Diagnostic Imaging UtilizationNCT02917837
Effect of Diagnostic Imaging Utilization Reports
A study testing Usual QCNL DI utilization report, New DI utilization report and Detailing in people with Diagnostic Imaging Utilization, run by Memorial University of Newfoundland at 1 site in Canada.
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. Read more about this study
- Who is it for?
- Any ageHealthy volunteers can take part
- Conditions the study is for
- Diagnostic Imaging Utilization
- What is being tested?
- Usual QCNL DI utilization report, New DI utilization report and Detailing
- Could I receive a placebo?
- No, everyone receives an active treatment
- How many people
- 192 participants
- Where
- 1 siteCanada
- Study dates
- 15 Nov 2019to 31 Dec 2020
- Phase
- Interventional
- Are there results?
- None posted in the registry
Key requirements
Who can take part, as listed by the sponsor. Only the study team can confirm whether you are eligible, so take this list to your doctor.
- Ages Any age
- All sexes
- Healthy volunteers accepted
- Child, Adult, Older adult
Who may be able to join
- 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.
Who cannot join
- 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.
Trial locations and contacts
1 site in 1 country.
Canada1 site
Health Sciences Centre
St. John's, Newfoundland and Labrador, A1B3V6
About this study
Official title: Effect of a Diagnostic Imaging Utilization Report on Family Physician Ordering Practices in the Eastern Health Regional Health Authority, Newfoundland and Labrador
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.
Read the detailed 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.
- Conditions
- Diagnostic Imaging Utilization
- Being tested
- Usual QCNL DI utilization report, New DI utilization report, Detailing
What participants receive
What participants receive. In a randomised study each person is assigned to one group by chance.
Usual QCNL DI utilization reportOther
See arm descriptions.
New DI utilization reportOther
See arm descriptions.
DetailingOther
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.
| Study group | Role | What they receive |
|---|---|---|
| Usual QCNL report group | Active comparator | 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. Receives: Other: Usual QCNL DI utilization report |
| Usual QCNL report plus detailing. | Experimental | 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. Receives: Other: Usual QCNL DI utilization report; Other: Detailing |
| New utilization report | Experimental | 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). Receives: Other: New DI utilization report |
| New utilization report plus detailing | Experimental | New type of report plus detailing as described above. Receives: Other: New DI utilization report; Other: Detailing |
What is being measured
The primary outcome is the main question the study is designed to answer.
Combined CT, x-ray and ultrasound exam orders per patient
Number of DI tests ordered per patient seen
Measured: 1 year
Secondary outcomes (6)
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.
Measured: 1 year
Uptake of detailing
Proportion of invited physicians who take part in a detailing session
Measured: 1 year
CT exam orders per patient
Measured: 1 year
X-ray exam orders per patient
Measured: 1 year
Ultrasound exam orders per patient
Measured: 1 year
Uptake of utilization reports
Proportion of physicians in report groups who open the link for the online report.
Measured: 1 year
Timeline
From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.
- First posted28 Sep 2016 (estimated)
- Study start15 Nov 2019
- Primary completion31 Dec 2020
- Study completion31 Dec 2020
Resources
- Official record on ClinicalTrials.govThe registry entry this page is built from, with its full change history.
- Publications (10)Papers the sponsor has linked to this study.
- Other trials for Diagnostic Imaging UtilizationStudies of the same condition, open and under way.
- What the trial phases meanHow a treatment moves from first tests in people to approval.
More details
For doctors and researchers: how the study is designed, who runs it, and its registry IDs.
Study design
- Study type
- Interventional
- Phase
- Phase N/A
- Primary purpose
- Health services research
- Allocation
- Randomised
- Intervention model
- Factorial
- Masking
- Triple blind
- Who is masked
- Participant, Care provider, Outcomes assessor
- Enrolment
- 192 participants (actual)
Sponsor and investigators
- Lead sponsor
- Memorial University of Newfoundland
- Sponsor type
- University, hospital or other
- Collaborators
- NL SUPPORT Strategy for Patient-Oriented Research
- Responsible party
- Principal investigator, Kris Aubrey-Bassler, Memorial University of Newfoundland
- Investigators
- Kris Aubrey-Bassler, MD, CCFP(EM), Principal investigator, Primary Healthcare Research Unit, Memorial University
IDs, dates and publications
- ClinicalTrials.gov ID
- NCT02917837
- Sponsor's protocol ID
- NLSUPPORT-Aubrey
- Status last verified
- Oct 2021
- First submitted
- 23 Sep 2016
- Last updated
- 11 Oct 2021
- Results posted
- No
- Data monitoring committee
- No
- FDA-regulated drug
- No
- FDA-regulated device
- No
Publications
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.
PubMed 22679126Jain 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.
PubMed 21088636Goldzweig 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.
PubMed 25894025Jain 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.
PubMed 26260722Schwappach 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. doi: 10.1093/intqhc/mzg078.
PubMed 14660530Campbell 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.
PubMed 19625717Campbell S, Reeves D, Kontopantelis E, Middleton E, Sibbald B, Roland M. Quality of primary care in England with the introduction of pay for performance. N Engl J Med. 2007 Jul 12;357(2):181-90. doi: 10.1056/NEJMsr065990. No abstract available.
PubMed 17625132Michie 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. doi: 10.1136/qshc.2004.011155.
PubMed 15692000Charlson 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. doi: 10.1016/0021-9681(87)90171-8.
PubMed 3558716Klabunde 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. doi: 10.1097/01.mlr.0000223480.52713.b9.
PubMed 17001263
Study at a glance
From the registry record, last updated by the sponsor on 11 Oct 2021. Recruitment status is as the sponsor reported it: confirm with the study team.
- Official title
- Effect of a Diagnostic Imaging Utilization Report on Family Physician Ordering Practices in the Eastern Health Regional Health Authority, Newfoundland and Labrador
- ClinicalTrials.gov ID
- NCT02917837
- Acronym / sponsor ID
- NLSUPPORT-Aubrey
- Conditions
- Diagnostic Imaging Utilization
- Study type
- Interventional
- Recruitment status
- Completed
- Enrolment
- 192 participants (actual)
- Lead sponsor
- Memorial University of NewfoundlandUniversity, hospital or other
- Collaborators
- NL SUPPORT Strategy for Patient-Oriented Research
- Study start
- 15 Nov 2019 (actual)
- Primary completion
- 31 Dec 2020 (actual)
- Study completion
- 31 Dec 2020 (actual)
- First posted
- 28 Sep 2016 (estimated)
- Results
- Not posted in the source record
Clinical summary
The research question as the sponsor registered it. This describes what the study plans to test, not what it found.
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
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.
Study design
- Primary purpose
- Health services research
- Allocation
- Randomised
- Intervention model
- Factorial
- Masking
- Triple blind (participant, care provider, outcomes assessor)
- Number of arms
- 4
| Arm | Type | Receives |
|---|---|---|
| Usual QCNL report group | Active comparator | Other: Usual QCNL DI utilization reportPhysicians 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. |
| Usual QCNL report plus detailing. | Experimental | Other: Usual QCNL DI utilization report, Other: DetailingThis 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. |
| New utilization report | Experimental | Other: New DI utilization reportThis 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). |
| New utilization report plus detailing | Experimental | Other: New DI utilization report, Other: DetailingNew type of report plus detailing as described above. |
Who may qualify
- Sex
- All
- Healthy volunteers
- Accepted
- Age groups
- Child, Adult, Older adult
Key inclusion criteria (2 listed)
- 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.
Key exclusion criteria (1 listed)
- 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.
Eligibility is decided by the study team after screening; this overview does not establish that a patient qualifies. Full inclusion and exclusion criteria.
Interventions
| Intervention | Type | Arms |
|---|---|---|
| Usual QCNL DI utilization reportSee arm descriptions. | Other | Usual QCNL report group, Usual QCNL report plus detailing. |
| New DI utilization reportSee arm descriptions. | Other | New utilization report, New utilization report plus detailing |
| DetailingIn-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. | Other | New utilization report plus detailing, Usual QCNL report plus detailing. |
Primary outcome
Combined CT, x-ray and ultrasound exam orders per patient
Time frame: 1 year
Number of DI tests ordered per patient seen
6 secondary outcomes
Clinician subgroup Diagnostic imaging exam orders per patient
Time frame: 1 year
Uptake of detailing
Time frame: 1 year
CT exam orders per patient
Time frame: 1 year
X-ray exam orders per patient
Time frame: 1 year
Ultrasound exam orders per patient
Time frame: 1 year
Uptake of utilization reports
Time frame: 1 year
Results and safety
The study is completed, but results are not available in the source record. That does not mean the treatment did or did not work.
Research links
- Official record on ClinicalTrials.govLast updated by the sponsor 11 Oct 2021.
- Background: PubMed 22679126Mittal 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.
- Background: PubMed 21088636Jain 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.
- Background: PubMed 25894025Goldzweig 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.
- Background: PubMed 26260722Jain 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.
- Background: PubMed 14660530Schwappach 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. doi: 10.1093/intqhc/mzg078.
- Background: PubMed 19625717Campbell 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.
- Background: PubMed 17625132Campbell S, Reeves D, Kontopantelis E, Middleton E, Sibbald B, Roland M. Quality of primary care in England with the introduction of pay for performance. N Engl J Med. 2007 Jul 12;357(2):181-90. doi: 10.1056/NEJMsr065990. No abstract available.
- Background: PubMed 15692000Michie 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. doi: 10.1136/qshc.2004.011155.
- Background: PubMed 3558716Charlson 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. doi: 10.1016/0021-9681(87)90171-8.
- Background: PubMed 17001263Klabunde 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. doi: 10.1097/01.mlr.0000223480.52713.b9.
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Referral and contact
AzTrials does not enrol participants or take referrals. Contact the study team or a site listed below; they decide who can take part. This study is not recruiting at the moment.
Kris Aubrey-Bassler, MD, CCFP(EM) principal investigator
Primary Healthcare Research Unit, Memorial University
1 site in 1 country: see every site and its status.
Questions about this trial
What is this clinical trial studying?
A study testing Usual QCNL DI utilization report, New DI utilization report and Detailing in people with Diagnostic Imaging Utilization, run by Memorial University of Newfoundland at 1 site in Canada.
The full registered description is in the About this study section and the official record.
Who may be eligible to take part?
The sponsor lists 2 inclusion and 1 exclusion criteria. Eligibility is decided by the study team after screening, so read the full criteria and contact a listed site.
Is this clinical trial currently recruiting?
The record says: finished, as of the sponsor's last update on 11 Oct 2021. Status can change between updates, so confirm with the study contact before making plans.
Where is the study taking place?
The record lists 1 site in Canada. Whether a site is taking part right now should be confirmed with that site. See every site.
What are the possible benefits and risks?
They depend on the study and the treatment, and no study can promise a benefit. The study team explains the known risks during informed consent, before anyone joins; the record itself does not list them.
Are results available for this study?
The study is completed, but results are not available in the source record. That does not mean the treatment did or did not work.
How can a doctor refer a patient or contact the research team?
The record lists no contact. The official record names the sponsor, who can be asked directly. AzTrials does not enrol participants or take referrals.
What does the primary outcome measure?
Combined CT, x-ray and ultrasound exam orders per patient (time frame: 1 year). It is what the study was designed to measure, not a finding.
Where can I read the original study information?
On the ClinicalTrials.gov record for NCT02917837, which also lists 10 linked publications.
Does a listing mean the treatment is approved or proven to work?
No. A listing means the study is registered. It does not show that the treatment is safe, works, or is approved by a regulator.
How often is this information updated?
AzTrials copies changed records from ClinicalTrials.gov every night and reloads the whole registry every week. The sponsor last updated this record on 11 Oct 2021.