Appropriateness of general practitioner imaging requests for transient ischaemic attack patients: secondary analysis of a cluster randomised controlled trial
Annemarei Ranta 1 2 , Mark Weatherall 1 , John Gommans 3 , Murray Tilyard 4 , Des Odea 2 , Susan Dovey 41 Department of Medicine, University of Otago, Wellington, New Zealand
2 Department of Neurology, Capital & Coast District Health Board, New Zealand
3 Department of Medicine, Hawke’s Bay District Health Board, Hastings, New Zealand
4 Department of General Practice and Rural Health, University of Otago, Dunedin, New Zealand
Correspondence to: Dr Anna Ranta, Level 6, GNB, Wellington Regional Hospital, Private Bag 7902, Wellington South, New Zealand. Email: anna.ranta@otago.ac.nz
Journal of Primary Health Care 9(2) 131-135 https://doi.org/10.1071/HC17005
Published: 30 June 2017
Journal Compilation © Royal New Zealand College of General Practitioners 2017.
This is an open access article licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
Abstract
AIMS: Many transient ischaemic attack (TIA) patients receive initial assessments by general practitioners (GPs). In a randomised controlled trial (RCT) we showed that BPAC Inc. TIA/stroke electronic decision support (EDS) for GPs improves patient outcomes and guideline adherence. This secondary analysis assesses the impact of trial associated enhanced GP access to radiological investigation.
METHODS: Post-hoc analysis of a multi-centre, single blind, parallel group, cluster RCT comparing TIA/stroke EDS guided GP management with usual care to assess whether imaging requests and their appropriateness differed between study groups.
RESULTS: GPs requested 15/291 (5.2%) carotid ultrasounds and 19/291 (6.5%) computed tomography (CT) head scans. Scans were obtained more frequently in the intervention group (ultrasound cluster adjusted OR (95% CI) 1.41 (0.44 to 4.49), P = 0.56 and CT 13.8 (1.7 to 110.7), P < 0.001). All CTs were clinically appropriate. More ultrasounds were appropriate in the EDS group (cluster adjusted OR (95% CI) of 8.4 (0.39 to 92.3), P = 0.18). Overall investigation costs did not differ between groups (P = 0.83). Some apparent avoidable imaging duplication occurred where patients were subsequently assessed by secondary services.
CONCLUSION: In the setting of a RCT assessing GP electronic decision support, frequency of GP initiated imaging requests was low and largely appropriate especially in the setting of EDS use. Thus enhanced GP imaging access as part of the EDS tool did not result in inappropriate or excessive GP imaging requests. However, some duplication occurred and practitioners need to ensure that test referrals and results are adequately communicated between sectors.
KEYWORDS: Stroke; Transient Ischemic Attack; Electronic Decision Support; Health Service Research; Imaging
References
[1] Lasserson DS, Chandratheva A, Giles MF, et al. Influence of general practice opening hours on delay in seeking medical attention after transient ischaemic attack (TIA) and minor stroke: Prospective population based study. BMJ 2008; 337 a1569| Influence of general practice opening hours on delay in seeking medical attention after transient ischaemic attack (TIA) and minor stroke: Prospective population based study.Crossref | GoogleScholarGoogle Scholar |
[2] Ranta A, Cariga P. Who should manage transient ischemic attacks? A comparison between stroke experts, generalists, and electronic decision support N Z Med J 2013; 126 25–31.
[3] Ferro JM, Falcao I, Rodrigues G, et al. Diagnosis of transient ischemic attack by the nonneurologist. A validation study. Stroke 1996; 27 2225–9.
| Diagnosis of transient ischemic attack by the nonneurologist. A validation study.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaK2s7isVKitw%3D%3D&md5=d1f31d43e5f4aff24a398f8074a63b1aCAS |
[4] Lysdahl KB, Hofmann BM. What causes increasing and unnecessary use of radiological investigations? A survey of radiologists’ perceptions. BMC Health Serv Res 2009; 9 155
| What causes increasing and unnecessary use of radiological investigations? A survey of radiologists’ perceptions.Crossref | GoogleScholarGoogle Scholar |
[5] Ranta A, Dovey S, Weatherall M, et al. Efficacy and safety of a tia/stroke electronic support tool (fastest) trial: Study protocol. Implement Sci 2012; 7 107
| Efficacy and safety of a tia/stroke electronic support tool (fastest) trial: Study protocol.Crossref | GoogleScholarGoogle Scholar |
[6] Ranta A, Dovey S, Weatherall M, et al. Cluster randomised controlled trial of tia electronic decision support in primary care. Neurology 2015; 84 1545–51.
| Cluster randomised controlled trial of tia electronic decision support in primary care.Crossref | GoogleScholarGoogle Scholar |
[7] NZ Guideline Group. New Zealand clinical guidelines for stroke management 2010. www.nzgg.org.nz. 2010.
[8] Drummond MFSM, Torrance GW. Methods for the economic evaluation of health care programmes. London: Oxford University Press; 2005.
[9] Rothwell PM, Giles M, Chandratheva A, et al. Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (express study): A prospective population-based sequential comparison. Lancet 2007; 370 1432–42.
| Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (express study): A prospective population-based sequential comparison.Crossref | GoogleScholarGoogle Scholar |
[10] Ranta A, Barber PA. Transient ischemic attack service provision: A review of available service models. Neurology 2016; 86 947–53.
| Transient ischemic attack service provision: A review of available service models.Crossref | GoogleScholarGoogle Scholar |
[11] Lavallée PC, Meseguer E, Abboud H, et al. A transient ischaemic attack clinic with round-the-clock access (SOS-TIA): feasibility and effects. Lancet Neurol 2007; 6 953–60.
| A transient ischaemic attack clinic with round-the-clock access (SOS-TIA): feasibility and effects.Crossref | GoogleScholarGoogle Scholar |
