Upon receiving a just-the-facts letter from a federal health official, Australia’s most frequent referrers for musculoskeletal imaging significantly curbed their inclination to place these orders over the next 12 months.
By comparison, high-requesting peers who heard no word continued to order MSK imaging unabated.
The voluntary dampening effect was striking since both groups had been randomly assembled out of a broad field of high-requesting MSK referrers—some 3,819 physicians from 2,271 practices.
All were general practitioners (GPs). The investigation was conducted across Australia and is described in a study published online Sept. 6 in JAMA [1].
Denise O’Connor, PhD, of Monash University in Melbourne and colleagues note the letter contained individualized audit data, feedback and peer-group comparisons based on orders placed per 1,000 consultations.
It was sent through the mail to practices with at least one practitioner in the top 20% of referrers in Australia for 11 imaging tests (lumbosacral or cervical spine, shoulder, hip, knee and ankle/hind foot).
Letterheaded and signed by the CMO of the Australian Government Department of Health and Aged Care, the letter’s text began as follows:
Your musculoskeletal diagnostic imaging request rate is higher than 80% of General Practitioners practicing in a similar geographical region in Australia.
You may be aware that overuse of diagnostic imaging services has become a problem in Australia. Most people who present with musculoskeletal pain in the absence of worrying features do not need any imaging as it does not help management. Pain can improve rapidly; for example, around 50% of people who experience an episode of back pain will recover within 2 weeks …”
The letter’s data section presented each GP’s ordering figures from the prior year on the 11 MSK exams of concern.
It Pays to Send Twice and Highlight Key Sections
In the wake of the mailing, the researchers monitored MSK imaging orders placed by 3,055 GPs and by 764 controls who received no such intervention.
They found the letter led to a statistically significant reduction of about 10% in the overall rate of imaging requests per 1,000 consultations compared with control over 12 months: The letter recipients ordered 27.7 MSK exams while the controls ordered 30.4 (adjusted means).
In addition, O’Connor and co-authors report that:
- Audit and feedback produced statistically significant reductions in overall imaging requests over six and 18 months, as well as for most individual imaging tests over six, 12 and 18 months, compared with a control condition of no audit and feedback.
- A second round of feedback to GPs at 12 months led to a further modest statistically significant reduction in overall imaging requests over 18 months compared with once-only delivery.
- Enhanced display calling GPs’ attention to ordering rates greater than 80% of peers’ rates also resulted in further modest statistically significant reductions in overall imaging over 6 and 12 months but not 18 months. (The enhancements consisted of highlighting and formatting text for special emphasis.)
Checked Impulse to Order Low-Value Imaging: Fleeting or Here to Stay?
In their discussion the researchers note the unknowability of the intervention’s staying power.
“It is unclear to what extent the observed effect of audit and feedback will be maintained over time and whether one or more additional interventions will be needed to sustain the effect,” they write. “It is also not known whether audit and feedback interventions like that used in this study influence other related imaging behaviors or low-value care practices.”
O’Connor and co-authors call for future research to take up such questions while also testing other means of persuasion on heavy orderers of imaging.
US Observers: Audit and Feedback Interventions ‘Can Reduce Low-Value Care’
In invited commentary published alongside the study [2], Deborah Korenstein, MD, and Erin Gillespie, MD, of Memorial Sloan Kettering Cancer Center and Weill Cornell Medicine, remark the study “represents a rigorous and large-scale evaluation and suggests that use of an audit and feedback intervention targeting a specific clinician audience with a relatively nonspecific intervention can reduce low-value care, and contributes valuable insights to feedback design and implementation.”
More from Korenstein and Gillespie:
The observed 10% reduction in test ordering, while modest, could have significant benefit across a health system when delivered in areas where overuse of low-value care is frequent, although attention should be paid to patient outcomes.”
Dave P. has worked in journalism, marketing and public relations for more than 30 years, frequently concentrating on hospitals, healthcare technology and Catholic communications. He has also specialized in fundraising communications, ghostwriting for CEOs of local, national and global charities, nonprofits and foundations.