Effect of audit and feedback, and reminder messages on primary-care radiology referrals: a randomised trial

BACKGROUND

Radiological tests are often used by general practitioners (GPs). These tests can be overused and contribute little to clinical management. We aimed to assess two methods of reducing GP requests for radiological tests in accordance with the UK Royal College of Radiologists' guidelines on lumbar spine and knee radiographs.

METHODS

We assessed audit and feedback, and educational reminder messages in six radiology departments and 244 general practices that they served. The study was a before-and-after, pragmatic, cluster randomised controlled trial with a 232 factorial design. A random subset of GP patients' records were examined for concordance with the guidelines. The main outcome measure was number of radiograph requests per 1000 patients per year. Analysis was by intention to treat.

FINDINGS

The effect of educational reminder messages (ie, the change in request rate after intervention) was an absolute change of -1.53 (95% CI -2.5 to -0.57) for lumbar spine and of -1.61 (-2.6 to -0.62) for knee radiographs, both relative reductions of about 20%. The effect of audit and feedback was an absolute change of -0.07 (-1.3 to 0.9) for lumbar spine of 0.04 (-0.95 to 1.03) for knee radiograph requests, both relative reductions of about 1%. Concordance between groups did not differ significantly.

INTERPRETATION

6-monthly feedback of audit data is ineffective but the routine attachment of educational reminder messages to radiographs is effective and does not affect quality of referrals. Any department of radiology that handles referrals from primary care could deliver this intervention to good effect.

Guidelines in professions allied to medicine

BACKGROUND

Clinical practice guidelines aim to reduce inappropriate variations in practice and to promote the delivery of evidence-based health care.

OBJECTIVES

To identify and assess the effects of studies of the introduction of clinical practice guidelines in nursing (including health visiting), midwifery and other professions allied to medicine.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care Group specialised register, MEDLINE (1975 to 1996), EMBASE, Cinahl and Sigle to 1996, the NHS Economic Evaluations Database (1994 to 1996), DHSS-Data (1983 to 1996), the Database of Abstracts of Reviews of Effectiveness (1994 to 1996) and reference lists of articles. We also hand searched the journal Quality in Health Care, made personal contact with content experts and contacted libraries identified by an expert panel.

SELECTION CRITERIA

Randomised trials, controlled before-and-after studies and interrupted time series analyses of the introduction of interventions comparing 1. Clinical guidelines plus dissemination and/or implementation strategies versus no guidelines; 2. Guidelines plus dissemination and/or implementation strategies versus guidelines plus alternative dissemination and/or implementation strategies; and 3. (post hoc) Guidelines used by professions allied to medicine versus standard physician care. The participants were nurses, midwives and other professions allied to medicine.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed study quality.

MAIN RESULTS

Eighteen studies were included involving more than 467 health care professionals. The reporting of study methods was inadequate for all studies. In all but one study, nurses were the targeted professional group; one study was aimed solely at dieticians. The various behaviours targeted included the management of hypertension, low back pain and hyperlipidaemia. Nine studies were identified for comparison 1. Three out of five studies observed improvements in at least some processes of care and six out of eight studies observed improvements in outcomes of care. Only one study included a formal economic evaluation, with equivocal findings. Three studies were identified for comparison 2 but it was difficult to draw firm conclusions because of poor methods. Six studies were identified for comparison 3 (post hoc). These studies generally supported the hypothesis that there was no difference between care given by nurses using clinical guidelines and standard physician care.

REVIEWER'S CONCLUSIONS

There is some evidence that guideline-driven care is effective in changing the process and outcome of care provided by professions allied to medicine. However, caution is needed in generalising findings to other professions and settings.

Clinical guidelines in nursing, midwifery and the therapies: a systematic review

BACKGROUND

While nursing, midwifery and professions allied to medicine (PAMs) are increasingly using clinical guidelines to reduce inappropriate variations in practice and ensure higher quality care, there have been no rigorous overviews of their effectiveness in relation to these professions. We identified 18 evaluations of guidelines which met established quality for evaluations of interventions aimed at changing professional practice. This paper describes characteristics of guidelines evaluated and the effectiveness of different dissemination and implementation strategies used.

METHODS

Guideline evaluations conducted since 1975 which used a randomized controlled trial, controlled before-and-after, or interrupted time-series design, were identified using a combination of database and hand searching.

FINDINGS

It is mostly impossible to tell whether the guidelines evaluated were based on evidence. The most common method of guideline dissemination was the distribution of printed educational materials. Three studies compared different dissemination and/or implementation strategies: findings suggest educational interventions may be of value in the dissemination of guidelines and confer a benefit over passive dissemination.

Effect of clinical guidelines in nursing, midwifery, and the therapies: a systematic review of evaluations

BACKGROUND

Although nursing, midwifery, and professions allied to medicine are increasingly using clinical guidelines to reduce inappropriate variations in practice and ensure higher quality care, there have been no rigorous overviews of their effectiveness, 18 evaluations of guidelines were identified that meet Cochrane criteria for scientific rigor.

METHODS

Guideline evaluations conducted since 1975 which used a randomised controlled trial, controlled before and after, or interrupted time series design were identified through a combination of database and hand searching.

RESULTS

18 studies met the inclusion criteria. Three studies evaluated guideline dissemination or implementation strategies, nine compared use of a guideline with a no guideline state; six studies examined skill substitution: performance of nurses operating according to a guideline were compared with standard care, generally provided by a physician. Significant changes in the process of care were found in six out of eight studies measuring process and in which guidelines were expected to have a positive impact on performance. In seven of the nine studies measuring outcomes of care, significant differences in favour of the intervention group were found. Skill substitution studies generally supported the hypothesis of no difference between protocol driven by nurses and care by a physician. Only one study included a formal economic evaluation, with equivocal findings.

CONCLUSIONS

Findings from the review provide some evidence that care driven by a guideline can be effective in changing the process and outcome of care. However, many studies fell short of the criteria of the Cochrane Effective Practice and Organisation of Care Group (EPOC) for methodological quality.

Early supported hospital discharge following acute stroke: pilot study results

OBJECTIVE

To establish the feasibility and method of evaluation of an early supported hospital discharge policy for patients with acute stroke.

DESIGN

A randomized controlled trial comparing an early supported discharge service to conventional care.

SETTING

Three acute hospitals in Newcastle upon Tyne.

SUBJECTS

Ninety-two eligible patients with acute stroke admitted between 1 February 1995 and 31 January 1996.

MAIN OUTCOME MEASURES

Placement, length of stay, readmission rates, mortality, functional ability (Nottingham Extended Activities of Daily Living (ADL) Scale), handicap (Oxford Handicap Scale), global health status (Dartmouth Coop Function Charts) and carer stress (General Health Questionnaire 30 item).

RESULTS

The median length of stay for patients randomized to early supported discharge was 13 days compared to 22 days in the conventional care group (p = 0.02). The median Barthel ADL index at seven days post stroke of patients randomized to early supported discharge was 15, and 13 for those randomized to conventional care (NS). At three months post stroke the median Nottingham EADL score of patients randomized to early supported discharge was 10 compared to 7 for those who received conventional care (NS). There were no statistically significant differences in the global health status of patients or carer stress.

CONCLUSION

An early supported discharge service following acute stroke with individualized rehabilitation in the community is feasible and can be evaluated by a randomized controlled trial but a larger multicentre trial is needed before such a service is widely adopted.

Influences on prescribing in non-fundholding general practices

BACKGROUND

The experience from general practice fundholding suggests that financial incentives may influence prescribing; guidelines and hospital prescribing are two other suggested influences.

AIM

A study was undertaken to establish general practitioners' attitudes to a financial prescribing incentive scheme, the presence and use of guidelines, and the influence of prescribing initiated within secondary care.

METHOD

A postal questionnaire survey of non-fundholding general practices in the former Northern Region was conducted.

RESULTS

Practices' thinking and subsequent decisions about the incentive prescribing scheme were most often influenced by discussions within the practice (45%). Those practices that achieved their savings under the incentive scheme were less likely than those not achieving savings to feel that the target was not achievable, the time scale was unacceptable, and that the philosophy behind the scheme was unacceptable. Forty-five per cent of practices received advice from neither a medical nor a pharmaceutical adviser; 27% of practices received advice from both, 12% from a medical adviser only and 16% from a pharmaceutical adviser only. Of the practices that tried to make their target savings, 91% intended to increase generic prescribing; fewer than one-third of practices mentioned any other measure. Prescribing guidelines were reported by a minority of practices, although reported rates of use were high when these were present. Clinical guidelines for three conditions, asthma, diabetes and hypertension, were present in more than 50% of practices; 25% of practices had no clinical guidelines. Hospital prescribing was reported as 'always' or 'usually' influencing prescribing for diabetes by 57% of respondents, ischaemic heart disease by 55%, peptic ulceration by 49%, asthma by 42% and hypertension by 39%.

CONCLUSIONS

General practitioner prescribing is influenced by a complex web of factors, with no single factor pre-eminent. To understand this area further, there is a need to take each of these areas and ascertain the match between doctors' perceptions and actual practice.

Can we understand partnerships in general practice? A pilot study

BACKGROUND

Partnerships have been investigated in different professions, but other than identifying problems, little work has been carried out on general practice.

OBJECTIVE

The aim of this present study was to develop methods for studying partnerships in general practice.

METHOD

A tripartite methodological approach was used, with questionnaires adapted from other instruments in use in other professions, followed by an individual interview with each partner, and non-participant observation at a partnership meeting. Results for one case-study partnership are given.

RESULTS

There were no major differences between the partners on all dimensions measured; the minor differences indicated by the results of the questionnaires were corroborated by the partner interviews and observations.

CONCLUSIONS

We conclude that the use of such techniques could provide support to partnerships going through significant periods of change.

Setting standards of prescribing performance in primary care: use of a consensus group of general practitioners and application of standards to practices in the north of England

BACKGROUND

There is considerable variation in prescribing, and existing standards against which primary care prescribing is routinely judged consist largely of local or national averages. There is thus a need for more sophisticated standards, which must be widely applicable and have credibility among the general practice profession.

AIM

A study aimed to develop a range of criteria of prescribing quality, to set standards of performance for these criteria, and apply these standards to practices.

METHOD

A consensus group consisting of eight general practitioners and a resource team was convened to develop and define criteria and set standards of prescribing performance using prescribing analyses and cost (PACT) data. The standards were applied to 1992-93 prescribing data from all 518 practices in the former Northern Regional Health Authority.

RESULTS

The group developed criteria and set numeric standards for 13 aspects of prescribing performance in four areas: generic prescribing, prescribing within specific therapeutic groups, drugs of limited clinical value and standards based on prescribing volume. Except for generic prescribing, standards for individual criteria were achieved by between 9% and 34% of practices. For each criterion, a score was allocated based on whether the standard was achieved or not. Total scores showed considerable variation between practices. The distribution of scores was similar between fundholding and non-fundholding practices, and also between dispensing and non-dispensing practices.

CONCLUSION

Using a consensus group of general practitioners it is possible to agree criteria and standards of prescribing performance. This novel approach offers a professionally driven method for assessing the quality of prescribing in primary care.

General practice partnerships: an exploratory review

Presents the results of a literature review on general practice partnerships. The objective was to find out what has been written and by whom. The results of the review indicate that very little empirical work has been carried out and most of the publications are by doctors addressing the practical problems of working in partnerships. Given this paucity of material, goes on to discuss relevant literature from social science disciplines and presents five perspectives on partnerships. Each perspective yields questions worthy of further investigation particularly at a time when primary care is experiencing rapid change and development.

A strategy for caring for families in bereavement

This study, which is part of the Department of Health initiative examining care for children with life-threatening illnesses and their families, aimed to create a strategy for such care for families in the Northern Region. Current service provision tends to consider the family and child during the life of that child, but we were interested to learn also of parents' views of services provided and their expectations after the child had died. Our research showed that there was a considerable unmet need for support during the child's illness and immediately after the child's death as well as in the longer term. While such support was available through a children's hospice and for certain conditions, it was not so universally.