Title

Non-compliance with diagnostic imaging pathways: Can information-communication technology help?

Abstract

Background: An ‘on-line’ application called Diagnostic Imaging Pathways (DIP) was developed at Royal Perth Hospital (RPH), Western Australia. DIP is an evidence-based decision support tool designed to assist clinicians to request the most appropriate examinations to achieve a diagnosis. The application is accessed from the ‘desk-top’ and the Internet (www.imagingpathways.health.wa.gov.au). Clinicians at RPH are regularly alerted to the desirability of complying to DIP recommendations.

Purpose: To evaluate compliance between diagnostic imaging requests and recommendations in DIP.

Methods: Retrospective audits, followed by intervention and re-audits were carried out in the Emergency Department (ED). Pathways targeted were:

‘Suspected Pulmonary Embolism’

(http://www.imagingpathways.health.wa.gov.au/includes/DIPMenu/pe/chart.html),

‘Ankle Injury’

(http://www.imagingpathways.health.wa.gov.au/includes/DIPMenu/ankle/chart.html),

‘Suspected Renal Colic’

(http://www.imagingpathways.health.wa.gov.au/includes/DIPMenu/rencolic/chart.html) and

‘Non Traumatic Acute Abdominal Pain’

(http://www.imagingpathways.health.wa.gov.au/includes/DIPMenu/axr/Summary.html).

Interventions included education on DIP recommendations, request forms requiring proof of adherence to pathways, and refusal of inappropriate examinations.

Results: In the initial audits (N= 658), 285 (43%) received imaging of doubtful appropriateness whilst 158 (24%) received examinations without indications. Follow-up audits demonstrate only partial improvements in compliance. Requesters failed to follow Guidelines International Network (GIN)recommendations for many reasons including; insufficient time to learn about recommendations, disbelief in their validity, and not understanding the importance of adhering to recommendations. Requesters then provide inaccurate pre-requisite information or ‘pressurise’ providers to accept a request without pre-requisites. Providers fail in their ‘gatekeeper’ function because of insufficient time to 5th International conferencedeliver education, difficulty obtaining pre-requisite information, and reluctance to resist a demand.

Discussion: The easy availability and marketing of DIP did not eliminate inappropriate diagnostic imaging. Targeted interventions failed to eliminate non-compliance. In planning for electronic ordering linked to decision support, we need to investigate the extent to which information-communication technology can suppress inappropriate practice.

Keywords

Peer-reviewed

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