GP strategies to avoid imaging overuse. A qualitative study in Norwegian general practice

Abstract

Objectives The aim of the study was to identify general practitioners’ (GPs) strategies to avoid unnecessary diagnostic imaging when encountering patients with such expectations and to explore how patients experience these strategies. Design, setting and subjects We conducted a qualitative study that combined observations of consultations and interviews with GPs and patients. A total of 24 patients visiting nine different GPs in two Norwegian urban areas were included in the study. Of these, 12 consultations were considered suitable for studying GP strategies and were therefore selected for a more thorough analysis. Main outcome measures GPs’ communication strategies to avoid unnecessary medical imaging and patients’ experiences with such strategies. Results Five categories of strategies were identified: (1) wait and see – or suggest an alternative; (2) the art of rejection; (3) seek support from a professional authority; (4) partnership and shared decision-making and (5) reassurance, normalisation and recognition. The GPs often used multiple strategies. Factors related to a long-term doctor–patient relationship seemed to influence both communication and how both parties experienced the decision. Three important factors were evident: the patient trusted the doctor, the doctor knew the patient’s medical history and the doctor knew the patient as a person. The patients seemed to be generally satisfied with the outcomes of the consultations. Conclusion GPs largely combine different strategies when meeting patients’ expectations of diagnostic imaging that are not strictly medically indicated. Continuity of the doctor–patient relationship with good personal knowledge and trust between doctor and patient appeared crucial for patients to accept the doctors' decisions. Key points GPs usually combine a broad range of strategies to avoid unnecessary medical imaging The patients appeared generally satisfied regardless of the strategy the strategy used by the GPs and even where their referral request were rejected Factors related to a long-term doctor–patient relationship appeared decisive

The use of low-value imaging: the role of referral practice and access to imaging services in a representative area of Norway

“…Kool and colleagues found that 67% of their responding GPs acknowledged that low-value care practice was regularly provided in general practice [ 31 ]. There may be many reasons for high referral rates, such as time pressure and patient-related factors [ 31 , 32 ], (un)familiarity with guidelines [ 33 ], and difficulties in handling professional uncertainties [ 10 ]. Several strategies are used to avoid imaging overuse [ 32 ].…”

“…There may be many reasons for high referral rates, such as time pressure and patient-related factors [ 31 , 32 ], (un)familiarity with guidelines [ 33 ], and difficulties in handling professional uncertainties [ 10 ]. Several strategies are used to avoid imaging overuse [ 32 ]. Interventions targeting referrers, including decision support tools, such as the ESR iGuide, guideline implementation, education, feedback to referrers, using various hand-outs, either alone or in combination, have been tried out.…”

Patients' requests for radiological imaging: A qualitative study on general practitioners' perspectives

“…Participants provided demographic information such as their length of time in practice, and their experiences of patients requesting radiological referrals. The interview was then guided by open-ended questions developed through an extensive literature search 10,13,[21][22][23][24] and expert consultation with the imaging department's healthcare professionals, for example, radiologists, specialists and physiotherapists. These included the types of exams frequently requested, the characteristics of patients, their concerns and demographics of patients likely to request referrals.…”

“…Overall, the evolving landscape of patient consumerism, driven by increased internet access and patient‐centred expectations, necessitates a response from GPs. The perceived pressure on GPs to order diagnostic tests has been explored by Griffith et al 19 with additional studies centred on patient–GP communication, concerns over unnecessary expenditure in imaging 20 and avoiding imaging overuse 21 . However, there is limited research on how GPs personally respond to patients requesting radiological studies.…”

“…The perceived pressure on GPs to order diagnostic tests has been explored by Griffith et al 19 with additional studies centred on patient-GP communication, concerns over unnecessary expenditure in imaging 20 and avoiding imaging overuse. 21 However, there is limited research on how GPs personally respond to patients requesting radiological studies. Our study aimed to explore with GPs, the patient-GP relationship factors that influence granting patient requests and the relationship between request fulfilment and patient characteristics.…”