Reducing neuroimaging in first-episode psychosis by facilitating uptake of choosing wisely recommendations: a quality improvement initiative

• Published in: BMJ open quality Vol. 10; no. 3; p. e001307
• Main Authors: Srivastava, Raman, Holmes, R Davis, Noel, Christopher W, Lam, Tong V, Shewchuk, Jason R
• Format: Journal Article
• Language: English
• Published: London BMJ Publishing Group LTD 08.07.2021; BMJ Publishing Group
• Subjects: Age; Audits; Data analysis; Data collection; Education; Ethics; Feedback; Health administration; Initiatives; Intervention; Medical diagnosis; Medical imaging; Neuroimaging; Patients; Physicians; Psychiatrists; Psychosis; Quality control; Quality improvement; Short Report; Canada
• ISSN: 2399-6641; 2399-6641
• DOI: 10.1136/bmjoq-2020-001307

Correspondence to Dr Raman Srivastava; raman.srivastava@alumni.ubc.ca Introduction First-episode psychosis (FEP) is a frequent presentation to hospital.1 Neuroimaging is often ordered during the initial assessment to facilitate diagnostic buy-in, mitigate medico-legal concerns, and maximise assessment in a patient population that is typically marginalised.2 3 These benefits, however, are outweighed by the unnecessary radiation, cost, and strong evidence that neuroimaging rarely yields actionable findings.2 3 This stance is evidenced in international guidelines2 3 and Choosing Wisely Canada (CWC) recommendations.4 Our site’s radiology department queried inconsistent (per guidelines) CT imaging in FEP, given requisition patterns. Stakeholder and literature evidence suggested the combination of audit and feedback with education, and separately visual prompts, could be successful in effecting change.9 From these considerations, we created a one-page infographic incorporating pre-intervention audit results and CWC guidelines (see online supplemental file 1), which was then emailed by department heads to high yield physician groups (emergency and psychiatry physicians) and physically posted throughout physician workspaces (walls and doors). A recent study found that among reviewed initiatives with sustained results, each of our three strategies—audit and feedback, education, and reminders—were present.11 A 2017 systematic review found that provider education, performance feedback, and multicomponent interventions all have strong evidence for reducing low-value health services.12 Most recently, a similar education and feedback intervention was shown to durably reduce cardiac echocardiograms.13 Critical to our success was our team, multicomponent approach, and visual prompts. [...]while our preference would have been to display the data in a run chart format,16 our dichotomous outcome and insufficient number of observations precluded its usage.