Impact of active implementation of the Norwegian Musculoskeletal Guideline on the use of non-traumatic musculoskeletal imaging: A multimethod study
Background: During the last few decades, an increase in the complexity of the field of diagnostic imaging with the development of new modalities and technology has spurred a significant increase in the use of diagnostic imaging. This development, in combination with a rise in the challenge of unwarranted imaging has enhanced the need for guidelines in this field. These guidelines are usually aimed at referrers, and aim to increase justification of examinations and ensure uniform and best possible care, i.e., reducing unwarranted use of health services and unwarranted geographical variation. However, guideline implementation is challenging, and especially challenging is developing implementation strategies that achieve lasting changes in behaviour and referral patterns.
Aim: The overall aim of this thesis is to identify the need for guideline implementation, identifying what is a fitting implementation strategy for the national guideline for diagnostic imaging of non-traumatic musculoskeletal diseases, what effect this implementation strategy has on the use of musculoskeletal imaging in addition evaluate the implementation process itself, to find how the implementation was perceived by participants.
Methodology: This thesis uses a multimethod approach. Paper 1 is a quantitative evaluation of geographical variation in the use of musculoskeletal imaging in Norway during the first half of 2016. This is done through a high/low analysis of age-adjusted data consisting of the musculoskeletal examinations registered during the first half of 2016. Paper 2 was a qualitative study involving individual semi-structured interviews with eight general practitioners and ten radiologists. This is the basis for the development of an implementation strategy, which consisted of informational meetings, digital access of the guideline, and distribution of physical short versions and educational videos. Paper 3 describes the process of developing and delivery of the implementation strategy. Paper 4 is a quantitative study consisting of an interrupted time series using register data from the Norwegian Health Economics Administration. Paper 5 is a qualitative study consisting of four focus group interviews with in total seven GPs, one radiologist, one registrar and three radiographers.
Findings: This thesis presents new insights about geographical variations in the use of diagnostic imaging, as well as barriers and facilitators for guideline adherence; the effect of a multifaceted implementation strategy on the use of diagnostic imaging, and the perceived outcome of the implementation by the target groups, as well as factors perceived to influence the outcome. This adds to a vast field of research, and provides a more comprehensive knowledge of guideline implementation taking the different parts of the work system and work process into consideration.
The findings from paper 1 show a moderate to high geographical variation in the use of musculoskeletal imaging, indicating there was a need for further implementation. The most common barriers for guideline use were lack of time, and pressure from patients, among others. The findings from the ITS analysis indicate that the implementation strategy has had an effect on the use of the musculoskeletal examinations assumed to contain a high degree of unwarranted imaging. Many of the barriers identified in paper 2 were still mentioned during the evaluation of the implementation, indicating that these had not been overcome. There were not perceived any major changes use of diagnostic imaging by the target groups, even though the ITS analysis showed a decrease in the use of some procedures.
Conclusion: This thesis highlights the complexity of guideline implementation, and the complexity that is involved in the process of referring a patient to diagnostic imaging, contributing new insights to this field of research. The papers have generated new knowledge of not only barriers and facilitators for guideline adherence, but also of the effect a multifaceted implementation strategy has on the use of diagnostic imaging, which may influence the patient outcome. This provides insights into the effects this has over time, as well as the outcome of the implementation strategy in terms of perceived and observed changes in use of diagnostic imaging, as well as the communication between the different healthcare-professions involved in the diagnostic imaging process.