Successful implementation of a guideline by peer comparisons, education, and positive physician feedback

The objective of this study was to determine if peer comparisons, an educat ional intervention, and positive physician feedback would decrease ordering of knee X-ray studies. We prospectively studied the ordering of knee :Xray studies for patients presenting with knee injuries before and after an edu cational program to encourage use of the Ottawa decision rule for knee radi ography. Physicians were able to privately compare their individual baselin e X-ray utilization data with that of their colleagues, Although acceptance of the rule was voluntary, both oral and written feedback encouraged consi deration of the rule in clinical decision-making. The percentage of knee in jury patients who received X-ray studies, as well as the Percentage Abnorma l Results (PAR, defined as the percentage of X-ray studies demonstrating a fracture or effusion), were calculated before and after the educational mee ting. Results of the study showed that the percentage of patients presentin g with knee injuries who received X-ray studies decreased 23%, In addition, the PAR increased 58.4% between the two study periods. In conclusion, phys ician behavior can be altered positively with reinforcement, Peer compariso ns, education, and positive physician feedback decreased test ordering by p hysicians even without mandating use of a protocol. PAR is a useful outcome measure to track physician utilization. (C) 1999 Elsevier Science Inc.