Guidelines, training and quality assurance: influence on general practitioner MRI referral quality
Stephen Kara 1 7 , Alexandra Smart 1 , Tara Officer 2 , Chan Dassanayake 3 , Phil Clark 4 , Amy Smit 5 , Alana Cavadino 61 ProCare PHO, Level 2/110 Stanley St, Grafton, Auckland 1143, New Zealand
2 Health Services Research Centre, Victoria University of Wellington 6140, New Zealand
3 Karori Medical Centre, 11 Parkvale Rd, Karori, Wellington 6012, New Zealand
4 Mercy Radiology, 98 Mountain Rd, Epsom, Auckland 1149, New Zealand
5 School of Medical and Health Sciences, University of Auckland, Auckland 1142, New Zealand
6 Section of Epidemiology and Biostatistics, School of Population Health, University of Auckland, Auckland 1142, New Zealand
7 Corresponding author. Email: Stephen.kara@procare.co.nz
Journal of Primary Health Care 11(3) 235-242 https://doi.org/10.1071/HC19034
Published: 30 September 2019
Journal Compilation © Royal New Zealand College of General Practitioners 2019 This is an open access article licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License
Abstract
INTRODUCTION: Magnetic resonance imaging (MRI) is an accurate diagnostic test used mainly in secondary care. Uncertainty exists regarding the ability of general practitioners (GPs) to use direct access high-tech imaging pathways appropriately when managing musculoskeletal injury.
AIM: To evaluate the use of primary care-centric guidelines, training and quality assurance on the appropriateness of GP MRI referrals for patients with selected musculoskeletal injuries.
METHODS: This is an 18-month primary care retrospective study. GPs participated in clinical musculoskeletal training, enabling patient referral for MRI on four body sites. Two reviewers categorised referral appropriateness independently, and reviewer inter-rater agreement between categorisations was measured. MRI results and patient management pathways were described. Associations of scan status and patient management were examined using logistic regression.
RESULTS: In total, 273 GPs from 72 practices attended training sessions to receive MRI referral accreditation. Of these, 150 (55%) GPs requested 550 MRI scans, with 527 (96%) eligible for analysis, resulting in 86% considered appropriate; 79% consistent with guidelines and 7% clinically useful but for conditions outside of guidelines. Inter-rater agreement was 75%. Cohen’s weighted kappa statistic was 0.38 (95% CI: 0.28–0.48). MRI referrals consistent with guidelines were more likely to show pathology requiring specialist intervention (reviewer 1: odds ratio = 2.64, 95% CI 1.51–4.62; reviewer 2: odds ratio = 4.44, 95% CI 2.47–7.99), compared to scan requests graded not consistent.
DISCUSSION: Study findings indicate GPs use decision support guidance well, and this has resulted in appropriate MRI referrals and higher specialist intervention rates for selected conditions.
KEYWORDS: General practitioner; magnetic resonance imaging; direct access; guidelines; training; quality assurance
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