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11 Oct 2019

BY DR RICHARD KIDD, CHAIR, AMA COUNCIL OF GENERAL PRACTICE

I recently attended a Department of Health presentation on reducing unnecessary diagnostic imaging requests. The purpose of the presentation was to run through the Department’s latest approach to changing provider behaviour. This presentation coming ahead of almost 4,000 of the top 20 per cent of diagnostic requesting GPs being sent a letter aimed at reducing diagnostic testing that may cause unintended harms including overdiagnosis and overtreatment.

As highlighted in a recent article in the Medical Journal of Australia, part of the solution in reducing overdiagnosis and its associated harms potentially lies in an enhanced awareness, particularly for referrers and their patients about the evidence for, and the consequences of, overdiagnosis and related overtreatment. Wiser Healthcare, as part of the National Action Plan to Prevent Overdiagnosis and Overtreatment in Australia, is conducting research to this end – its research informing the Department’s approach.

As presented, the evidence suggests that the majority of cases for low back pain imaging and specialist referral are unwarranted. With a quarter of patients in Australia who present to GPs with lower back pain receiving some form of imaging there is a need to look at the drivers and potential solutions in order to support appropriate care and cost-effective use of resources. Particularly, given only one to four per cent of patients presenting with lower back pain will have a spinal fracture, and less than one per cent will have some form of underlying malignancy.

The AMA is pleased to see that the Department appears to be taking more of nuanced and nudge approach with this exercise, as opposed to the seemingly more threatening approach they took last year with the opioid letter. An approach, that brought claims of unintended consequences, such as palliative care patients not receiving adequate pain relief as their GPs became fearful of being referred to the Professional Services Review if there was no change in their prescribing rates.

This time around, the Department has taken a more researched and GP tested approach as to how to encourage behavioural change were appropriate within the target group. The Department is looking at how it presents information to GPs to best inform them about their diagnostic imaging referrals and to highlight how they differ from their peers and in what specific areas. The Department also looking into its follow-up approach and what tools may be of assistance to GPs and their patients regarding when and for what conditions imaging is appropriate.

Effectively, the Department’s revised approach is an experiment to see what impact the process has in eliciting a change in diagnostic requesting behaviour. The outcomes from this latest letter to be monitored over the next year and a half, to determine if this approach is more effective in stimulating a reduction in unnecessary requesting.

The AMA is concerned that the metrics for determining the target group does not recognise that some GPs may have special interests in sports and musculoskeletal medicine. This was also a problem with the opioid letters which failed to recognise those practitioners providing palliative care. The AMA does not want to see a situation where patients are denied referrals where their presenting condition indicates it is the appropriate course of action. If this were to be the outcome it is likely not only to adversely impact patient outcomes but the costs associated with delayed diagnosis and treatment could be substantial.

Whether a letter is received or not it is always worthwhile for referrers to consider whether their referrals align with appropriate referral pathways and to assist patients in understanding why a referral at any time is warranted or not. As part of that process patients should of course understand the risks associated with any proposed diagnostic imaging, particularly in relation to repetitive exposure to ionising radiation. 

GPs, in deciding to request diagnostic imagining, need to look for any red flags that would signal the inappropriateness of a wait and see approach. GPs who receive a letter are encouraged to contact the Department with any questions or feedback, including suggestions on how you can be better supported with diagnostic imaging requesting.

While fear of missing a diagnosis and a desire to keep the patient happy can provide strong motivation for a diagnostic request, our duty of care to the patient, needs to be stronger. As per the AMA’s position statement on The Doctor’s Role in Stewardship of Health Care Resources, effective stewardship positively influences quality of care.

Resources are available to assist GPs with appropriate requesting. These include PHN Pathways, RANZCR’s Education Modules for Appropriate Imaging Referrals, and the WA Department of Health’s Diagnostic Imaging Pathways, which is also available via the AMA GP Desktop Toolkit.

Information that may be useful for patients can be found at Inside Radiology and includes the Australian Radiation Protection and Nuclear Safety Agency’s Guide For Medical Imaging.

The AMA will be watching with interest the impact of the Department’s latest experiment in behavioural science.


Published: 11 Oct 2019