF) using the Theory and Techniques Tool.

Results

We identified 36 eligible studies from 1984 citations in our electronic search and a further 2 studies from hand-searching resulting in 38 studies that targeted physician behaviour to reduce unnecessary LBP imaging. The studies were conducted in 6 countries in primary (n = 31) or emergency care (n = 7) settings. Thirty-four studies were included in our BCT synthesis which found the most frequently used BCTs were ‘4.1 instruction on how to perform the behaviour’ (e.g. Active/passive guideline dissemination and/or educational seminars/workshops), followed by ‘9.1 credible source’, ‘2.2 feedback on behaviour’ (e.g. electronic feedback reports on physicians’ image ordering) and 7.1 prompts and cues (electronic decision support or hard-copy posters/booklets for the office). This review highlighted that the majority of studies used education and/or feedback on behaviour to target the domains of knowledge and in some cases also skills and beliefs about capabilities to bring about a change in LBP imaging behaviour. Additionally, we found there to be a growing use of electronic or hard copy reminders to target the domains of memory and environmental context and resources.

Conclusions

This is the first study to identify what BCTs have been used to target a reduction in physician image ordering behaviour. The majority of included studies lacked the use of theory to inform their intervention design and failed to target known physician-reported barriers to following LBP imaging guidelines.

Protocol Registation

PROSPERO CRD42017072518

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-021-01136-w.

Ultrasound evaluation of persistent cervical lymph nodes in young children

AIM

To review the ultrasonographic outcomes of persistent lymph nodes, in the absence of other concerning signs or symptoms, in patients <6 years of age.

MATERIALS AND METHODS

A retrospective analysis was undertaken of 98 patients <6 years old who had neck ultrasound for persistent lymph nodes at a single university hospital over a 3.5 year period between January 2016 and June 2019.

RESULTS

There were no cases of malignant disease or serious systemic illness. Ninety-two of the 98 examinations showed normal or reactive lymph nodes. There were three sonographically indeterminate cases and two non-lymph-node structures: haemangioma and dermoid cyst. One examination reported an abnormal lymph node, which had resolved by the time of review in clinic.

CONCLUSION

Persistently enlarged or abnormal lymph nodes should be investigated; however, a distinction should be made between lymph nodes that have regressed to <1 cm but are still palpable and persistently enlarged or abnormal lymph nodes. The findings of the present study indicate that persistence of non-enlarged lymph nodes is not a predictor for malignancy. It is advised that clear guidelines are used, which state the criteria for further investigation, to promote the best use of imaging.

Strategies to reduce the use of low-value medical tests in primary care: a systematic review

BACKGROUND

It is recognised that medical tests are overused in primary care; however, it is unclear how best to reduce their use.

AIM

To identify which strategies are effective in reducing the use of low-value medical tests in primary care settings.

DESIGN AND SETTING

Systematic review.

METHOD

The databases MEDLINE, EMBASE, and Rx for Change were searched (January 1990 to November 2019) for randomised controlled trials (RCTs) that evaluated strategies to reduce the use of low-value medical tests in primary care settings. Two reviewers selected eligible RCTs, extracted data, and assessed their risk of bias.

RESULTS

Of the 16 RCTs included in the review, 11 reported a statistically significant reduction in the use of low-value medical tests. The median of the differences between the relative reductions in the intervention and control arms was 17% (interquartile range 12% to 24%). Strategies using reminders or audit/feedback showed larger reduction than those without these components (22% versus 14%, and 22% versus 13%, respectively) and patient-targeted strategies showed larger reductions than those not targeted at patients (51% versus 17%). Very few studies investigated the sustainability of the effect, adverse events, cost-effectiveness, or patient-reported outcomes related to reducing the use of low-value tests.

CONCLUSION

This review indicates that it is possible to reduce the use of low-value medical tests in primary care, especially by using multiple components including reminders, audit/feedback, and patient-targeted interventions. To implement these strategies widely in primary care settings, more research is needed not only to investigate their effectiveness, but also to examine adverse events, cost-effectiveness, and patient-reported outcomes.

Clinician and patient beliefs about diagnostic imaging for low back pain: a systematic qualitative evidence synthesis

OBJECTIVE

Overuse of diagnostic imaging for patients with low back pain remains common. The underlying beliefs about diagnostic imaging that could drive overuse remain unclear. We synthesised qualitative research that has explored clinician, patient or general public beliefs about diagnostic imaging for low back pain.

DESIGN

A qualitative evidence synthesis using a thematic analysis.

METHODS

We searched MEDLINE, EMBASE, CINAHL, AMED and PsycINFO from inception to 17 June 2019. Qualitative studies that interviewed clinicians, patients and/or general public exploring beliefs about diagnostic imaging for low back pain were included. Four review authors independently extracted data and organised these according to themes and subthemes. We used the Critical Appraisal Skills Programme tool to critically appraise included studies. To assess confidence in review findings, we used the GRADE-Confidence in the Evidence from Reviews of Qualitative Research method.

RESULTS

We included 69 qualitative studies with 1747 participants. Key findings included: Patients and clinicians believe diagnostic imaging is an important test to locate the source of low back pain (33 studies, high confidence); patients with chronic low back pain believe pathological findings on diagnostic imaging provide evidence that pain is real (12 studies, moderate confidence); and clinicians ordered diagnostic imaging to reduce the risk of a missed diagnosis that could lead to litigation, and to manage patients' expectations (12 studies, moderate confidence).

CONCLUSION

Clinicians and patients can believe that diagnostic imaging is an important tool for locating the source of non-specific low back pain. Patients may underestimate the harms of unnecessary imaging tests. These beliefs could be important targets for intervention.

PROSPERO REGISTRATION NUMBER

CRD42017076047.

The effect of interventions on appropriate use of lumbar spine radiograph and CT examinations in young adults and children: a three-year follow-up

BACKGROUND

According to international guidelines, radiological examinations of the lumbar spine are of limited value and do not improve clinical outcome unless there are clinical red flags present suggesting serious pathology. Nevertheless, the utilization of lumbar spine imaging remains high.

PURPOSE

To follow up the effects of active referral guideline implementation and education on the number and appropriateness of lumbar spine radiographs and computed tomography (CT) examinations in young patients and to evaluate whether the appropriate radiographs have more significant findings.

MATERIAL AND METHODS

Referral guidelines for spine examinations and info pocket cards on radiation protection were distributed to referring practitioners. Educational lectures were provided annually. The number of lumbar spine radiographs and CT examinations on patients aged <35 years was analyzed before and three years after the interventions. Appropriateness and findings of 313 radiographs and appropriateness of 117 CT scans of the lumbar spine were assessed.

RESULTS

The number of lumbar spine radiographs and CT scans decreased significantly after the interventions and the level remained unchanged during the follow-up (-33% and -72%, respectively, P < 0.001). Appropriateness improved significantly in radiographs from 2005 to 2009 (65% vs. 85%) and in CT scans already from 2005 to 2007 (23% vs. 63%). Radiographs that were in accordance with the guidelines had more significant findings compared to radiographs that were not; in young adults, this was 56% versus 21% (P < 0.001).

CONCLUSION

A combination of interventions can achieve a sustained reduction in the number of lumbar spine examinations and improve appropriateness. Inappropriate lumbar spine radiographs do not seem to contain significant findings that would affect patient care.

Nudge strategies to improve healthcare providers' implementation of evidence-based guidelines, policies and practices: a systematic review of trials included within Cochrane systematic reviews

BACKGROUND

Nudge interventions are those that seek to modify the social and physical environment to enhance capacity for subconscious behaviours that align with the intrinsic values of an individual, without actively restricting options. This study sought to describe the application and effects of nudge strategies on clinician implementation of health-related guidelines, policies and practices within studies included in relevant Cochrane systematic reviews.

METHODS

As there is varied terminology used to describe nudge, this study examined studies within relevant systematic reviews. A two-stage screening process was undertaken where, firstly, all systematic reviews published in the Cochrane Library between 2016 and 2018 were screened to identify reviews that included quantitative studies to improve implementation of guidelines among healthcare providers. Secondly, individual studies within relevant systematic reviews were included if they were (i) randomised controlled trials (RCTs), (ii) included a nudge strategy in at least one intervention arm, and (iii) explicitly aimed to improve clinician implementation behaviour. We categorised nudge strategies into priming, salience and affect, default, incentives, commitment and ego, and norms and messenger based on the Mindspace framework.

SYNTHESIS

The number and percentage of trials using each nudge strategy was calculated. Due to substantial heterogeneity, we did not undertake a meta-analysis. Instead, we calculated within-study point estimates and 95% confidence intervals, and used a vote-counting approach to explore effects.

RESULTS

Seven reviews including 42 trials reporting on 57 outcomes were included. The most common nudge strategy was priming (69%), then norms and messenger (40%). Of the 57 outcomes, 86% had an effect on clinician behaviour in the hypothesised direction, and 53% of those were statistically significant. For continuous outcomes, the median effect size was 0.39 (0.22, 0.45), while for dichotomous outcomes the median Odds Ratio was 1.62 (1.13, 2.76).

CONCLUSIONS

This review of 42 RCTs included in Cochrane systematic reviews found that the impact of nudge strategies on clinician behaviour was at least comparable to other interventions targeting implementation of evidence-based guidelines. While uncertainty remains, the review provides justification for ongoing investigation of the evaluation and application of nudge interventions to support provider behaviour change.

TRIAL REGISTRATION

This review was not prospectively registered.

Physician-reported barriers to using evidence-based recommendations for low back pain in clinical practice: a systematic review and synthesis of qualitative studies using the Theoretical Domains Framework

BACKGROUND

Adoption of low back pain guidelines is a well-documented problem. Information to guide the development of behaviour change interventions is needed. The review is the first to synthesise the evidence regarding physicians' barriers to providing evidence-based care for LBP using the Theoretical Domains Framework (TDF). Using the TDF allowed us to map specific physician-reported barriers to individual guideline recommendations. Therefore, the results can provide direction to future interventions to increase physician compliance with evidence-based care for LBP.

METHODS

We searched the literature for qualitative studies from inception to July 2018. Two authors independently screened titles, abstracts, and full texts for eligibility and extracted data on study characteristics, reporting quality, and methodological rigour. Guided by a TDF coding manual, two reviewers independently coded the individual study themes using NVivo. After coding, we assessed confidence in the findings using the GRADE-CERQual approach.

RESULTS

Fourteen studies (n = 318 physicians) from 9 countries reported barriers to adopting one of the 5 guideline-recommended behaviours regarding in-clinic diagnostic assessments (9 studies, n = 198), advice on activity (7 studies, n = 194), medication prescription (2 studies, n = 39), imaging referrals (11 studies, n = 270), and treatment/specialist referrals (8 studies, n = 193). Imaging behaviour is influenced by (1) social influence-from patients requesting an image or wanting a diagnosis (n = 252, 9 studies), (2) beliefs about consequence-physicians believe that providing a scan will reassure patients (n = 175, 6 studies), and (3) environmental context and resources-physicians report a lack of time to have a conversation with patients about diagnosis and why a scan is not needed (n = 179, 6 studies). Referrals to conservative care is influenced by environmental context and resources-long wait-times or a complete lack of access to adjunct services prevented physicians from referring to these services (n = 82, 5 studies).

CONCLUSIONS

Physicians face numerous barriers to providing evidence-based LBP care which we have mapped onto 7 TDF domains. Two to five TDF domains are involved in determining physician behaviour, confirming the complexity of this problem. This is important as interventions often target a single domain where multiple domains are involved. Interventions designed to address all the domains involved while considering context-specific factors may prove most successful in increasing guideline adoption.

REGISTRATION

PROSPERO 2017, CRD42017070703.

Development and conduction of an active re-implementation of the Norwegian musculoskeletal guidelines

Objective

Significant geographical variations in the use of diagnostic imaging have been demonstrated in Norway and elsewhere. Non-traumatic musculoskeletal conditions is one area where this has been demonstrated. A national musculoskeletal guideline was implemented in response by online publishing and postal dissemination in Norway in 2014 by national policy makers. The objective of our study was to develop and conduct an intervention as an active re-implementation of this guideline in one Norwegian county to investigate and facilitate guideline adherence. The development and implementation process is reported here, to facilitate understanding of the future evaluation results of this study.

Results

The consolidated framework for implementation research guided the intervention development and implementation. The implementation development was also based on earlier reported success factors in combination with interviews with general practitioners and radiologists regarding facilitators and barriers to guideline adherence. A combined implementation strategy was developed, including educational meetings, shortening of the guideline and easier access. All the aspects of the implementation strategy were adapted towards general practitioners, radiological personnel and the Norwegian Labor and Welfare Administration. Sixteen educational meetings were held, and six educational videos were made for those unable to attend, or where meetings could not be held.

Electronic supplementary material

The online version of this article (10.1186/s13104-018-3894-4) contains supplementary material, which is available to authorized users.

Adoption and use of guidelines for whiplash: an audit of insurer and health professional practice in New South Wales, Australia

BACKGROUND

In Australia, the New South Wales (NSW) State Insurance Regulatory Authority has been continuously developing and implementing clinical practice guidelines to address the health and economic burden from whiplash associated disorders (WAD). Despite this, it is uncertain the extent to which the guidelines are followed. This study aimed to determine insurer and health professional compliance with recommendations of the 2014 NSW clinical practice guidelines for the management of acute WAD; and explore factors related to adherence.

METHODS

This was an observational study involving an audit of 288 randomly-selected claimant files from 4 insurance providers in NSW, Australia between March and October 2016. Data extracted included demographic, claim and injury details, use of health services, and insurer and health professional practices related to the guidelines. Analyses involved descriptive statistics and correlation analysis.

RESULTS

Median time for general practitioner medical consultation was 4 days post-injury and 25 days for physical treatment (e.g. physiotherapy). Rates of x-ray investigations were low (21.5%) and most patients (90%) were given active treatments in line with the guideline recommendations. The frequency of other practices recommended by the guidelines suggested lower guideline adherence in some areas such as; using the Quebec Task Force classification (19.9%); not using specialised imaging for WAD grades I and II (e.g. MRI, 45.8%); not using routine passive treatments (e.g. manual therapy, 94.0%); and assessing risk of non-recovery using relevant prognostic tools (e.g. Neck Disability Index, 12.8%). Over half of the claimants (59.0%) were referred to other professionals at 9-12 weeks post-injury, among which 31.2% were to psychologists and 68.8% to specialists (surgical specialists, 43.6%; WAD specialists, 20.5%). Legal representation and lodgment of full claim were associated with increased number of medical visits and imaging (ρ 0.23 to 0.3; p < 0.01).

CONCLUSION

There is evidence of positive uptake of some guideline recommendations by insurers and health professionals; however, there are practices that are not compliant and might lead to poor health outcomes and greater treatment cost. Organisational, regulatory and professional implementation strategies may be considered to change practice, improve scheme performance and ultimately improve outcomes for people with WAD.

Barriers and facilitators for guideline adherence in diagnostic imaging: an explorative study of GPs' and radiologists' perspectives

Background

Diagnostic imaging has been a part of medicine for the last century. It has been difficult to implement guidelines in this field, and unwarranted imaging has been a frequent problem. Some work has been done to explain these phenomena separately. Identifying the barriers to and facilitators of guideline use has been one strategy. The aim of this study is to offer a more comprehensive explanation of deviations from the guideline by studying the two phenomena together.

Methods

Eight general practitioners and 10 radiologists from two counties in Norway agreed to semi-structured interviews. Topics covered in the interviews were knowledge of the guideline, barriers to and facilitators of guideline use, implementation of guidelines and factors that influence unwarranted imaging.

Results

Several barriers to and facilitators of guideline use were identified. Among these are lack of time, pressure from patients, and guidelines being too long, rigid or unclear. Facilitators of guideline use were easy accessibility and having the guidelines adapted to the target group. Some of the factors that influence unwarranted imaging are lack of time, pressure from patients and availability of imaging services.

Conclusion

There are similarities between the perceived barriers for guideline adherence and the perceived factors that influence unwarranted imaging. There may be a few reasons that explains the deviation from guidelines, and the amount of unwarranted imaging.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3372-7) contains supplementary material, which is available to authorized users.

Clinician, patient and general public beliefs about diagnostic imaging for low back pain: protocol for a qualitative evidence synthesis

INTRODUCTION

Little is known about how to reduce unnecessary imaging for low back pain. Understanding clinician, patient and general public beliefs about imaging is critical to developing strategies to reduce overuse.

OBJECTIVE

To synthesise qualitative research that has explored clinician, patient or general public beliefs about diagnostic imaging for low back pain.

METHODS AND ANALYSIS

We will perform a qualitative evidence synthesis of relevant qualitative research exploring clinician, patient and general public beliefs about diagnostic imaging for low back pain. Exclusions will be studies not using qualitative methods and studies not published in English. Studies will be identified using sensitive search strategies in MEDLINE, EMBASE, CINAHL, AMED and PsycINFO. Two reviewers will independently apply inclusion and exclusion criteria, extract data, and use the Critical Appraisal Skills Programme quality assessment tool to assess the quality of included studies. To synthesise the data we will use a narrative synthesis approach that involves developing a theoretical model, conducting a preliminary synthesis, exploring relations in the data, and providing a structured summary. We will code the data using NVivo. At least two reviewers will independently apply the thematic framework to extracted data. Confidence in synthesis findings will be evaluated using the GRADE Confidence in the Evidence from Reviews of Qualitative Research tool.

ETHICS AND DISSEMINATION

Ethical approval is not required to conduct this review. We will publish the results in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42017076047.

Lumbar Spine X-Ray as a Standard Investigation for all Low back Pain in Ghana: Is It Evidence Based?

BACKGROUND

Low back pain (LBP) has a prevalence of 84% in Africa. The commonest form of imaging is plain lumbar spine x-ray. It gives a radiation dose equivalent to 65 times a chest x-ray dose and sends one of the highest doses to the human reproductive organs. The commonest cause of LBP in Africa is degenerative disease. X-ray findings do not change mode of treatment yet most physicians still routinely request for x-rays.

METHODS

This is a systematic review of databases including The Cochrane, CINAHL plus, AMED, and MEDLINE. Key evidence was clinical guidelines on x-ray use for low back pain. Key search terms included low back pain, x-rays, guidelines, Ghana.

RESULTS

Four clinical guidelines on LBP emerged from two Systematic Reviews rated excellent and four good Randomized Controlled Trials: The European guidelines for acute and sub-acute non-specific Low Back Pain, The American College of Physicians and the American Pain Society guideline for diagnostic imaging for Low Back Pain, The NICE guidelines for persistent non-specific Low Back Pain and the Ghana Standard Treatment Guidelines (GSTG). All the guidelines agree that a good history and clinical examination for all LBP patients helps in diagnosing. Only GSTG recommends routine plain spinal x-rays.

CONCLUSION

There is strong evidence indicating very little benefit from routine lumbar spine x-rays for all LBP. The GSTG needs to be revised considering the increased risks of radiation exposure and the x-ray costs.

FUNDING

None declared.

Reducing Inappropriate Lumbar Spine MRI for Low Back Pain: Radiology Support, Communication and Alignment Network

PURPOSE

The aim of this study is to evaluate the impact of educational sessions on reducing lumbar spine MRI inappropriateness for uncomplicated low back pain and to present our institutional experience on the use of ACR's Radiology Support, Communication and Alignment Network (R-SCAN) program toward achieving appropriateness.

METHODS

The R-SCAN web portal was accessed to register a project. Using order entry data, the number of lumbar spine MRI orders placed per month at three family medicine clinics was assessed over a 10-month period. After educational presentations were given at those three clinics highlighting the American College of Physicians and Choosing Wisely campaign imaging guidelines, the number of MRI orders placed was reassessed over an additional 10 months. For a subset of these exams, the ACR Appropriateness Criteria rating of the lumbar spine MRIs were compared between the pre- and posteducation periods. A P value < .05 was considered statistically significant.

RESULTS

The average number of monthly MRIs ordered from all three clinics combined was 6.3 during the posteducation period, which was significantly less than during the pre-education period of 10.0 (P = .009). The combined average ACR Appropriateness Criteria rating made at all three clinics was 5.8 after educational sessions, which was significantly higher than the rating of 4.7 before educational sessions (P = .014).

CONCLUSION

Clinician education, facilitated by R-SCAN, resulted in a reduced number of MRI lumbar spine studies performed for uncomplicated low back pain and improved appropriateness of those studies as measured by the ACR Appropriateness Criteria rating.

Developing implementation science to improve the translation of research to address low back pain: A critical review

The evidence base regarding treatment for back pain does not align with clinical practice. Currently there is relatively little evidence to guide health decision-makers on how to improve the use, uptake or adoption of evidence-based recommended practice for low back pain. Improving the design, conduct and reporting of strategies to improve the implementation of back pain care will help address this important evidence-practice gap. In this paper, we.

Implementation interventions to improve the management of non-specific low back pain: a systematic review

BACKGROUND

Recommendations in clinical practice guidelines for non-specific low back pain (NSLBP) are not necessarily translated into practice. Multiple studies have investigated different interventions to implement best evidence into clinical practice yet no synthesis of these studies has been carried out to date. The aim of this study was to systematically review available studies to determine whether implementation interventions in this field have been effective and to identify which strategies have been most successful in changing healthcare practitioner behaviours and improving patient outcomes.

METHODS

A systematic review was undertaken, searching electronic databases until end of December 2012 plus hand searching, writing to key authors and using prior knowledge of the field to identify papers. Included studies evaluated an implementation intervention to improve the management of NSLBP in clinical practice, measured key outcomes regarding change in practitioner behaviour and/or patient outcomes and subjected their data to statistical analysis. The Cochrane Effective Practice and Organisation of Care (EPOC) recommendations about systematic review conduct were followed. Study inclusion, data extraction and study risk of bias assessments were conducted independently by two review authors.

RESULTS

Of 7654 potentially eligible citations, 17 papers reporting on 14 studies were included. Risk of bias of included studies was highly variable with 7 of 17 papers rated at high risk. Single intervention or one-off implementation efforts were consistently ineffective in changing clinical practice. Increasing the frequency and duration of implementation interventions led to greater success with those continuously ongoing over time the most successful in improving clinical practice in line with best evidence recommendations.

CONCLUSIONS

Single intervention or one-off implementation interventions may seem attractive but are largely unsuccessful in effecting meaningful change in clinical practice for NSLBP. Increasing frequency and duration of implementation interventions seems to lead to greater success and the most successful implementation interventions used consistently sustained strategies.

Professional interventions for general practitioners on the management of musculoskeletal conditions

BACKGROUND

Musculoskeletal conditions require particular management skills. Identification of interventions which are effective in equipping general practitioners (GPs) with such necessary skills could translate to improved health outcomes for patients and reduced healthcare and societal costs.

OBJECTIVES

To determine the effectiveness of professional interventions for GPs that aim to improve the management of musculoskeletal conditions in primary care. 

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), 2010, Issue 2; MEDLINE, Ovid (1950 - October 2013); EMBASE, Ovid (1980 - Ocotber 2013); CINAHL, EbscoHost (1980 - November 2013), and the EPOC Specialised Register. We conducted cited reference searches using ISI Web of Knowledge and Google Scholar; and handsearched selected issues of Arthritis and Rheumatism and Primary Care-Clinics in Office Practice. The latest search was conducted in November 2013.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before-and-after studies (CBAs) and interrupted time series (ITS) studies of professional interventions for GPs, taking place in a community setting, aiming to improve the management (including diagnosis and treatment) of musculoskeletal conditions and reporting any objective measure of GP behaviour, patient or economic outcomes. We considered professional interventions of any length, duration, intensity and complexity compared with active or inactive controls.

DATA COLLECTION AND ANALYSIS

Two review authors independently abstracted all data. We calculated the risk difference (RD) and risk ratio (RR) of compliance with desired practice for dichotomous outcomes, and the mean difference (MD) and standardised mean difference (SMD) for continuous outcomes. We investigated whether the direction of the targeted behavioural change affects the effectiveness of interventions.

MAIN RESULTS

Thirty studies met our inclusion criteria.From 11 studies on osteoporosis, meta-analysis of five studies (high-certainty evidence) showed that a combination of a GP alerting system on a patient's increased risk of osteoporosis and a patient-directed intervention (including patient education and a reminder to see their GP) improves GP behaviour with regard to diagnostic bone mineral density (BMD) testing and osteoporosis medication prescribing (RR 4.44; (95% confidence interval (CI) 3.54 to 5.55; 3 studies; 3,386 participants)) for BMD and RR 1.71 (95% CI 1.50 to 1.94; 5 studies; 4,223 participants) for osteoporosis medication. Meta-analysis of two studies showed that GP alerting on its own also probably improves osteoporosis guideline-consistent GP behaviour (RR 4.75 (95% CI 3.62 to 6.24; 3,047 participants)) for BMD and RR 1.52 (95% CI 1.26 to 1.84; 3.047 participants) for osteoporosis medication) and that adding the patient-directed component probably does not lead to a greater effect (RR 0.94 (95% CI 0.81 to 1.09; 2,995 participants)) for BMD and RR 0.93 (95% CI 0.79 to 1.10; 2,995 participants) for osteoporosis medication.Of the 10 studies on low back pain, seven showed that guideline dissemination and educational opportunities for GPs may lead to little or no improvement with regard to guideline-consistent GP behaviour. Two studies showed that the combination of guidelines and GP feedback on the total number of investigations requested may have an effect on GP behaviour and result in a slight reduction in the number of tests, while one of these studies showed that the combination of guidelines and GP reminders attached to radiology reports may result in a small but sustained reduction in the number of investigation requests.Of the four studies on osteoarthritis, one study showed that using educationally influential physicians may result in improvement in guideline-consistent GP behaviour. Another study showed slight improvements in patient outcomes (pain control) after training GPs on pain management.Of three studies on shoulder pain, one study reported that there may be little or no improvement in patient outcomes (functional capacity) after GP education on shoulder pain and injection training.Of two studies on other musculoskeletal conditions, one study on pain management showed that there may be worse patient outcomes (pain control) after GP training on the use of validated assessment scales.The 12 remaining studies across all musculoskeletal conditions showed little or no improvement in GP behaviour and patient outcomes.The direction of the targeted behaviour (i.e. increasing or decreasing a behaviour) does not seem to affect the effectiveness of an intervention. The majority of the studies did not investigate the potential adverse effects of the interventions and only three studies included a cost-effectiveness analysis.Overall, there were important methodological limitations in the body of evidence, with just a third of the studies reporting adequate allocation concealment and blinded outcome assessments. While our confidence in the pooled effect estimate of interventions for improving diagnostic testing and medication prescribing in osteoporosis is high, our confidence in the reported effect estimates in the remaining studies is low.

AUTHORS' CONCLUSIONS

There is good-quality evidence that a GP alerting system with or without patient-directed education on osteoporosis improves guideline-consistent GP behaviour, resulting in better diagnosis and treatment rates.Interventions such as GP reminder messages and GP feedback on performance combined with guideline dissemination may lead to small improvements in guideline-consistent GP behaviour with regard to low back pain, while GP education on osteoarthritis pain and the use of educationally influential physicians may lead to slight improvement in patient outcomes and guideline-consistent behaviour respectively. However, further studies are needed to ascertain the effectiveness of such interventions in improving GP behaviour and patient outcomes.

[Acceptability and quality of abdominal ultrasound studies requested by medical professionals]

OBJECTIVE

To evaluate the acceptability/quality of abdominal ultrasound studies requested by primary care physicians in Barcelona; to develop ultrasound guidelines and assess their impact on acceptability.

METHODS

DESIGN

2-phase study, one retrospective, descriptive phase evaluating the acceptability/quality of requests (pre-intervention phase) and another to assess the impact of guidelines on acceptability/quality (post-intervention phase).

SUBJECTS

Requests for ultrasound studies from January-June 2010 from 10 primary care centers and the same number of requests from the same centers after the intervention.

VARIABLES

Pre-intervention phase: reason for consultation and request; presence of diagnostic orientation; results of ultrasound; acceptability/quality of the request.

INTERVENTION

design guidelines using the nominal group technique, dissemination of guidelines in the same centers. Post-intervention phase: three months after dissemination analyze the same number of requests assessing the same variables included in the pre-intervention phase.

RESULTS

Pre-intervention phase: 1,063 requests, 52.4% women, mean age 52±16years (range 11-94). Post-intervention phase: 1,060 requests, 57.6% women, mean age 54±17years (range 6-91). Main reasons for requests: abdominal pain/discomfort 38.3% (pre-intervention) and 43.1% (post-intervention). Diagnostic orientation in 14.5% (pre-intervention) and 40.8% (post-intervention). Normal ultrasound results in 46.0% (pre-intervention) and 42.3% (post-intervention). Good quality of requests in 42.7% (pre-intervention) and 46.5% (post-intervention). Acceptability of ultrasound: 70.5% (pre-intervention) and 94.1% (post-intervention). The better the quality of the request, the better the acceptability of the studies and the greater the number of pathological conditions identified.

CONCLUSIONS

Guidelines for ultrasound improve the quality of requests, diagnostic orientation and acceptability of the studies.

Knowledge and satisfaction of pharmacists attending an educational workshop on evidence-based management of low back pain

Pharmacists are well positioned to provide quality care to people with low back pain (LBP). Education and training can equip pharmacists with the knowledge to optimally manage LBP in primary care. The aim of this study was to investigate the knowledge and satisfaction of pharmacists who attended a 2-h educational workshop on the evidence-based management of LBP. Case-based learning, underpinned by key adult learning principles, was one teaching method used to deliver important educational messages. Knowledge was assessed using a questionnaire consisting of multiple-choice, true/false questions and a written vignette based on a real-life clinical case scenario. Written feedback from pharmacists was used to gauge the success and limitations of the intervention. One hundred and ninety-three pharmacists completed the in-house assessment. Pharmacists demonstrated an accurate understanding of evidence-based pharmacological management of LBP, with all identifying paracetamol as the first-line drug choice for non-specific LBP. Ninety-nine per cent of pharmacists identified the symptoms presented in the vignette as a syndrome representing a significant clinical red flag requiring urgent referral. This educational intervention has delivered key messages on LBP management to pharmacists. There is a continued need for educational interventions addressing common conditions.

Evaluation of clinical presentation and referral indications for ultrasound-guided fine-needle aspiration biopsy of the thyroid as possible predictors of thyroid cancer

BACKGROUND

Whether initial clinical presentation and thyroid ultrasonography referral indications can significantly predict malignant/suspicious for malignancy (Bethesda System for Reporting Thyroid Cytopathology [Bethesda] V/VI) thyroid ultrasound-guided fine-needle aspiration (FNA) cytology results is unknown.

METHODS

Between January 2010 and May 2014, we performed 705 thyroid ultrasound-guided FNA biopsies, according to the American Thyroid Association (ATA) guidelines. Univariate analysis was used to identify significant predictors for Bethesda V/VI thyroid ultrasound-guided FNA cytology, including age, sex, imaging modality, thyroid dysfunction, neck pain, breathing difficulties, dysphagia, odynophagia, fatigue, lateral cervical mass, parotid mass, and hyperparathyroidism.

RESULTS

Sixty percent of patients were referred to thyroid ultrasound-guided FNA because of thyroid incidentalomas and 40% because of palpable thyroid nodules found on physical examination. Only positron emission tomography (PET)-CT emerged as being a significant predictor for Bethesda V/VI thyroid ultrasound-guided FNA cytology (odds ratio [OR] = 5.64; 95% confidence interval [CI] = 1.16-27.33; p = .03).

CONCLUSION

Patient symptomatology and initial clinical thyroid ultrasound-guided FNA referral indications cannot predict the nature of thyroid nodules. © 2015 Wiley Periodicals, Inc. Head Neck 38: E991-E995, 2016.

What is the evidence on interventions to manage referral from primary to specialist non-emergency care? A systematic review and logic model synthesis

Background

Demand management describes any method used to monitor, direct or regulate patient referrals. Several strategies have been developed to manage the referral of patients to secondary care, with interventions targeting primary care, specialist services, or infrastructure.

Objective

This research aimed to conduct an inclusive systematic review and logic model synthesis in order to better understand factors impacting on the effectiveness of interventions targeting referral between primary and secondary medical health care.

Design

The approach combined systematic review with logic modelling synthesis techniques to develop an evidence-based framework of factors influencing the pathway between interventions and system-wide changes.

Setting

Primary health care.

Main outcome measures

Referral from primary to secondary care.

Review methods

Systematic searches were undertaken to identify recent, relevant studies. Quality of individual studies was appraised, with consideration of overall strength of evidence. A narrative synthesis and logic model summary of the data was completed.

Results

From a database of 8327 unique papers, 290 were included in the review. The intervention studies were grouped into four categories of education interventions (n = 50); process change interventions (n = 49); system change interventions (n = 38); and patient-focused interventions (n = 3). Effectiveness was assessed variously in these papers; however, there was a gap regarding the mechanisms whereby these interventions lead to demand management impacts. The findings suggest that, although individual-level interventions may be popular, the stronger evidence relates only to peer-review and feedback interventions. Process change interventions appeared to be more effective when the change resulted in the specialist being provided with more or better quality information about the patient. System changes including the community provision of specialist services by general practitioners, outreach provision by specialists and the return of inappropriate referrals appeared to have evidence of effect. The pathway whereby interventions might lead to service-wide impact was complex, with multiple factors potentially acting as barriers or facilitators to the change process. Factors related, first, to the doctor (including knowledge, attitudes and beliefs, and previous experiences of a service), second, to the patient (including condition and social factors) and, third, to the influence of the doctor–patient relationship. We also identified a number of potentially influential factors at a local level, such as perceived waiting times and the availability of a specialist. These elements are key factors in the pathway between an intervention and intended demand management outcomes influencing both applicability and effectiveness.

Conclusions

The findings highlight the complexity of the referral process and multiple elements that will impact on intervention outcomes and applicability to a local area. Any interventions seeking to change referral practice need to address factors relating to the individual practitioner, the patient and also the situation in which the referral is taking place. These conclusions apply especially to referral management in a UK context where this whole range of factors/issues lies well within the remit of the NHS. This work highlights that intermediate outcomes are important in the referral pathway. It is recommended that researchers include measure of these intermediate outcomes in their evaluation of intervention effectiveness in order to determine where blocks to or facilitators of system-wide impact may be occurring.

Study registration

The study is registered as PROSPERO CRD42013004037.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Effectiveness of interventions designed to reduce the use of imaging for low-back pain: a systematic review

BACKGROUND

Rates of imaging for low-back pain are high and are associated with increased health care costs and radiation exposure as well as potentially poorer patient outcomes. We conducted a systematic review to investigate the effectiveness of interventions aimed at reducing the use of imaging for low-back pain.

METHODS

We searched MEDLINE, Embase, CINAHL and the Cochrane Central Register of Controlled Trials from the earliest records to June 23, 2014. We included randomized controlled trials, controlled clinical trials and interrupted time series studies that assessed interventions designed to reduce the use of imaging in any clinical setting, including primary, emergency and specialist care. Two independent reviewers extracted data and assessed risk of bias. We used raw data on imaging rates to calculate summary statistics. Study heterogeneity prevented meta-analysis.

RESULTS

A total of 8500 records were identified through the literature search. Of the 54 potentially eligible studies reviewed in full, 7 were included in our review. Clinical decision support involving a modified referral form in a hospital setting reduced imaging by 36.8% (95% confidence interval [CI] 33.2% to 40.5%). Targeted reminders to primary care physicians of appropriate indications for imaging reduced referrals for imaging by 22.5% (95% CI 8.4% to 36.8%). Interventions that used practitioner audits and feedback, practitioner education or guideline dissemination did not significantly reduce imaging rates. Lack of power within some of the included studies resulted in lack of statistical significance despite potentially clinically important effects.

INTERPRETATION

Clinical decision support in a hospital setting and targeted reminders to primary care doctors were effective interventions in reducing the use of imaging for low-back pain. These are potentially low-cost interventions that would substantially decrease medical expenditures associated with the management of low-back pain.

Referral interventions from primary to specialist care: a systematic review of international evidence

BACKGROUND

Demand management defines any method used to monitor, direct, or regulate patient referrals. Strategies have been developed to manage the referral of patients to secondary care, with interventions that target primary care, specialist services, or infrastructure.

AIM

To review the international evidence on interventions to manage referral from primary to specialist care.

DESIGN AND SETTING

Systematic review.

METHOD

Iterative, systematic searches of published and unpublished sources public health, health management, management, and grey literature databases from health care and other industries were undertaken to identify recent, relevant studies. A narrative synthesis of the data was completed to structure the evidence into groups of similar interventions.

RESULTS

The searches generated 8327 unique results, of which 140 studies were included. Interventions were grouped into four intervention categories: GP education (n = 50); process change (n = 49); system change (n = 38); and patient-focused (n = 3). It is clear that there is no 'magic bullet' to managing demand for secondary care services: although some groups of interventions may have greater potential for development, given the existing evidence that they can be effective in specific contexts.

CONCLUSIONS

To tackle demand management of primary care services, the focus cannot be on primary care alone; a whole-systems approach is needed because the introduction of interventions in primary care is often just the starting point of the referral process. In addition, more research is needed to develop and evaluate interventions that acknowledge the role of the patient in the referral decision.

Trends in ultrasound examination in family practice

Background:

Ultrasound examination is very frequently used for the evaluation of abnormalities in various organs of the body. Our aim was to determine whether the requests by family physicians (FPs) for ultrasound examinations were appropriate. Our secondary objective was to enumerate positive and negative ultrasound reports for various diagnostic indications.

Materials and Methods:

This cross-sectional study was conducted during the period of month between June and August 2010, at the Family Medicine Department of North West Armed Forces Prince Salman Hospital, Tabuk. We reviewed the ultrasound requests of all patients included in this study and the findings of the procedure. Data were analyzed using the Statistical Package for the Social Sciences (SPSS Inc., Chicago, IL), version 16.0.

Results:

The requests and reports of 815 patients for ultrasound were reviewed. Females comprised 58.7% of the referred cases. The mean age of the sample at referral was 30 ± 18.5 for females and 34 ± 20.7 for males. Only 46% of the request forms contained conclusive information and instructions. Abdominal/pelvic ultrasounds were the most frequently requested; Nearly 71.2% of the ultrasound scans were normal. Abdominal/pelvis ultrasound was more likely to be reported as normal than ultrasound scans of other regions (P = 0.007). Patients aged 41-60 years were more likely to have an abnormal ultrasound (P = 0.02).

Conclusion:

Our findings suggest that FPs have to be educated about imaging referral protocols in order to achieve better outcomes.

Impact of a referral management "gateway" on the quality of referral letters; a retrospective time series cross sectional review

Background

Referral management centres (RMC) for elective referrals are designed to facilitate the primary to secondary care referral path, by improving quality of referrals and easing pressures on finite secondary care services, without inadvertently compromising patient care.

This study aimed to evaluate whether the introduction of a RMC which includes triage and feedback improved the quality of elective outpatient referral letters.

Methods

Retrospective, time-series, cross-sectional review involving 47 general practices in one primary care trust (PCT) in South-East England. Comparison of a random sample of referral letters at baseline (n = 301) and after seven months of referral management (n = 280). Letters were assessed for inclusion of four core pieces of information which are used locally to monitor referral quality (blood pressure, body mass index, past medical history, medication history) and against research-based quality criteria for referral letters (provision of clinical information and clarity of reason for referral).

Results

Following introduction of the RMC, the proportion of letters containing each of the core items increased compared to baseline. Statistically significant increases in the recording of ‘past medical history’ (from 71% to 84%, p < 0.001) and ‘medication history’ (78% to 87%, p = 0.006) were observed. Forty four percent of letters met the research-based quality criteria at baseline but there was no significant change in quality of referral letters judged on these criteria across the two time periods.

Conclusion

Introduction of RMC has improved the inclusion of past medical history and medication history in referral letters, but not other measures of quality. In approximately half of letters there remains room for further improvement.

Evaluation of a theory-informed implementation intervention for the management of acute low back pain in general medical practice: the IMPLEMENT cluster randomised trial

INTRODUCTION

This cluster randomised trial evaluated an intervention to decrease x-ray referrals and increase giving advice to stay active for people with acute low back pain (LBP) in general practice.

METHODS

General practices were randomised to either access to a guideline for acute LBP (control) or facilitated interactive workshops (intervention). We measured behavioural predictors (e.g. knowledge, attitudes and intentions) and fear avoidance beliefs. We were unable to recruit sufficient patients to measure our original primary outcomes so we introduced other outcomes measured at the general practitioner (GP) level: behavioural simulation (clinical decision about vignettes) and rates of x-ray and CT-scan (medical administrative data). All those not involved in the delivery of the intervention were blinded to allocation.

RESULTS

47 practices (53 GPs) were randomised to the control and 45 practices (59 GPs) to the intervention. The number of GPs available for analysis at 12 months varied by outcome due to missing confounder information; a minimum of 38 GPs were available from the intervention group, and a minimum of 40 GPs from the control group. For the behavioural constructs, although effect estimates were small, the intervention group GPs had greater intention of practising consistent with the guideline for the clinical behaviour of x-ray referral. For behavioural simulation, intervention group GPs were more likely to adhere to guideline recommendations about x-ray (OR 1.76, 95%CI 1.01, 3.05) and more likely to give advice to stay active (OR 4.49, 95%CI 1.90 to 10.60). Imaging referral was not statistically significantly different between groups and the potential importance of effects was unclear; rate ratio 0.87 (95%CI 0.68, 1.10) for x-ray or CT-scan.

CONCLUSIONS

The intervention led to small changes in GP intention to practice in a manner that is consistent with an evidence-based guideline, but it did not result in statistically significant changes in actual behaviour.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN012606000098538.

Audit and feedback: effects on professional practice and healthcare outcomes

BACKGROUND

Audit and feedback is widely used as a strategy to improve professional practice either on its own or as a component of multifaceted quality improvement interventions. This is based on the belief that healthcare professionals are prompted to modify their practice when given performance feedback showing that their clinical practice is inconsistent with a desirable target. Despite its prevalence as a quality improvement strategy, there remains uncertainty regarding both the effectiveness of audit and feedback in improving healthcare practice and the characteristics of audit and feedback that lead to greater impact.

OBJECTIVES

To assess the effects of audit and feedback on the practice of healthcare professionals and patient outcomes and to examine factors that may explain variation in the effectiveness of audit and feedback.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) 2010, Issue 4, part of The Cochrane Library. www.thecochranelibrary.com, including the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register (searched 10 December 2010); MEDLINE, Ovid (1950 to November Week 3 2010) (searched 09 December 2010); EMBASE, Ovid (1980 to 2010 Week 48) (searched 09 December 2010); CINAHL, Ebsco (1981 to present) (searched 10 December 2010); Science Citation Index and Social Sciences Citation Index, ISI Web of Science (1975 to present) (searched 12-15 September 2011).

SELECTION CRITERIA

Randomised trials of audit and feedback (defined as a summary of clinical performance over a specified period of time) that reported objectively measured health professional practice or patient outcomes. In the case of multifaceted interventions, only trials in which audit and feedback was considered the core, essential aspect of at least one intervention arm were included.

DATA COLLECTION AND ANALYSIS

All data were abstracted by two independent review authors. For the primary outcome(s) in each study, we calculated the median absolute risk difference (RD) (adjusted for baseline performance) of compliance with desired practice compliance for dichotomous outcomes and the median percent change relative to the control group for continuous outcomes. Across studies the median effect size was weighted by number of health professionals involved in each study. We investigated the following factors as possible explanations for the variation in the effectiveness of interventions across comparisons: format of feedback, source of feedback, frequency of feedback, instructions for improvement, direction of change required, baseline performance, profession of recipient, and risk of bias within the trial itself. We also conducted exploratory analyses to assess the role of context and the targeted clinical behaviour. Quantitative (meta-regression), visual, and qualitative analyses were undertaken to examine variation in effect size related to these factors.

MAIN RESULTS

We included and analysed 140 studies for this review. In the main analyses, a total of 108 comparisons from 70 studies compared any intervention in which audit and feedback was a core, essential component to usual care and evaluated effects on professional practice. After excluding studies at high risk of bias, there were 82 comparisons from 49 studies featuring dichotomous outcomes, and the weighted median adjusted RD was a 4.3% (interquartile range (IQR) 0.5% to 16%) absolute increase in healthcare professionals' compliance with desired practice. Across 26 comparisons from 21 studies with continuous outcomes, the weighted median adjusted percent change relative to control was 1.3% (IQR = 1.3% to 28.9%). For patient outcomes, the weighted median RD was -0.4% (IQR -1.3% to 1.6%) for 12 comparisons from six studies reporting dichotomous outcomes and the weighted median percentage change was 17% (IQR 1.5% to 17%) for eight comparisons from five studies reporting continuous outcomes. Multivariable meta-regression indicated that feedback may be more effective when baseline performance is low, the source is a supervisor or colleague, it is provided more than once, it is delivered in both verbal and written formats, and when it includes both explicit targets and an action plan. In addition, the effect size varied based on the clinical behaviour targeted by the intervention.

AUTHORS' CONCLUSIONS

Audit and feedback generally leads to small but potentially important improvements in professional practice. The effectiveness of audit and feedback seems to depend on baseline performance and how the feedback is provided. Future studies of audit and feedback should directly compare different ways of providing feedback.

Appropriateness: analysis of outpatient radiology requests

PURPOSE

This study assessed radiology requests and the influence of previous radiological procedures on their specificity and appropriateness, evaluated diagnostic outcomes and recorded the economic impact of inappropriate examinations.

MATERIALS AND METHODS

We prospectively analysed 4,018 outpatient requests, the appropriateness of which was assessed using an evaluation form. Economic analysis was based on costs listed in the Italian National Health Services (NHS) national tariff as established by the Ministerial Decree of 22 July 1996. Statistical analysis was carried out using Pearson's test and univariate and multivariate logistic regression models.

RESULTS

Of 4,018 outpatient requests, 57% were not included in a follow-up protocol and 56% were found to be appropriate. The diagnostic question was confirmed in 66% of cases considered appropriate (p<0.001). The existence of previous investigations had a significant impact on appropriateness and diagnostic outcome (p<0.001). The total cost of the requests was 257,317 euro, with inappropriate requests accounting for 94,012 euro (36.5%).

CONCLUSIONS

We found a 56% rate of appropriate requests and demonstrated that appropriate prescriptions provided with a specific clinical question led to significantly higher confirmation rates of the diagnostic hypothesis. In addition, inappropriate requests had a major negative economic impact.

Improving the care for people with acute low-back pain by allied health professionals (the ALIGN trial): A cluster randomised trial protocol

BACKGROUND

Variability between clinical practice guideline recommendations and actual clinical practice exists in many areas of health care. A 2004 systematic review examining the effectiveness of guideline implementation interventions concluded there was a lack of evidence to support decisions about effective interventions to promote the uptake of guidelines. Further, the review recommended the use of theory in the development of implementation interventions. A clinical practice guideline for the management of acute low-back pain has been developed in Australia (2003). Acute low-back pain is a common condition, has a high burden, and there is some indication of an evidence-practice gap in the allied health setting. This provides an opportunity to develop and test a theory-based implementation intervention which, if effective, may provide benefits for patients with this condition.

AIMS

This study aims to estimate the effectiveness of a theory-based intervention to increase allied health practitioners' (physiotherapists and chiropractors in Victoria, Australia) compliance with a clinical practice guideline for acute non-specific low back pain (LBP), compared with providing practitioners with a printed copy of the guideline. Specifically, our primary objectives are to establish if the intervention is effective in reducing the percentage of acute non-specific LBP patients who are either referred for or receive an x-ray, and improving mean level of disability for patients three months post-onset of acute LBP.

METHODS

The design of the study is a cluster randomised trial. Restricted randomisation was used to randomise 210 practices (clusters) to an intervention or control group. Practitioners in the control group received a printed copy of the guideline. Practitioners in the intervention group received a theory-based intervention developed to address prospectively identified barriers to practitioner compliance with the guideline. The intervention primarily consisted of an educational symposium. Patients aged 18 years or older who visit a participating practitioner for acute non-specific LBP of less than three months duration over a two-week data collection period, three months post the intervention symposia, are eligible for inclusion. Sample size calculations are based on recruiting between 15 to 40 patients per practice. Outcome assessors will be blinded to group allocation.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12609001022257 (date registered 25th November 2009).

Comparison of outcomes of two skills-teaching methods on lay-rescuers' acquisition of infant basic life support skills

OBJECTIVES

The objective was to determine if lay-rescuers' acquisition of infant basic life support (BLS) skills would be better when skills teaching consisted of videotaping practice and providing feedback on performances, compared to conventional skills-teaching and feedback methods.

METHODS

  This pilot-exploratory, single-blind, prospective, controlled, randomized study was conducted on November 12, 2007, at the Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel. The population under study consisted of all first-year medical students enrolled in the 2007-2008 year. BLS training is part of their mandatory introductory course in emergency medicine. Twenty-three students with previous BLS training were excluded. The remaining 71 were randomized into four and then two groups, with final allocation to an intervention and control group of 18 and 16 students, respectively. All the students participated in infant BLS classroom teaching. Those in the intervention group practiced skills acquisition independently, and four were videotaped while practicing. Tapes were reviewed by the group and feedback was provided. Controls practiced using conventional teaching and feedback methods. After 3 hours, all subjects were videotaped performing an unassisted, lone-rescuer, infant BLS resuscitation scenario. A skills assessment tool was developed. It consisted of 25 checklist items, grouped into four sections: 6 points for "categories" (with specific actions in six categories), 14 points for "scoring" (of accuracy of performance of each action), 4 points for "sequence" (of actions within a category), and 1 point for "order" of resuscitation (complete and well-sequenced categories). Two blinded expert raters were given a workshop on the use of the scoring tool. They further refined it to increase scoring consistency. The main outcome of the study was defined as evidence of better skills acquisition in overall skills in the four sections and in the specific skills sets for actions in any individual category. Data analysis consisted of descriptive statistics.

RESULTS

Means and mean percentages were greater in the intervention group in all four sections compared to controls: categories (5.72 [95.33%] and 4.69 [92.66%]), scoring (10.57 [75.50%] and 7.41 [43.59%]), sequence (2.28 [57.00%] and 1.66 [41.50%]), and order of resuscitation (0.96 [96.00%] and 0.19 [19.00%]). The means and mean percentages of the actions (skill sets) in the intervention group were also larger than those of controls in five out of six categories: assessing responsiveness (1.69 [84.50%] and 1.13 [56.50%]), breathing technique (1.69 [93.00%] and 1.13 [47.20%]), chest compression technique (3.19 [77.50%] and 1.84 [46.00%]), activating emergency medical services (EMS) (3.00 [100.00%] and 2.81 [84.50%]), and resuming cardiopulmonary resuscitation (0.97 [97.00%] and 0.47 [47.00%]). These results demonstrate better performance in the intervention group.

CONCLUSIONS

The use of videotaped practice and feedback for the acquisition of overall infant BLS skills and of specific skill sets is effective. Observation and participation in the feedback and assessment of nonexperts attempting infant BLS skills appeared to improve the ability of this group of students to perform the task.

Interventions for improving the appropriate use of imaging in people with musculoskeletal conditions

BACKGROUND

Imaging is commonly performed for musculoskeletal conditions. Identifying interventions to improve the appropriate use of imaging for musculoskeletal conditions could potentially result in improved health outcomes for patients and reduced health care costs.

OBJECTIVES

To determine the effects of interventions that aim to improve the appropriate use of imaging for people with musculoskeletal conditions.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care Group Specialised Register (June 2007), The Cochrane Central Register of Controlled Trials (The Cochrane Library 2007, Issue 2), MEDLINE (January 1966 to June 2007), EMBASE (January 1980 to June 2007) and CINAHL (January 1982 to June 2007). We also searched reference lists of included studies and relevant reviews. We undertook citation searches of all included studies, contacted authors of included studies, and contacted other experts in the field of effective professional practice.

SELECTION CRITERIA

Randomised controlled trials, non-randomised controlled clinical trials and interrupted time-series analyses that evaluated interventions designed to improve the use of imaging for musculoskeletal symptoms.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed risk of bias and extracted data. We contacted study authors for additional information.

MAIN RESULTS

Twenty eight studies met our inclusion criteria. The majority of the studies were for the management of osteoporosis or low back pain, and most evaluated interventions aimed at health professionals. To improve the use of imaging in the management of osteoporosis, the effect of any type of intervention compared to no-intervention controls was modest (absolute improvement in bone mineral density test ordering +10%, IQR 0.0 to +27.7). Patient mediated, reminder, and organisational interventions appeared to have most potential for improving imaging use in osteoporosis. For low back pain studies, the most common intervention evaluated was distribution of educational materials and this showed varying effects. Other interventions in low back pain studies also showed variable effects. For other musculoskeletal conditions, distribution of educational materials, educational meetings and audit and feedback were not shown to be effective for changing imaging ordering behaviour. Across all conditions, increasing the number of intervention components did not increase effect.

AUTHORS' CONCLUSIONS

For improving the use of imaging in osteoporosis, most professional interventions demonstrated benefit, and patient mediated, reminder, and organisational interventions appeared to have most potential for benefit. For low back pain studies interventions showed varying effects. For other musculoskeletal conditions, no firm conclusions can be drawn.

Doctors with a special interest in back pain have poorer knowledge about how to treat back pain

STUDY DESIGN

We conducted an observational study using mailed questionnaires to 3 random samples of general practitioners from Victoria and New South Wales, Australia in 1997, 2000, and 2004.

OBJECTIVE

To determine whether general practitioners' beliefs about low back pain (LBP) differ according to whether they have a special interest in back pain, musculoskeletal, or occupational medicine; and whether these beliefs are modified by having had continuing medical education (CME) about back pain in the previous 2 years.

SUMMARY OF BACKGROUND DATA

Physician surveys continue to demonstrate that general practitioners only partially manage LBP in an evidence-based way. Identified barriers to changing physician behavior, in regard to management of back pain, have included patient factors such as their past back pain experiences and preferences for care as well as physician beliefs about the association of pain and activity; although the influence of physician special interests has not been studied.

METHODS

Back pain beliefs of different subsets (special interests vs. no special interests and CME vs. no CME) were compared using relative risks (RRs) adjusted for state and survey. The analysis was then repeated including all special interests and recent back pain CME in the model.

RESULTS

Responses were received from 3831 general practitioners (overall response rate [RR]: 38.2%). Physicians with a special interest in LBP were more likely to believe that complete bed rest and avoidance of work is appropriate for acute low back pain (RR: 1.89 [95% CI: 1.53-2.33] and 1.55 [95% CI: 1.31-1.83], respectively) and lumbar spine radiographs are useful (RR: 1.36 [95% CI: 1.21-1.51]). The disparity between those with and without a special interest in LBP was still evident after adjusting for the presence of other special interests and recent CME. After adjusting for the presence of other special interests and recent CME, there were no important differences in back pain beliefs between those with and without a special interest in musculoskeletal medicine, while those with a special interest in occupational medicine and those who had received recent CME had better beliefs.

CONCLUSION

A special interest in back pain is associated with back pain management beliefs contrary to the best available evidence. This has serious implications for management of back pain in the community.

Is e-mail communication effective in changing ordering patterns in the emergency department? A case study of computed tomography for pulmonary embolus

RATIONALE AND OBJECTIVES

We sought to evaluate the effectiveness of e-mail communication to reduce the utilization of computed tomography for pulmonary thromboembolism (PE) in young patients (aged 40 and under) in our institution.

MATERIALS AND METHODS

An e-mail was sent to all of our institution's emergency department (ED) physicians in response to a series of negative PE studies in young females. The periods 90 days before and 90 days after were evaluated to assess the total number of PE studies performed in patients aged 40 and younger, the rate of positivity, and the utilization of D-dimer and ventilation/perfusion scans during each period.

RESULTS

Over the 180-day period, a total of 65 PE studies were ordered in patients aged 40 and younger in the ED. Studies were positive for PE in 1 of 33 (3%) before the e-mail and 4 of 32 (12.5%) after (P = .343). There was no difference in the number of D-dimer studies ordered during each period for patients studied with computed tomography. Ventilation/perfusion scanning was not performed on any ED patients younger than 40 during the 180-day period.

CONCLUSIONS

One-time e-mail communication was not effective in changing ED ordering habits of PE studies. Scant information exists in regard to effective clinician-to-clinician communication. Further evaluation for successful mechanisms to promote health practice reform and quality improvement is necessary.

IMPLEmenting a clinical practice guideline for acute low back pain evidence-based manageMENT in general practice (IMPLEMENT): cluster randomised controlled trial study protocol

Background

Evidence generated from reliable research is not frequently implemented into clinical practice. Evidence-based clinical practice guidelines are a potential vehicle to achieve this. A recent systematic review of implementation strategies of guideline dissemination concluded that there was a lack of evidence regarding effective strategies to promote the uptake of guidelines. Recommendations from this review, and other studies, have suggested the use of interventions that are theoretically based because these may be more effective than those that are not. An evidence-based clinical practice guideline for the management of acute low back pain was recently developed in Australia. This provides an opportunity to develop and test a theory-based implementation intervention for a condition which is common, has a high burden, and for which there is an evidence-practice gap in the primary care setting.

Aim

This study aims to test the effectiveness of a theory-based intervention for implementing a clinical practice guideline for acute low back pain in general practice in Victoria, Australia. Specifically, our primary objectives are to establish if the intervention is effective in reducing the percentage of patients who are referred for a plain x-ray, and improving mean level of disability for patients three months post-consultation.

Methods/Design

This study protocol describes the details of a cluster randomised controlled trial. Ninety-two general practices (clusters), which include at least one consenting general practitioner, will be randomised to an intervention or control arm using restricted randomisation. Patients aged 18 years or older who visit a participating practitioner for acute non-specific low back pain of less than three months duration will be eligible for inclusion. An average of twenty-five patients per general practice will be recruited, providing a total of 2,300 patient participants. General practitioners in the control arm will receive access to the guideline using the existing dissemination strategy. Practitioners in the intervention arm will be invited to participate in facilitated face-to-face workshops that have been underpinned by behavioural theory. Investigators (not involved in the delivery of the intervention), patients, outcome assessors and the study statistician will be blinded to group allocation.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN012606000098538 (date registered 14/03/2006).

Preauthorization of CT and MRI examinations: assessment of a managed care preauthorization program based on the ACR Appropriateness Criteria and the Royal College of Radiology guidelines

PURPOSE

To evaluate computed tomography (CT) and magnetic resonance imaging (MRI) utilization patterns before and after the implementation of a preauthorization program based on the ACR Appropriateness Criteria((R)) and the guidelines of the Royal College of Radiologists.

MATERIALS AND METHODS

All CT and MRI requests received at the preauthorization center and CT and MRI examinations actually performed were identified by our health care service's centralized computerized database between January 1, 2000, and December 31, 2003. The obligatory preauthorization of CT and MRI requests was established for CT in September 2001 and for MRI in February 2002. All ambulatory CT and MRI examination requests sent for approval during the study period by most of our health care physicians were included in the study. The preauthorization program model is presented, and multiple parameters were evaluated from January 2000 to December 2003, before and after preauthorization was established.

RESULTS

Before preauthorization was required, the CT and MRI utilization rates were constantly increasing by 20% and 5% per year for CT and MRI, respectively. After preauthorization was implemented, CT and MRI annual performance rates decreased from 25.9 and 7 examinations per 1,000, respectively, in 2000 to 17.3 and 5.6 examinations per 1,000, respectively, in 2003. The decreases in the utilization of MRI and CT imaging between 2001 and 2003 were 9% (12,129 compared with 11,070 MRI examinations) and 33% (81,223 compared with 57,204 CT examinations), respectively, resulting in substantial, statistically significant cost savings. The deferral rate ranged from 7.5% to 12.2% (mean = 9.8%) for CT and 13.9% to 21.4% (mean = 17%) for MRI. Deferred cases in CT were most commonly in neuroradiology, musculoskeletal radiology, and CT angiography (ranges of deferred cases 9% to 12%, 11% to 12%, and 10% to 12%, respectively). Deferred cases in MRI were most commonly in abdominal and chest radiology (ranges of deferred cases 32% to 37% and 20% to 31%, respectively). Computed tomography was more commonly utilized inappropriately by pediatric professions, and MRI was more commonly utilized inappropriately by medical subspecialty professions.

CONCLUSION

Preauthorization of CT and MRI requests results in a substantial decrease in utilization of these modalities with reduction in imaging costs.

An audit of referral practice for patients with impacted palatal canines and the impact of referral guidelines

OBJECTIVE

To assess referral practice for patients presenting with impacted palatal maxillary canines, and to develop and evaluate the effectiveness of referral guidelines.

DESIGN

Prospective clinical audit.

SETTING

Southend and Basildon district general hospitals.

SUBJECTS AND METHODS

The 'gold' standard was identified as regular dental attenders with unerupted palatal canines being referred by 12 years old, with a wait of no longer than 20 weeks from referral to assessment. Data were collected and compared to the defined standard. An algorithm outlining the correct management was developed and distributed to all local dentists. The cycle was repeated for a similar time period.

RESULTS

Ninety-eight per cent of patients were seen within 20 weeks during both cycles while the referrals increased from 85 to 109 patients. The percentage of patients referred by 12 years of age increased from 16.5% to 27% (p = 0.09). During the first cycle 82% of patients presented with retained deciduous maxillary canines. This was reduced to 76% during the second cycle (p = 0.29).

CONCLUSION

Referral practice was generally poor when compared to the recommended good practice. More patients were referred after distribution of the guidelines, but the percentage referred by the recommended age was not statistically significantly improved.

Audit and feedback: effects on professional practice and health care outcomes

BACKGROUND

Audit and feedback continues to be widely used as a strategy to improve professional practice. It appears logical that healthcare professionals would be prompted to modify their practice if given feedback that their clinical practice was inconsistent with that of their peers or accepted guidelines. Yet, audit and feedback has not consistently been found to be effective.

OBJECTIVES

To assess the effects of audit and feedback on the practice of healthcare professionals and patient outcomes.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care Group's register and pending file up to January 2004.

SELECTION CRITERIA

Randomised trials of audit and feedback (defined as any summary of clinical performance over a specified period of time) that reported objectively measured professional practice in a healthcare setting or healthcare outcomes.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed study quality. Quantitative (meta-regression), visual and qualitative analyses were undertaken. For each comparison we calculated the risk difference (RD) and risk ratio (RR), adjusted for baseline compliance when possible, for dichotomous outcomes and the percentage and the percent change relative to the control group average after the intervention, adjusted for baseline performance when possible, for continuous outcomes. We investigated the following factors as possible explanations for the variation in the effectiveness of interventions across comparisons: the type of intervention (audit and feedback alone, audit and feedback with educational meetings, or multifaceted interventions that included audit and feedback), the intensity of the audit and feedback, the complexity of the targeted behaviour, the seriousness of the outcome, baseline compliance and study quality.

MAIN RESULTS

Thirty new studies were added to this update, and a total of 118 studies are included. In the primary analysis 88 comparisons from 72 studies were included that compared any intervention in which audit and feedback is a component compared to no intervention. For dichotomous outcomes the adjusted risk difference of compliance with desired practice varied from - 0.16 (a 16 % absolute decrease in compliance) to 0.70 (a 70% increase in compliance) (median = 0.05, inter-quartile range = 0.03 to 0.11) and the adjusted risk ratio varied from 0.71 to 18.3 (median = 1.08, inter-quartile range = 0.99 to 1.30). For continuous outcomes the adjusted percent change relative to control varied from -0.10 (a 10 % absolute decrease in compliance) to 0.68 (a 68% increase in compliance) (median = 0.16, inter-quartile range = 0.05 to 0.37). Low baseline compliance with recommended practice and higher intensity of audit and feedback were associated with larger adjusted risk ratios (greater effectiveness) across studies.

AUTHORS' CONCLUSIONS

Audit and feedback can be effective in improving professional practice. When it is effective, the effects are generally small to moderate. The relative effectiveness of audit and feedback is likely to be greater when baseline adherence to recommended practice is low and when feedback is delivered more intensively.

The use of radiological guidelines to achieve a sustained reduction in the number of radiographic examinations of the cervical spine, lumbar spine and knees performed for GPs

AIM

To determine if the use of request guidelines can achieve a sustained reduction in the number of radiographic examinations of the cervical spine, lumbar spine and knee joints performed for general practitioners (GPs).

METHODS

GPs referring to three community hospitals and a district general hospital were circulated with referral guidelines for radiography of the cervical spine, lumbar spine and knee, and all requests for these three examinations were checked. Requests that did not fit the guidelines were returned to the GP with an explanatory letter and a further copy of the guidelines. Where applicable, a large-joint replacement algorithm was also enclosed. If the GP maintained the opinion that the examination was indicated, she or he had the option of supplying further justifying information in writing or speaking to a consultant radiologist.

RESULTS

Overall the number of radiographic examinations fell by 68% in the first year, achieving a 79% reduction in the second year. For knees, lumbar spine and cervical spine radiographs the total reductions were 77%, 78% and 86%, respectively.

CONCLUSION

The use of referral guidelines, reinforced by request checking and clinical management algorithms, can produce a dramatic and sustained reduction in the number of radiographs of the cervical spine, lumbar spine and knees performed for GPs.

Implementing evidence-based guidelines for radiography in acute low back pain: a pilot study in a chiropractic community

OBJECTIVE

To evaluate the ability of a systematic educational intervention strategy to change the plain radiography ordering behavior of chiropractors toward evidence-based practice for patients with acute low back pain (LBP).

DESIGN

A quasi-experimental method was used comparing outcomes before and after the intervention with those of a control community.

SETTING

Two communities in southern Ontario.

DATA SOURCE

Mailed survey data on the management of acute LBP. Outcome Measures Plain radiography use rates for acute LBP based on responses to mailed surveys.

RESULTS

Following the intervention, there was a 42% reduction in the self-report need for plain radiography for uncomplicated acute LBP (P <.025) and a 50% reduction for patients with acute LBP < 1 month (P <.025) in the intervention community. There was no significant change in the self-report need for plain radiography in the control community (P >.05).

CONCLUSIONS

The educational intervention strategy used in this study appeared to have an effect in reducing the perceived need for plain radiography in acute LBP.

Factors affecting general practitioners' decisions about plain radiography for back pain: implications for classification of guideline barriers--a qualitative study

BACKGROUND

General practitioners often diverge from clinical guidelines regarding spine radiography. This study aimed to identify and describe A) factors general practitioners consider may affect their decisions about ordering plain radiography for back pain and B) barriers to guideline adherence suggested by such factors.

METHODS

Focus group interviews regarding factors affecting ordering decisions were carried out on a diverse sample of Norwegian general practitioners and were analysed qualitatively. Results of this study and two qualitative studies from the Netherlands and USA on use of spine radiography were interpreted for barriers to guideline adherence. These were compared with an existing barrier classification system described by Dr Cabana's group.

RESULTS

The factors which Norwegian general practitioners considered might affect their decisions about ordering plain radiography for back pain concerned the following broader issues: clinical ordering criteria, patients' wishes for radiography and the general practitioner's response, uncertainty, professional dignity, access to radiology services, perception of whether the patient really was ill, sense of pressure from other health care providers/social security, and expectations about the consequences of ordering radiography. The three studies suggested several attitude-related and external barriers as classified in a previously reported system described by Dr Cabana in another study. Identified barriers not listed in this system were: lack of expectancy that guideline adherence will lead to desired health care process, emotional difficulty with adherence, improper access to actual/alternative health care services, and pressure from health care providers/organisations.

CONCLUSIONS

Our findings may help implement spine radiography guidelines. They also indicate that Cabana et al.'s barrier classification system needs extending. A revised system is proposed.

Audit and feedback: effects on professional practice and health care outcomes

BACKGROUND

Audit and feedback continues to be widely used as a strategy to improve professional practice. It appears logical that healthcare professionals would be prompted to modify their practice if given feedback that their clinical practice was inconsistent with that of their peers or accepted guidelines. Yet, audit and feedback has not been found to be consistently effective.

OBJECTIVES

To assess the effects of audit and feedback on the practice of healthcare professionals and patient outcomes.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care Group's register up to January 2001. This was supplemented with searches of MEDLINE and reference lists, which did not yield additional relevant studies.

SELECTION CRITERIA

Randomised trials of audit and feedback (defined as any summary of clinical performance over a specified period of time) that reported objectively measured professional practice in a healthcare setting or healthcare outcomes.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed study quality. Quantitative (meta-regression), visual and qualitative analyses were undertaken.

MAIN RESULTS

We included 85 studies, 48 of which have been added to the previous version of this review. There were 52 comparisons of dichotomous outcomes from 47 trials with over 3500 health professionals that compared audit and feedback to no intervention. The adjusted RDs of non-compliance with desired practice varied from 0.09 (a 9% absolute increase in non-compliance) to 0.71 (a 71% decrease in non-compliance) (median = 0.07, inter-quartile range = 0.02 to 0.11). The one factor that appeared to predict the effectiveness of audit and feedback across studies was baseline non-compliance with recommended practice.

REVIEWER'S CONCLUSIONS

Audit and feedback can be effective in improving professional practice. When it is effective, the effects are generally small to moderate. The absolute effects of audit and feedback are more likely to be larger when baseline adherence to recommended practice is low.