Effect of Diagnostic Imaging Utilization Reports

Study Overview
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Brief Summary
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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.

Detailed Description
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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.

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

Conditions
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Diagnostic Imaging Utilization

Intervention / Treatment
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* Other: Usual QCNL DI utilization report
* Other: New DI utilization report
* Other: Detailing


Participation Criteria
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Eligibility Criteria
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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.
Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Health Services Research
Allocation: Randomized
Intervention Model: Factorial Assignment
Masking: Triple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Usual QCNL report group<br>Physicians receive the usual Quality of Care Newfoundland and Labrador utilization report: This reports ranks the physician on a figure of their peers according to the total number of tests ordered in a one-year period. | Other: Usual QCNL DI utilization report<br>* See arm descriptions.<br>|
| Experimental: Usual QCNL report plus detailing.<br>This group receives the usual QCNL report described above. Shortly after the reports are sent, this group will be contacted at least three times to attempt to arrange a single in-person detailing session. | Other: Usual QCNL DI utilization report<br>* See arm descriptions.<br>Other: Detailing<br>* 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.<br>|
| Experimental: New utilization report<br>This group will receive a new type of report that shows individual physician ordering per 100 patients compared to the mean of all physicians, adjusted for patient complexity (age, sex, comorbidity, education, income, rurality). | Other: New DI utilization report<br>* See arm descriptions.<br>|
| Experimental: New utilization report plus detailing<br>New type of report plus detailing as described above. | Other: New DI utilization report<br>* See arm descriptions.<br>Other: Detailing<br>* 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.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Combined CT, x-ray and ultrasound exam orders per patient | Number of DI tests ordered per patient seen | 1 year | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| 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 | 
| Uptake of detailing | Proportion of invited physicians who take part in a detailing session | 1 year | 
| CT exam orders per patient |  | 1 year | 
| X-ray exam orders per patient |  | 1 year | 
| Ultrasound exam orders per patient |  | 1 year | 
| Uptake of utilization reports | Proportion of physicians in report groups who open the link for the online report. | 1 year |