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 educational intervention, and positive physician feedback would decrease ordering of knee X-ray studies. We prospectively studied the ordering of knee X-ray studies for patients presenting with knee injuries before and after an educational program to encourage use of the Ottawa decision rule for knee radiography. Physicians were able to privately compare their individual baseline X-ray utilization data with that of their colleagues. Although acceptance of the rule was voluntary, both oral and written feedback encouraged consideration of the rule in clinical decision-making. The percentage of knee injury patients who received X-ray studies, as well as the Percentage Abnormal Results (PAR, defined as the percentage of X-ray studies demonstrating a fracture or effusion), were calculated before and after the educational meeting. Results of the study showed that the percentage of patients presenting with knee injuries who received X-ray studies decreased 23%. In addition, the PAR increased 58.4% between the two study periods. In conclusion, physician behavior can be altered positively with reinforcement. Peer comparisons, education, and positive physician feedback decreased test ordering by physicians even without mandating use of a protocol. PAR is a useful outcome measure to track physician utilization.