Effect of audit and feedback, and reminder messages on primary- care radiology referrals: a randomised trial

Summary Background Radiological tests are often used by general practitioners (GPs). These tests can be overused and contribute little to clinical management. We aimed to assess two methods of reducing GP requests for radiological tests in accordance with the UK Royal College of Radiologists' guidelines on lumbar spine and knee radiographs. Methods We assessed audit and feedback, and educational reminder messages in six radiology departments and 244 general practices that they served. The study was a before-and-after, pragmatic, cluster randomised controlled trial with a 2·2 factorial design. A random subset of GP patients' records were examined for concordance with the guidelines. The main outcome measure was number of radiograph requests per 1000 patients per year. Analysis was by intention to treat. Findings The effect of educational reminder messages (ie, the change in request rate after intervention) was an absolute change of −1·53 (95% CI −2·5 to −0·57) for lumbar spine and of −1·61 (−2·6 to −0·62) for knee radiographs, both relative reductions of about 20%. The effect of audit and feedback was an absolute change of −0·07 (−1·3 to 0·9) for lumbar spine of 0·04 (−0·95 to 1·03) for knee radiograph requests, both relative reductions of about 1%. Concordance between groups did not differ significantly. Interpretation 6-monthly feedback of audit data is ineffective but the routine attachment of educational reminder messages to radiographs is effective and does not affect quality of referrals. Any department of radiology that handles referrals from primary care could deliver this intervention to good effect.