Family Practice Vol. 17, No. 1, 46-52
© Oxford University Press 2000
Influence of postal distribution of The Royal College of Radiologists' guidelines, together with feedback on radiological referral rates, on X-ray referrals from general practice: a randomized controlled trial
Department of General Practice and Primary Care, St George's Hospital Medical School, London SW17 0RE and
a Department of Diagnostic Radiology, St George's Hospital, London SW17 0QT.
Mrs Kerry.
Kerry S, Oakeshott P, Dundas D and Williams J. Influence of postal distribution of The Royal College of Radiologists' guidelines, together with feedback on radiological referral rates, on X-ray referrals from general practice: a randomized controlled trial. Family Practice 2000; 17: 46–52.
Received 20 September 1999; Accepted 6 October 1999.
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Abstract |
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 Top Abstract IntroductionMethodsResultsDiscussionAppendix 1Appendix 2Appendix 3References |
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Background. The Royal College of Radiologists (RCR) have produced regularly updated guidelines on radiological referrals since 1990. A small study in 1992 showed postal distribution of guidelines reduced general practitioners' referrals over the subsequent 9 weeks. However there have been no randomized trials of the longer term effects of radiological guidelines and feedback on referral rates on X-ray requests from primary care.
Objectives. To see if the introduction of radiological guidelines into general practices together with feedback on referral rates reduces the number of GP radiological requests over one year; and to explore GPs'attitudes to the guidelines.
Methods. Sixty-nine practices referring patients to St George's Healthcare Trust were randomly allocated to intervention or control groups. In February 1995 a GP version of the RCR guidelines was sent to each GP in the 33 practices in the intervention group. After 9 months intervention, practices were sent revised guidelines with individual feedback on the number of examinations requested in the past 6 months. The total number of requests per practice was compared for the year before and the year after the introduction of the guidelines. Control practices were sent the guidelines at the end of the study. All doctors were sent a questionnaire about the guidelines.
Results. A total of 43 778 radiological requests were made during the two years 1994–1996. In practices receiving the guidelines there was a 20% reduction in requests for spinal examinations compared with control practices (P < 0.05). This corresponded to the effect reported by GPs. There was also a 10% difference between the groups in the total number of requests made, but due to wide interpractice variation in referral rates this failed to reach statistical significance.
Conclusions. Introduction of radiological guidelines together with feedback on referral rates was effective in reducing the number of requests for spinal examinations over one year. Wider use of GP-orientated guidelines with regular updating and feedback might save costs and reduce unnecessary irradiation of patients.
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Introduction |
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TopAbstractIntroductionMethodsResultsDiscussionAppendix 1Appendix 2Appendix 3References |
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Effective implementation of guidelines in general practice often involves considerable participation from GPs in drawing up of the guidelines and attending teaching sessions.1–4 As the number of guideline topics which are relevant to GPs increases, it may be impractical to use such intensive methods. There is also conflicting evidence whether end user involvement in drawing up guidelines improves their implementation.2
The Royal College of Radiologists (RCR) first produced guidelines for radiological referral in 19905 and subsequently updated them in 1993, 1995 and 1998. However a survey published in 1996 showed that 17% of GPs had not heard of these guidelines and a greater number did not use them regularly.6 We chose a simple, postal distribution of a locally produced version of the RCR guidelines and used routinely collected hospital data on GPs' radiological requests. A previous small study of the introduction of GP X-ray guidelines had shown some changes in referrals over a brief 9 week follow-up period.7 Our aims were to see if introduction of guidelines together with feedback on radiological referral rates was effective in reducing GPs' radiological referrals over one year, and to use a postal questionnaire to explore doctors' attitudes to the guidelines.
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Methods |
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TopAbstractIntroductionMethodsResultsDiscussionAppendix 1Appendix 2Appendix 3References |
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All 69 practices (175 doctors) referring more than 50 patients in a six month period (1.6.93–30.11.93) to St George's Healthcare Trust for diagnostic radiology were included in the study. Practices were randomly allocated to an intervention or a control group using a stratified randomization. Ten strata were defined using number of partners (1 or 2, 3 or more), referral rates (>100 or
100 in six months), fundholding status and having received guidelines in a previous study.7 Thirty-three practices were randomly allocated to the intervention group and 36 to the control group. The 1993 RCR guidelines were 73 pages long and contained much that was not relevant to general practice. We selected guidelines for examination of chest, hips, knees, spine, skull and sinuses and printed these verbatim on two sides of a sheet of A4 paper which was then laminated. These guidelines were sent with a covering letter to all 91 doctors in the intervention group in February 1995 (Appendix 1).
In September 1995 we sent these doctors a questionnaire about the guidelines (Appendix 2). We revised our guidelines in the light of their responses and of new national guidelines published in 1995. In November 1995 we redistributed these to intervention practices accompanied by individual feedback on their referral rates. The feedback compared the number and type of X-rays the practice had requested in the two six month periods: February to August 1995 and the same months in 1994. This information was obtained from computerized data on all patients referred to St George's Healthcare Trust for diagnostic radiology. We also included a graph of the average radiation dose for different examinations (Appendix 3). At the end of the study we sent guidelines to all doctors in the control group followed by the questionnaire three weeks later.
Statistical analysis
For each practice the number of requests before and after the introduction of the guidelines were compared by calculating the ratio of the number of requests in the year after the introduction of the guidelines (1.2.95 to 31.1.96) to the number of requests the year before the guidelines were introduced (1.2.94 to 31.1.95).8 The mean percentage reduction for intervention and control groups was calculated weighting9 for the number of X-rays in the year before the guidelines were introduced, and confidence intervals calculated using the t-distribution. The percentage reduction in the intervention and control groups were compared using a t-test. In this way the percentage reduction is the same as the reduction calculated from the total numbers in each group but the confidence intervals allow for randomization by practice rather than patient. Practices making large numbers of requests are therefore given more weight.
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Results |
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TopAbstractIntroductionMethodsResultsDiscussionAppendix 1Appendix 2Appendix 3References |
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Number of radiological requests
Table 1
shows the number of referrals made in each of the main types of examination during the study year (1/2/95 to 31/1/96) and the previous year. The number of referrals for all spinal examinations fell by 18% in the intervention group compared with a 2% rise in the control group (P < 0.05). Fifty-six per cent of these requests were for examination of the lumbar spine. Taking requests for the lumbar spine alone, there was a reduction of 15% in the intervention group compared with a rise of 5% in the control group, giving a difference of 20% between the groups (95% CI 3–37). Overall an 8% reduction in total numbers of radiological requests was observed in the intervention group compared with a 2% increase in the control group, giving a difference of 10% between the two groups, but this did not achieve statistical significance.
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Questionnaire
A total of 108 GPs replied to the questionnaire (57 intervention, 51 control) giving a response rate of 60%. Ninety-two per cent of GPs could remember receiving the guidelines and 88% found them easy to use. Seventy-seven per cent of the GPs thought the guidelines had changed their clinical practice (Table 2
). Where a reason was given, this was usually that they thought they were referring fewer patients for X-ray.
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Table 3
gives the guidelines which GPs considered the most/least helpful.
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Thirty GPs specifically stated that the spine guidelines were the most useful with another 13 mentioning the "six-week rule". This applies to clinical situations such as backache or hip pain where the problem often resolves with time, and radiology is recommended if symptoms are still a problem after six weeks.
Table 4 gives the factors which GPs gave which might make them ignore the guidelines. The most common reason given was pressure from patients. Some GPs commented that this is increasing.
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionAppendix 1Appendix 2Appendix 3References |
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This is the first randomized controlled trial of the effect of the RCR guidelines plus feedback on GPs' radiological referrals over one year. The 20% reduction in referrals for lumbar spine examinations is particularly important in view of the high radiation dose. Since most of the guidelines are negative indicating when a radiological examination is not appropriate,5,10 any influence of the guidelines is likely to reduce the number of requests made. The overall reduction of 10% in number of requests, although not statistically significant, is comparable to the 13% observed reduction in the Royal College of Radiologists' audit of GP referrals.10 Our study was of similar size but was a randomized trial and the analysis took into account the large variation in referral rates both between practices and from year to year.
The study design also avoided a common problem with guideline intervention trials, that of volunteer bias, where practices have to be actively involved in the study and only the enthusiasts may agree to take part. This may bias the results in favour of the intervention when compared to routine introduction of guidelines to an unselected group of doctors. In this study these effects were minimized by randomizing all referring practices and using routinely collected data to assess the impact of the guidelines.
The RCR study was much more intensive, involving the setting up of a committee to oversee the introduction of the guidelines and meeting with all the large practices. In contrast, our intervention was designed to be low cost and one that could be implemented with few extra resources. In both studies the number of X-rays requested was used as the main outcome measure but with the caveat that this does not necessarily reflect the quality of individual decision making. In addition, both studies included feedback and reminders which may reinforce guideline interventions.
Barriers to implementing the guidelines came mainly from pressure from patients to refer for X-ray. Most guideline implementation studies have concentrated on educating the health professionals involved and have largely ignored patient groups. In future guideline implementation strategies may need to involve patient education as well.
This study shows that postal distribution of a locally produced version of national radiological guidelines with feedback on referral rates was associated with a significant reduction in referrals for spinal examinations. This corresponded with the effect reported by doctors. Wider use of GP-orientated guidelines with regular updating and feedback might save costs and reduce unnecessary irradiation of patients.
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Appendix 1 |
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TopAbstractIntroductionMethodsResultsDiscussionAppendix 1Appendix 2Appendix 3References |
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Appendix 2 |
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TopAbstractIntroductionMethodsResultsDiscussionAppendix 1Appendix 2Appendix 3References |
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Appendix 3 |
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TopAbstractIntroductionMethodsResultsDiscussionAppendix 1Appendix 2Appendix 3References |
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Acknowledgments |
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This study was funded by The South Thames Project Grant Scheme
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References |
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TopAbstractIntroductionMethodsResultsDiscussionAppendix 1Appendix 2Appendix 3References |
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2 Implementing clinical practice guidelines: can guidelines be used to improve clinical practice? Effective Health Care 1994; 8: 1–12.
3
Thomson R, Lavender M, Madhok R. How to ensure that guidelines are effective. Br Med J 1995; 311: 237–242.
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Grimshaw JM, Russell IT. Achieving health gain through clinical guidelines II: Ensuring guidelines change medical practice. Qual Health Care 1994; 3: 45–52.
5 Royal College of Radiologists. Making Best Use of a Department of Clinical Radiology. Guidelines for Doctors. London: RCR, 1990.
6 Newton J, Knight D, Woolhead G. General practitioner and clinical guidelines: a survey of knowledge, use and beliefs. Br J Gen Pract 1996; 46: 513–517.[Web of Science][Medline]
7 Oakeshott P, Kerry SM, Williams JE. Randomised controlled trial of the effect of the Royal College of Radiologists' guidelines on general practioners' referrals for radiographic examination. Br J Gen Pract 1994; 44: 197–200.[Web of Science][Medline]
8
Kerry SM, Bland JM. Analysis of a trial randomised in clusters. Br Med J 1998; 316: 54.
9
Bland JM, Kerry SM. Weighted comparison of means. Br Med J 1998; 316: 129.
10 Influence of the Royal College of Radiologists' guidelines on referral from general practice. Royal College of Radiologists' Working Party. Br Med J 1993; 306: 110–111.
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