Academic detailing and informed use of imaging of the shoulder in general practice

Aims: There has been a marked increase in the use of ultrasound imaging for problems relating to the shoulder. Our aim was to assess the impact that academic detailing (AD) had on use of diagnostic imaging for shoulder complaints in general practice. Method: One-to-one academic detailing (AD) for management of shoulder pain was delivered to 87 general practitioners (GPs) in metropolitan Adelaide, South Australia, together with clinical guidelines and a video/DVD on how to examine the shoulder. Three months after the initial AD a further small group or individual follow up session was offered. A 10 item questionnaire to assess knowledge about the management of shoulder complaints was administered before and three months after AD, together with questions to assess GP confidence to manage shoulder complaints. The number of requests for plain film (x-ray) and ultrasound (US) imaging of the shoulder was obtained for the detailed group as well as a random comparison group of 90 GPs from the same two GP divisions from the Health Insurance Commission (HIC). The change in the rate of requests was assessed using a log Poisson model. Linear mixed effects models were used to analyse changes in knowledge. A p value less than or equal to 0.05 was required for statistical significance. Results: Participating GPs were predominately male (59%). In an average week 54% of GPs reported seeing fewer than six patients with musculoskeletal (MSK) problems. Mean (SD) GP knowledge before, immediately after and three months after AD, was 6.2/10 (1.5); 8.6/10 (0.96) and; 7.2/10 (1.5) respectively (p<0.0001). After AD, GPs reported feeling able to take a more meaningful history, more confident managing shoulder pain, and felt their management of shoulder pain had improved. Analysis of imaging request data revealed a decrease in the use of ultrasound imaging (p<0.001). Requests for ultrasound imaging were approximately 43.8% lower in the period six months after detailing, but an upward trend toward baseline was observed in the period six months to one year after AD. There was no change in the rate of requests from before to after AD for x-ray (p=0.11). Conclusions: These results provide evidence that AD together with education materials and guidelines can reduce the use of imaging, at least in the short term. (author abstract)