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1
Department of Radiology, The Emory Clinic, Emory University School of
Medicine, Bldg. A, 1365 Clifton Rd. N.E., Atlanta, GA 30322.
2
Department of Radiology, University of Colorado Health Sciences Center, 4200
E. 9th Ave., Box A030, Denver, CO 80262.
Received December 2, 1999;
accepted after revision January 24, 2000.
Address correspondence to S. Tigges.
Abstract
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MATERIALS AND METHODS. Radiologists from the Society of Skeletal Radiology, Georgia Radiological Society, and Utah Radiological Society were surveyed regarding their use of the ACR musculoskeletal appropriateness criteria. The surveys were carried out during 1998 and data were collected using written survey forms, telephone, and fax.
RESULTS. The overall survey response rate was 298 (64%) of 465. Overall, 30% of respondents reported using the musculoskeletal appropriateness criteria. The proportion of respondents who used the musculoskeletal criteria was not different across the three organizations or for private practice compared with academic radiologists.
CONCLUSION. The proportion of radiologists who report using the ACR musculoskeletal radiology appropriateness criteria is low. This result is consistent with other reports in the literature that show little impact on the practice of physicians after the distribution of written practice guidelines.
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The ACR has invested significant effort in developing and distributing the appropriateness criteria [1] but, to our knowledge, has no way of determining what the impact of these guidelines has been on the practice of radiology. In addition, no reports concerning what proportion of radiologists have incorporated the criteria into their daily practice have been published. The purpose of this study is to determine the number of radiologists in three different radiology organizations who report using the musculoskeletal appropriateness criteria.
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The respondents who did use the criteria were then asked how often they used the criteria, whether clinicians responded favorably, and the most common type of use of the criteria. Options for this last question were restricted to the following: choosing an imaging methodology for a particular clinical situation; validating the choice of imaging methodology with a clinician; utilization review; and billing or insurance questions.
Members of three different radiology organizations, the Society of Skeletal Radiology, the Georgia Radiological Society, and the Utah Radiological Society, were surveyed during the 1998 calendar year. The same survey form was used for all three groups, but the methods used to carry out the survey were different. In the case of the Society of Skeletal Radiology, active members of the society as of 1997 practicing in the United States were surveyed. The survey was distributed to the attendees of the 1998 annual meeting and completed forms were collected at the end of the meeting. Surveys were then mailed to all eligible members of the society who had not yet completed the form. A second group of surveys was then mailed to nonresponders. Finally, those members who did not respond to either of the written surveys were called and queried over the telephone.
All active members of the Utah Radiological Society as of 1997 who had not already been surveyed as members of the Society of Skeletal Radiology were surveyed with two rounds of survey mailings. Nonresponders to the first mailing were sent a second form.
The Georgia Radiological Society was the largest organization that we surveyed: its membership list included 498 radiologists. To keep the number of responses manageable, we chose to survey every fourth member of this society. In addition, after we had reduced this list by 75%, we further limited the number to be surveyed by excluding all members who practiced radiology at the first author's institution or had already been surveyed as a member of the Society of Skeletal Radiology. This method of selection left 114 radiologists. We then randomly selected another 43 members to be surveyed for a total of 157 radiologists. We carried out these surveys by telephone or fax, depending on the preference of the respondent. After the surveys had been completed, we discovered that one radiologist had been surveyed both as a member of the Society of Skeletal Radiology and the Georgia Radiological Society. We kept his survey for the Skeletal Society but eliminated his Georgia response, leaving the Georgia survey group with a total of 156 radiologists.
For analysis, the data were entered into a SAS (SAS Institue, Cary, NC) data set. Tests of significance for comparing proportions in the various groups were carried out using the chi-square test.
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Overall, 30% of respondents reported using the musculoskeletal radiology appropriateness criteria [1], and 19% of the members of the Georgia Radiological Society reported using the criteria, whereas 33% and 34% of the members of the Society of Skeletal Radiology and the Utah Radiological Society, respectively, used the criteria. The proportions of respondents who reported using the musculoskeletal criteria in each of the three groups was not significantly different at an alpha of 0.05 (chi-square test, p = 0.091). Virtually identical proportions of academic (31%) and private practice (30%) radiologists reported using the musculoskeletal criteria (p > 0.50). Ninety percent of respondents were familiar with the ACR criteria, 83% reported receiving a copy of the criteria (Georgia Radiological Society, 88%; Society of Skeletal Radiology, 81%; Utah Radiological Society, 81%; chi-square test, p = 0.442), 78% had read some of the criteria, and 51% had read some of the musculoskeletal criteria. Thirty-four (37%) of the 91 radiologists who reported using the musculoskeletal criteria used them many times a day. Forty-nine (54%) of the 91 respondents who used the criteria reported a favorable reaction from referring physicians. The most common reason for using the criteria was for utilization review, followed by validation of the choice of imaging method with the clinician. No respondent reported using the criteria to handle billing or insurance questions.
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A previous article has shown that the ACR criteria can be applied to about three fourths of general internal medicine practice patients for whom radiologic evaluation is requested [3]. Despite this potentially high rate of use, most radiologists in our survey did not refer to the criteria for guidance. This disappointing finding may in part be a result of the format in which the criteria are presented. A recent review article found little impact on clinical practice after the distribution of printed educational material [4]. The authors of this review report that the most effective ways of changing practice patterns include outreach visits (defined as "use of a trained person who meet[s] with providers in their practice settings to provide information") and the influence of local opinion leaders (defined as "use of providers (for education) nominated by their colleagues as `educationally influential"') [4]. For example, in a study in Canada, the rates of cesarian section were not significantly changed after publication and distribution of guidelines designed to reduce the number of this procedure [5]. However, a second trial using an opinion leader to educate obstetricians in ways to decrease the number of cesarian sections did result in lower rates of this procedure [6]. Perhaps a completely novel approach such as using the Internet may prove effective [7].
Radiologists may actually use the ACR criteria more often than indicated by our results. Although we included both academic and private practice radiologists in our survey and sampled radiologists in two separate states, few radiologists from the northeast, Midwest, or the Pacific Coast were surveyed unless they happened to be members of the Society of Skeletal Radiology. Conceivably, practitioners in these areas may use the ACR appropriateness criteria more frequently than the radiologists whom we surveyed. In addition, the survey response rate for the Georgia Radiological Society was poor and for the Utah Radiological Society was only fair. Unsurveyed members of these organizations could use the criteria more often than those whom we were able to reach. Given that the rate of use of the criteria in the group with an excellent response rate (Society of Skeletal Radiology) was virtually identical to that of the other groups, we consider this explanation unlikely. Finally, it is possible that radiologists are already practicing in ways consistent with the criteria because all states require that physicians obtain a certain number of continuing medical education credits.
A significant limitation of this study is our inability to determine why radiologists do not use the ACR criteria and what factors (sex, level of training, age, years in practice) are associated with higher rates of use. Possible reasons for not using the criteria include inconvenience, lack of familiarity with the guidelines, and even disagreement with the recommendations. We chose not to include questions related to these issues in our survey because we believed that a shorter survey was more likely to get responses.
In summary, we found that less than one third of those surveyed reported using the ACR musculoskeletal appropriateness criteria. Perhaps the college, with its superior resources, could answer some of the questions left unanswered by this study such as why radiologists do not use the criteria. Such information is crucial to determining the most effective way of popularizing the criteria. More effective ways of influencing the day-to-day practice of radiologists might include using outreach visits or local opinion leaders to educate radiologists.
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