Implementation of a multicomponent intervention including clinical decision support (CDS), e-course and feedback to improve general practitioners' radiology referrals: a feasibility study and study protocol

Abstract

Introduction: Overuse of high-cost imaging like MRI and CT scans is a growing concern, with 4-100% of examinations deemed of low value. This contributes to unnecessary healthcare costs and patient risks such as overdiagnosis. Norwegian general practitioners (GPs) demonstrate variable referral practices, with many referrals being inconsistent with guidelines. The study aimed to evaluate the feasibility and usability of 'VeRaVest,' a multicomponent intervention targeting improved radiology referral practices among GPs in Western Norway.

Methods: The intervention combined three elements: (1) referral guidelines integrated into electronic systems, (2) group-based courses on guideline compliance using quality improvement principles and (3) a web-based feedback system. The study was conducted with 139 GPs recruited in two cohorts in 2023, evaluated using a step-wedge design. Data sources included qualitative feedback from GPs and quantitative measures like referral completion rates. Participants' referral data were anonymised and analysed using a PACS/RIS (Pictures Archive and Communications System/Radiology Information System) system.

Results: Preliminary results indicate high GP satisfaction with the intervention. About 76% of participants reported changes in referral practices, including improved indication assessments, better referral descriptions and enhanced patient communication. GPs emphasised the importance of accessible guidelines, peer-based learning and actionable feedback. Integration of decision support tools and guideline-based training was pivotal in aligning practices with national standards.

Discussion: The multicomponent VeRaVest intervention demonstrated feasibility and potential to reduce low-value imaging practices. Success hinged on embedding guidelines into workflows, fostering peer engagement and ensuring practical relevance. Future evaluations will focus on quantitative outcomes, including referral rates and quality. Findings suggest scalability to other healthcare settings and regions.

Keywords: Clinical practice guidelines; Diagnostic Imaging; General practice; Implementation science.

Figure 1. Screenshot of the referral system (DIPS Interactor) with decision support.

Figure 2. Screenshot of the website for feedback. The upper section is a run chart showing the number of referrals per month and per 100 patients on the patient list compared with your colleges. The next section is a list of your most frequent referring examinations (eg, X-ray of thorax). The third row is the number of referrals for a chosen period of time. The lower section is your top 10 referrals compared with your colleges.

Figure 3. Participating general practitioners’ evaluation of the course.

Figure 4. Participating general practitioners’ own statements of changes in practice after implementing the new implementation bundle.