Using text analysis software to identify determinants of inappropriate clinical question reporting and diagnostic procedure referrals in Reggio Emilia, Italy

Francesco Venturelli,Mirco Pinotti,Fabio Pignatti,Eletta Bellocchio,Paolo Giorgi Rossi,Marta Ottone,Giulia Besutti,Olivera Djuric

doi:10.1186/s12913-021-06093-0

Abstract

BackgroundInappropriate prescribing of diagnostic procedures leads to overdiagnosis, overtreatment and resource waste in healthcare systems. Effective strategies to measure and to overcome inappropriateness are essential to increasing the value and sustainability of care.We aimed to describe the determinants of inappropriate reporting of the clinical question and of inappropriate imaging and endoscopy referrals through an analysis of general practitioners’ (GP) referral forms in the province of Reggio Emilia, Italy.MethodsA clinical audit was conducted on routinely collected referral forms of all GPs of Reggio Emilia province. All prescriptions for gastroscopy, colonoscopy, neurological and musculoskeletal computerised tomography (CT) and magnetic resonance imaging (MRI) from 2012 to 2017 were included. The appropriateness of referral forms was assessed using Clinika VAP software, which combines semantic analysis of clinical questions and available metadata. Local protocols agreed on by all physicians defined criteria of appropriateness. Two multilevel logistic models were used to identify multiple predictors of inappropriateness of referral forms and to analyse variability among GPs, primary care subdistricts and healthcare districts.ResultsOverall, 37% of referral forms were classified as inappropriate, gastroscopy and CT showed higher proportions of inappropriate referrals compared to colonoscopy and MRI. Inappropriateness increased with patient age for CT and MRI; for gastroscopy, it was lower for patients aged 65–84 compared to those younger, and for colonoscopy, it was higher for older patients. Fee exemptions were associated with inappropriateness in MRI referral forms. The effect of GPs’ practice organization was consistent across all tests, showing higher inappropriateness for primary care medical networks than in primary care medical groups. Male GPs were associated with inappropriateness in endoscopy, and older GPs were associated with inappropriateness in musculoskeletal CT. While there was moderate variability in the inappropriate prescribing among GPs, there was not among the healthcare districts or primary care subdistricts.ConclusionsRoutinely collected data and IT tools can be useful to identify and monitor diagnostic procedures at high risk of inappropriate prescribing. Assessing determinants of inappropriate referral makes it possible to tailor educational and organizational interventions to those who need them.

Highlights

Inappropriate prescribing of diagnostic procedures leads to overdiagnosis, overtreatment and resource waste in healthcare systems
In each primary care subdistricts (PCSDs), the general practitioners’ (GP) are organised in practices sharing the same clinic and infrastructure and in which the beneficiaries are assisted by any one of the GPs in the group, or where beneficiaries are assisted by their own GP, who shares some IT infrastructures with other GPs (See Additional file 1: Appendix Table 1 for details)
Descriptive analysis Overall, 322,978 referral forms were included in the analysis, of which 203,620 (63.0%) proved to be appropriate according to our assessment criteria

Summary

Introduction

Inappropriate prescribing of diagnostic procedures leads to overdiagnosis, overtreatment and resource waste in healthcare systems. In 2017, experts from 19 countries who are members of the European Society of Radiology defined a list of critical issues and needs to increase appropriateness in the use of diagnostic imaging procedures [5], including the need for evidence-based imaging referral guidelines [5,6,7], the need to justify diagnostic procedures, invasive procedures using ionizing radiation or contrast medium, and the need for general practitioners and specialists to work jointly [5, 8]. Inappropriate referrals compete for allocation of resources to other, more useful and often more urgent procedures, thereby reducing the allocative efficiency of the system [14]

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Conclusion