Strategies for changing the use of diagnostic radiology

The relentles increase in the use diagnostic test in clinical medicine has led to cencern expressed in the NHS and elsewhere about rapidly escalating costs; staff in diagnostic departments are dismayed about workload rising faster than reosurces; and many clinicians are concerned about the profusion of tests to wich their patients are now exposed. This project paper addresses the problem of containing demand in one diagnostic service, radiology, and for one diagnostic test, pre-operative chest X-rays. However, the principles and strategies discussed are relevant to any test and any diagnostic service. Much of the discussion in this paper is based on the findings of a study supported by the Kind's Fund and conducted under the auspices of the Royal College of Radiologists Working Party on the Effective Use of Diagnostic Radiologists Working Party on the Effective Use of Diagnostic Radiologists Working Party on the Effective Use of Diagnostic Radiology in wich four strategies were evaluated for implementing guidelines on the use of pre-operative chest X-rays. Following approval of the guidelines by cogwheel divisions and medical executive committees in four hospitals, one of the following strategies was introduced into each hospital: 1. utilization review committee 2. feedback on use to consultants 3. new chest x-ray request for and 4. concurrent review of chest x-ray requests by radiological staff. The strategies were implemented for one year during which time the use of pre-operative chest x rays were monitored in the hospitals and in a control hospital which had no intervention strategy. During the fourth month of the intervention period adherence to the guidelines was determined in a sample of patients who had pre-operative chest x rays. In addition to describing briefly the effects of these strategies on utilization in the study hospitals, this paper discusses the need for strategies, the process of developing guidelines, and how strategies may be implemented in the hospitals. The success of the strategies are reviewed in the ligth of other studies in this field. Containing the use of diagnostic tests is discussed within the contex of the financial, organisational and attitudinal constraints within the NHS. Finally some recommendations are made on how unit managers and clinicians might initiate change to contain the use of diagnostic services in NHS hospitals.