Reducing inappropriate diagnostic practice through education and decision support.

OBJECTIVE To quantify non-compliance of diagnostic practice with recommendations in Diagnostic Imaging Pathways and the impact of interventions to reduce non-compliance. DESIGN Retrospective audits, followed by intervention and re-audits. SETTING Emergency department (ED) of Royal Perth Hospital. PARTICIPANTS Six hundred and thirty-eight patients (first audit) and 423 patients (second audit) presenting to the ED with one of the four conditions: suspected pulmonary embolism, ankle injury, suspected renal colic or non-traumatic acute abdominal pain. INTERVENTIONS Education of clinicians on Diagnostic Imaging Pathways recommendations for the four conditions. Decision support through the introduction of request forms, which required 'proof' of adherence to diagnostic pathways. MAIN OUTCOME MEASURES Percentage of patients with a deviation from recommended diagnostic practice. RESULTS Overall, 56% of patients had evidence of inappropriate diagnostic practice prior to interventions, with a reduction of 16% following the interventions. CONCLUSION The reduction was significant but inappropriate practice was not eliminated. For as long as decision-support systems are 'stand-alone' applications, achieving full compliance is dependent on continuous and expensive processes of education and enforcement. A better understanding of why clinicians fail to follow recommended practice is required, and decision support must be better embedded into clinical workflow.