Reducing low-value radiological services in Norway -a qualitative multi-professional study on measures and facilitators for change

Assessing MRI referrals' appropriateness for low back pain post a radiology-initiated intervention

INTRODUCTION

This study evaluated a pilot intervention to reduce low-value Magnetic Resonance Imaging (MRI) referrals for Low Back Pain (LBP).

METHODS

This before-after intervention study analysed MRI referrals for LBP at two private imaging centres in Norway. MRI referrals for LBP obtained before and after an intervention of information campaigns and sending a return letter to clinicians for declined referrals were evaluated on information, quality, and justification rates. Four radiologists and two radiographers assessed the referrals. A point system was used to calculate referral quality. Each referral was given a score 'good' when rated above 5.5 and 'poor' below 2.5. Justification was based on assessors categorised rating as justified, unjustified or need more information. Stata Statistical Software (Release 18) was used for analysis. A mixed model analysed variations of the referrals pre- and post-intervention. A p-value of <.05 in variations was considered statistically significant.

RESULTS

A total n = 300 patients' referrals (150 referrals pre- and post-intervention) were collected and assessed. Post-intervention, 68% of referrals were justified, up from 63% pre-intervention. The assessment showed a 4% decrease in referrals with poor scores and a 2% increase in those rated as good or intermediate quality post-intervention. These changes were not statistically significant.

CONCLUSION

It is important to state that it was not possible in our study to identify the subgroup of referrals that are known to be from clinicians who had received a return letter, although the information campaign targeted all referrers. Despite the limitations our findings suggest that providing reasons for declined referrals can serve as an educational tool for clinicians and contribute to the reduction of low value MRI for LBP.

IMPLICATIONS FOR PRACTICE

Radiology department initiatives that raise awareness and offer referral criteria guidance to clinicians can serve as valuable educational tools, and further emphasize the importance of providing comprehensive information in MRI referrals for LBP.

Norwegian general practitioners' and radiologists' perspectives on the referral, justification, and unnecessary imaging-a survey

AIM

This study aimed to survey general practitioners' (GPs) and radiologists' perspectives on referrals, imaging justification, and unnecessary imaging in Norway.

MATERIALS AND METHODS

The survey covered access to imaging, responsibilities, attitudes toward justification assessment, referral process, and demographics using multiple choice questions, statements to report agreement with using the Likert scale and one open question.

RESULTS

Forty radiologists and 58 GPs attending national conferences completed a web-based survey, with a 20/15% response rate, respectively. Both radiologists (97%) and GPs (100%) considered avoiding unnecessary examinations essential to their role in the healthcare service. Still, 91% of GPs admitted that they referred to imaging they thought was not helpful, while about 60% of the radiologists agreed that unnecessary imaging was conducted in their workplace. GPs reported pressure from patients and patients having private insurance as the most common reasons for doing unnecessary examinations. In contrast, radiologists reported a lack of clinical information and the inability to discuss patient cases with the GPs as the most common reasons.

CONCLUSION

This study adds to our understanding of radiologists' and GPs' perspectives on unnecessary imaging and referrals. Better guidelines and, even more importantly, better communication between the referrer and the radiologist are needed. Addressing these issues can reduce unnecessary imaging and improve the quality and safety of care.

Sustainability in healthcare by reducing low-value imaging - A narrative review

OBJECTIVES

This narrative review aims to present the concept of value in imaging and explore why we conduct low-value procedures, how to reduce this wasteful use, and what we could gain from reducing low-value imaging.

KEY FINDINGS

Imaging of low value to the patient contributes to thousands of metric tons of CO2 emissions, costing several billion US dollars annually. With a 20% reduction in low-value imaging, we would reduce the waste of resources related to 7.2 million procedures and, at the same time, reduce the risk of incidentalomas, overdiagnosis, and overtreatment and reduce wait times for patients in need of imaging services of high value. Multi-component initiatives targeting barriers in all levels of society and healthcare are needed to reduce low-value imaging. Radiographers are key actors in medical imaging and can make substantial contributions to this effort by, together with the radiologists, referrers, and managers, ensuring that all imaging procedures conducted are sustainable along four dimensions of sustainability: value, cost, risk, and environment.

CONCLUSION

Efforts to secure sustainable imaging considering the four crucial dimensions (value, cost, radiation, and environment) should be made at all levels of society and healthcare, from governmental management to the individual healthcare worker. Radiographers are vital in obtaining sustainability to ensure only sustainable imaging procedures are conducted.

IMPLICATIONS FOR PRACTICE

When assessing the appropriateness of imaging procedures, we need to consider the environment, safety, effectiveness, and efficiency. To obtain this, we need a collective and coordinated effort locally, nationally, and internationally to deliver sustainable imaging services.

Variations in wait times for imaging services: a register-based study of self-reported wait times for specific examinations in Norway

BACKGROUND

While the number of medical images has increased substantially, the demand has outpaced access, resulting in long wait times in many countries. Long wait times are a key problem for patient safety and quality of care as they can result in prolonged suffering, delayed diagnosis and treatment, as well as poorer prognosis and loss of lives. Surprisingly, little is known about wait times for imaging services.

OBJECTIVE

Investigate wait times for specific imaging services in Norway and to compare wait times with the total number of examinations and their development over time.

METHODS

Data from the wait time registry at the Norwegian Directorate of Health from 2018 to 2021 as well as data on outpatient imaging provided by the Norwegian Health Economics Administration (HELFO) and in-patient data afforded by fourteen hospital trusts and hospitals in Norway were analysed. Data include the total number of imaging examinations according to the Norwegian Classification of Radiological Procedures (NCRP). Analyses were performed with descriptive statistics.

RESULTS

Wait times vary through the months of the year. Conventional X-ray (XR) had the shortest wait times (3.0-4.4 weeks), and Magnetic Resonance Imaging (MRI) and ultrasound (US) had the lengthiest (8.7-12.0 and 7.9-11.4 weeks respectively). The wait times were lengthiest during the summer and winter holidays. Variations in wait times were also found for specific examination types between Norway's four public health regions. In addition, there was variation over time within the health regions. The wait times with the private health providers were substantially lower than with the public health providers. From 2018 to 2021, the wait time for MRIs increased by 6.6%, while the number of examinations (per 10,000) increased by 8.6%. Those regions with the highest number of examinations per 1,000 inhabitants per year had the lowest wait times.

CONCLUSION

Wait times for diagnostic imaging procedures varied with time, region, and modality in Norway from 2018 to 2021. Long wait times may entail many negative consequences for patients, professionals, and the healthcare system. Reducing long wait times is an obvious way to improve the quality, safety, and efficiency of care.

Drivers for low-value imaging: a qualitative study of stakeholders' perspectives in Norway

BACKGROUND

One kind of overutilization of diagnostic imaging is low-value imaging, i.e., imaging that does not lead to altered clinical pathways or improved health outcomes. Despite having well-documented extension and consequences, low-value imaging is still widespread. The objective of this study was to identify the drivers for the use of low-value imaging in the Norwegian healthcare services.

METHODS

We conducted individual, semi-structured interviews among representatives from the health authorities, general practitioners, specialists working in hospitals, radiologists, radiographers, and managers of imaging departments. Data analysis was carried out in line with framework analysis consisting of five steps: Familiarization, indexing, charting, mapping, and interpretation.

RESULTS

The analysis included 27 participants and resulted in two themes. The stakeholders identified drivers in the healthcare system and in the interaction between radiologists, referrers, and patients. The identified drivers were categorized in sub-themes, such as organization, communication, competence, expectations, defensive medicine, roles and responsibilities, and referral quality and time constraints. The drivers interact with each other and may strengthen the effect of other drivers.

CONCLUSIONS

Several drivers for low-value imaging in Norway were identified at all levels of the healthcare system. The drivers work simultaneously and synergistically. To free resources for high-value imaging, drivers should be targeted by appropriate measures at several levels to reduce low-value imaging.

Patient requests for radiological services: An Australian study of patient agency and the impact of online health information

ISSUE ADDRESSED

The Internet has been instrumental in patients' knowledge about health and medicine through increasing consultation of online sources that advocate self-management. For example, those patients who request referrals from their doctors for tests and procedures in radiology. Such patient-initiated referral requests can devolutionise the traditional model of health care. This study aimed to understand individuals who sought online health information (OHI) and whether requests for radiological referrals were the result of OHI seeking.

METHODS

The individuals targeted were those who have had a radiological procedure in the past 5 years. Using an online survey tool, individuals completed a 20-min anonymous survey. Included in the survey was a validated digital health literacy measurement scale, eHEALS.

RESULTS

Those who scored higher on the eHEALS measure were likely to be under 55 years of age and were more inclined to request radiological referrals. Though they were not concerned with the credibility of sourced websites, most secured the desired outcome from their requests.

CONCLUSION

Overall, this study indicates that patients are consulting online sites for health information, and individuals with higher digital literacy scores are asking doctors for referrals for radiological tests and procedures. These findings confirm our anecdotal experience in radiology departments. So what?: In conducting this study, we hope to better inform radiology and other health practitioners of the way OHI is impacting clinical practice.