On the road from low to high-value care: Designing, implementing and evaluating a pilot intervention to reduce low-value imaging in Norway

Abstract

Background The use of diagnostic imaging that does not contribute to improving patient health may be considered low value. Such examinations may result in delays for appropriate care and constitute potential risks in terms of false positives/negatives, incidental findings of unclear significance, and adverse effects from pharmaceuticals when such are used. Consequently, the use of low-value imaging constitutes a risk to patient safety and represents poor use of common health resources. It is therefore important to reduce the use of low-value imaging in order to free resources that can then be allocated to high-value examinations. Aim The overall aim of this thesis was to gain knowledge about low-value radiological services and about how the use of such services can be reduced. This was done by identifying factors that influence the use of low-value imaging, and leveraging this knowledge in order to design, implement and evaluate a targeted pilot intervention for reducing specific low-value imaging examinations in private imaging centres in Norway. Methods This multi-method study used both quantitative and qualitative methods. The thesis is built upon three studies containing four papers. In addition, the pilot intervention was designed and implemented based on existing knowledge (including findings from Study 1 and Study 2) and stakeholder discussions. In Study 1, register data for all outpatient imaging examinations conducted in 2019 within the catchment area of Vestre Viken Hospital Trust (VVHT) was gathered from the Norwegian Health Economics Administration (HELFO) and directly obtained from private imaging centres. The data was analysed to assess the utilisation of imaging. Referrer identification codes were collected to enable the assessment of referral practice, and referrers with high referral rates were categorised into high and super-referrers. Access to imaging services was calculated by estimating the travel distance (kilometres and driving time in minutes) from the patient municipality centre to the nearest MRI facility, using Google Maps. The data was mainly analysed descriptively. Individual interviews were used for the collection of data on drivers for low-value imaging utilisation and suitable measures to reduce the use of low-value imaging in Norway (Study 2). There were 27 participants, consisting of radiologists, radiographers, managers, hospital clinicians, general practitioners (GPs) and government representatives. Framework analysis was used to analyse data. The pilot intervention was designed based on findings from Study 1 and Study 2, in addition to other relevant literature. The foundation for the design was discussed in several rounds with an expert panel and an advisory board. The imaging procedures assessed as candidates for targeting in the intervention were selected based on stakeholder perceptions on value, available guidelines, volume, resource utilisation and possibilities to make a change. The pilot intervention was evaluated in Study 3 by using individual interviews conducted with seven healthcare providers, including two radiologists, two radiographers, one manual therapist, one practice consultant and one GP. The data was analysed in line with qualitative content analysis with a deductive approach. Main findings The thesis demonstrated that 42% of all MRIs performed in the catchment area of VVHT were of the head, lower-back or knee, the use of which could potentially be recommended against in the Norwegian Choosing Wisely campaign. Although 2.3% of referrers were identified as high-referrers, referrers’ experience and access to imaging did not influence the use of potential low-value imaging. Factors contributing to the utilisation of low-value imaging in Norway were found across all levels of the healthcare system, working simultaneously and synergistically, and are categorised as organisational or individual drivers. Consequently, strategies to diminish the use of low-value imaging should be implemented across all levels of the healthcare service. This thesis underscores the fact that reducing low-value imaging in the Norwegian setting is a complex task. However, this thesis provides a specific example of how to design a context-sensitive, evidence-based intervention to reduce the use of low-value imaging. The intervention consisted of a standardised procedure for referral assessment, a standardised return letter to referrers and an information campaign. The pilot intervention was deemed to be feasible, acceptable and appropriate among relevant stakeholders. Implications On an overarching level, this thesis identified changes to three aspects that should be considered when aiming to reduce the use of low-value imaging in Norway: the healthcare system, the support systems for healthcare providers, and the behaviour of individual patients and healthcare providers.