Targeting ‘super referrers’ a promising strategy for quashing low-value imaging
Targeting a select few “super referrers” may be promising strategy for addressing the use of unnecessary, wasteful imaging services, according to a new study.
Campaigns such as Choosing Wisely have sought to address such low-value exams, including certain MRIs of the head, lower back and knee. However, referrers have continued to order imaging that provides little to no benefit to the patient, experts wrote Feb. 6 in Insights into Imaging [1].
Researchers in Norway aimed to better understand these patterns, analyzing data from nearly 238,000 exams, performed across four public and two private imaging facilities. They found that about 42% of MRI exams in the study went against Choosing Wisely recommendations, with a small subset of super referrers (0.5%) making up 10% of that total.
“The identification of high- and super-referrers provides a valuable approach to addressing low-value care utilization,” Eivind Richter Andersen, with the Department of Health Sciences at the Norwegian University of Science and Technology in Gjøvik, Norway, and co-authors wrote. “Information about patient municipalities of residence and their use of radiological services also gives valuable insight into the relationship between healthcare utilization and accessibility,” they added.
For the study, Andersen et al. gathered 2019 data from the both Norwegian Health Economics Administration and directly from private imaging centers. “High referrers” were defined as those in the 95th percentile of ordering exams that do not meet Choosing Wisely guidelines, while super referrers fell in the 99th percentile.
Out of a total of 3,700, 2.3% were identified as high referrers, accounting for 33% of low-value exams. Private imaging centers also made up the lion’s share of such orders. The group of 86 high referrers skewed more male (59) and came from a variety of specialties. Those included general practitioners (47), those without a specialization (21), neurologists (12), orthopedic surgeons (3), and ear-nose and throat doctors (2). Most had more than a decade of experience, with little difference tied to the length of their tenure.
Meanwhile, the 17 super referrers each ordered 87 or more low-value exams in 2019. Most had more than 10 years of experience. They, too, were predominantly male (13) and included 10 general practitioners/docs without specialization, six neurologists and one orthopedist. All in this group worked in close proximity to an MRI scanner, typically located within 30 miles of their office.
“Interestingly, we found no differences in utilization in relation to travel distance, but a slightly higher MRI utilization per inhabitant was observed in the groups with longer travel distances,” the authors noted. “This may indicate that healthcare services fulfil the goal of providing equal healthcare to all citizens despite varying travel distances. Moreover, our findings demonstrate that people in rural areas are willing to travel for services, which is in line with other studies.”
Andersen et al. noted that reasons for the high rates could include time pressures, patient-related factors, unfamiliarity with guidelines and difficulties handling uncertainty. They suggested that possible interventions might include decision support tools, education, providing feedback to referrers, or creating handouts.
“Multi-component interventions that include education seem to be more effective than single-component interventions,” they advised.
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.