Providing feedback to GPs: an effective solution to overuse of musculoskeletal diagnostic imaging

A simple audit and feedback mechanism can successfully reduce overuse of musculoskeletal imaging by General Practitioners (GPs) at a national scale, saving precious health system resources, and saving patients’ time, money, potential for incidental findings, unnecessary treatment and risk of harm from cumulative exposure to ionising radiation. The findings, from a collaboration between musculoskeletal research experts at Monash Public Health and Preventive Medicine and the Australian Government Department of Health and Aged Care, were published in high-impact journal JAMA today.

Regional musculoskeletal conditions such as low back, neck, shoulder, hip, knee and foot pain are common, and contribute significantly to global disability. Evidence-based primary care guidelines for many of these conditions recommend against early diagnostic imaging, unless features suggest serious or specific underlying causes, or unexplained worsening or prolonged symptoms are observed.

Associate Professor Denise O'ConnorUnwarranted imaging carries no benefit; such scans may lead to unnecessary treatment, waste health resources that could be better used elsewhere, and drain patients’ time and money. It also carries secondary costs to society, including a sizeable carbon footprint. Yet overuse of diagnostic imaging by general practitioners for people with musculoskeletal conditions remains a persistent issue – one in five diagnostic imaging requests in Australia is considered low-value.

Study lead A/Prof Denise O’Connor and her colleagues from Wiser Healthcare, a national collaboration that conducts research to identify low-value healthcare services and design solutions to ensure better value healthcare for Australians said "Diagnostic imaging is ripe with opportunity, and we wondered if an audit and feedback process may help."

Audit and feedback is a well-established quality improvement activity, but few clinical trials have explored its utility in this context.

The team used routinely collected Medicare Benefits Schedule data to identify GPs who fell into the top 20 per cent of referrers for 11 imaging tests (of the lumbosacral or cervical spine, shoulder, hip, knee and ankle/hind foot), and for at least four individual tests. The 11 tests were representative of some of the more commonly over-ordered imaging tests.

Eligible GPs were randomised to a control group that received no feedback, or to one of four intervention groups that received feedback on their imaging requesting from the Chief Medical Officer of Australia. The content delivered to the four intervention group participants was the same, other than for its frequency and the visual display of data, which were two effect modifiers evaluated in the study. The primary outcome was the overall rate of requests for the 11 targeted imaging tests for each GP over 12 months.

Compared with no intervention, audit and feedback resulted in a 10.6 per cent relative reduction in imaging requests over 6 months, 9.2 per cent over 12 months and 8.0 per cent over 18 months, and an estimated 47,318 fewer imaging requests. Compared with once-only delivery, a second round of feedback led to further modest reductions in requesting over 18 months, and a simple visual display enhancement also further reduced requesting over 6 and 12 months compared with standard display.

A/Prof O’Connor says, "Our study shows providing feedback to GPs who request musculoskeletal imaging much more frequently than their peers can reduce overuse, which may translate into better patient outcomes while also strengthening the sustainability of Australia’s healthcare system and reducing carbon emissions from unnecessary imaging."

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