Effect of Diagnostic Imaging Utilization Reports

Diagnostic Imaging Utilization Clinical Trial

Official title:

Effect of a Diagnostic Imaging Utilization Report on Family Physician Ordering Practices in the Eastern Health Regional Health Authority, Newfoundland and Labrador

Clinical Trial Details — Status: Completed

Administrative data

• NCT number: NCT02917837
• Other study ID #: NLSUPPORT-Aubrey
• Status: Completed
• Phase: N/A
• Start date: November 15, 2019
• Est. completion date: December 31, 2020

Study information

• Verified date: October 2021
• Source: Memorial University of Newfoundland
• Contact: n/a
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

Diagnostic imaging (DI) tests (for example, x-ray tests, ultrasounds, CT scans, or MRIs) are used by health care providers to help diagnose patient illness, but decisions regarding when these tests should be ordered are subjective. As a result, some physicians order these tests more than others. Ordering rates between clinicians seeing similar kinds of patients have been shown to be considerably different, suggesting that many of the tests are unnecessary. DI currently accounts for about 6.6% of Canadian hospital budgets, but this percentage may be much higher in Newfoundland where test ordering rates are almost twice the national average. However, cost is not the only concern. Over-testing can lead to further unnecessary testing to follow-up on harmless findings, and in the case of CT, large doses of potentially harmful radiation. We suspect that many clinicians are not aware that they order more DI tests than their peers. We will therefore develop a "report card" for family physicians in the province that shows them how many tests they are ordering compared to other physicians in the region. We expect that physicians who are over-ordering DI tests will reduce the number of tests they order after receiving their report cards. This is a low-cost way to potentially prevent expensive over-ordering of DI tests that can easily be implemented in the province's other health regions and elsewhere. The Quality of Care Newfoundland and Labrador (QCNL) organization in the province currently provides feedback reports and in-person detailing sessions to physicians, but the effectiveness of these interventions has not been studied.

Description:

The purpose of this trial is to compare the effectiveness of two versions of a DI utilization feedback report for family physicians, and determine whether in-person detailing sessions offer additional benefit in changing ordering practices. Group practices (i.e. all physicians practicing at the same address) of family physicians and general practitioners will be stratified by community of practice within Eastern Health, then randomized into one of four groups: 1. A usual QCNL feedback report alone, 2. A usual QCNL feedback report plus in-person detailing, 3. A new feedback report alone, 4. A new feedback report plus in-person detailing. Communities with fewer than five physicians will be grouped with similar communities for stratified randomization purposes.

Physicians will be provided a semi-annual (every 6 months) report card outlining the number of CT scans, ultrasounds and plain x-rays they ordered per 100 patients for whom they were the primary provider. We will assume that the primary provider is the most frequent biller of primary care services. Participants will receive a link to the report card via email from the Newfoundland and Labrador Medical Association (NLMA) by a two-step process: The initial email gives a brief description of the report and contains a link which then redirects the clinician to a secure web page that displays the individual clinician diagnostic imaging utilization in a prior one year period compared to the aggregate of their peers in the same region. Physicians in the detailing groups will be contacted to arrange a single in-person session with one of their colleagues to discuss the detailing reports.

Recruitment information / eligibility

• Status: Completed
• Enrollment: 192
• Est. completion date: December 31, 2020
• Est. primary completion date: December 31, 2020
• Accepts healthy volunteers: Accepts Healthy Volunteers
• Gender: All
• Age group: N/A and older

Eligibility

There are no restrictions on the age of participants.

Inclusion Criteria:

• 1) All family physicians or general practitioners practicing within Eastern Health. In order to obtain an accurate assessment of the report in real-world implementation, we are requesting the right to enroll everyone who meets the inclusion criteria, and to waive the requirement to obtain informed consent

• 2) Be the most frequent provider of primary care billings for a minimum of 20 patients during the period.

Exclusion Criteria:

• 1) Physicians who will be within the Eastern Health network for a relatively short period, e.g. clinicians engaged in an exchange program for training, or locums.

Related Conditions & MeSH terms

• Diagnostic Imaging Utilization

Intervention

Other:
• Usual QCNL DI utilization report
See arm descriptions.
• New DI utilization report
See arm descriptions.
• Detailing
In-person detailing, usually with a small group of family physicians and a peer (physician) facilitator to discuss the topic over a 30-60 minute period.

Locations

Country	Name	City	State
Canada	Health Sciences Centre	Saint John's	Newfoundland and Labrador

Sponsors (2)

Lead Sponsor	Collaborator
Memorial University of Newfoundland	NL SUPPORT Strategy for Patient-Oriented Research

Country where clinical trial is conducted

Canada, 

References & Publications (10)

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Campbell SM, Reeves D, Kontopantelis E, Sibbald B, Roland M. Effects of pay for performance on the quality of primary care in England. N Engl J Med. 2009 Jul 23;361(4):368-78. doi: 10.1056/NEJMsa0807651. — View Citation

Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373-83. — View Citation

Goldzweig CL, Orshansky G, Paige NM, Miake-Lye IM, Beroes JM, Ewing BA, Shekelle PG. Electronic health record-based interventions for improving appropriate diagnostic imaging: a systematic review and meta-analysis. Ann Intern Med. 2015 Apr 21;162(8):557-65. doi: 10.7326/M14-2600. Review. — View Citation

Jain S, Elon LK, Johnson BA, Frank G, Deguzman M. Physician practice variation in the pediatric emergency department and its impact on resource use and quality of care. Pediatr Emerg Care. 2010 Dec;26(12):902-8. doi: 10.1097/PEC.0b013e3181fe9108. — View Citation

Jain S, Frank G, McCormick K, Wu B, Johnson BA. Impact of Physician Scorecards on Emergency Department Resource Use, Quality, and Efficiency. Pediatrics. 2015 Sep;136(3):e670-9. doi: 10.1542/peds.2014-2363. Epub 2015 Aug 10. — View Citation

Klabunde CN, Harlan LC, Warren JL. Data sources for measuring comorbidity: a comparison of hospital records and medicare claims for cancer patients. Med Care. 2006 Oct;44(10):921-8. — View Citation

Michie S, Johnston M, Abraham C, Lawton R, Parker D, Walker A; "Psychological Theory" Group. Making psychological theory useful for implementing evidence based practice: a consensus approach. Qual Saf Health Care. 2005 Feb;14(1):26-33. — View Citation

Mittal MK, Zorc JJ, Garcia-Espana JF, Shaw KN. An assessment of clinical performance measures for pediatric emergency physicians. Am J Med Qual. 2013 Jan-Feb;28(1):33-9. doi: 10.1177/1062860612443849. Epub 2012 Jun 7. — View Citation

Schwappach DL, Blaudszun A, Conen D, Ebner H, Eichler K, Hochreutener MA. 'Emerge': Benchmarking of clinical performance and patients' experiences with emergency care in Switzerland. Int J Qual Health Care. 2003 Dec;15(6):473-85. — View Citation

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Combined CT, x-ray and ultrasound exam orders per patient	Number of DI tests ordered per patient seen	1 year
Secondary	Clinician subgroup Diagnostic imaging exam orders per patient	Clinicians will be divided into high and low test ordering subgroups (based on pre-intervention ordering practices). The primary outcome will be measured in these subgroups as a secondary outcome.	1 year
Secondary	Uptake of detailing	Proportion of invited physicians who take part in a detailing session	1 year
Secondary	CT exam orders per patient		1 year
Secondary	X-ray exam orders per patient		1 year
Secondary	Ultrasound exam orders per patient		1 year
Secondary	Uptake of utilization reports	Proportion of physicians in report groups who open the link for the online report.	1 year