Do nudge letters to GPs work?

Targeted feedback to GPs who are among the country’s highest pathology requestors has led to a 36% reduction in the overall rate of requests, an evaluation has found.
 
‘Education’, ‘nudge’, or ‘warning’ letters have been increasingly used by the Department of Health, Disability and Ageing (DoHDA) in recent years, including for semaglutide prescribing and MBS claims – a divisive approach amongst GPs.
 
To determine their effectiveness, a study published in The Lancet analysed the impact of letters mailed out in May 2022 to 5339 GPs whose requesting for two or more selected combinations of pathology tests was above the 90th percentile.
 
These Australian GPs were the top requestors for 10 commonly overused pathology test combinations, and in the top 10% for at least two individual combinations in 2019–21.
 
The overused pathology tests included various combinations of iron studies, thyroid stimulating hormone, thyroid function tests, vitamin D and vitamin B12.
 
GPs were given either ‘no intervention’ or targeted ‘audit and feedback’. Those allocated to the control group (625 GPs) received no feedback on their pathology requests, whereas GPs in the intervention group received written feedback on their pathology test combination requests from Australia’s Chief Medical Officer.
 
Study co-author Professor Rachelle Buchbinder said the results show the intervention was ‘extremely successful, one of the largest effects ever observed in audit and feedback research’.
 
‘It reduced these overused combinations of pathology tests by 36% over six months compared to no intervention. And it was largely sustained at 12 months (32% reduction),’ she told newsGP. 
 
‘In real terms there were an estimated 24,000 fewer requests in the first six months rising to 42,000 fewer over 12 months.’
 
While the study also tested variations on the letter, including adding CPD-accredited RACGP education, adding pathology test cost information and providing the information in a more visually appealing pamphlet format, Professor Buchbinder said ‘none of these amplified the effect over just the letter’.
 
Over-requesting of pathology testing is ‘a significant and costly problem’, with up to 40% of tests considered unnecessary, Professor Buchbinder explained. 
 
‘Overtesting increases the risk of false positive results – for example if you do 10 tests, on average one will be abnormal just on the basis of probabilities,’ she said.
 
‘Over-requesting can cause unnecessary patient anxiety, and it can also trigger cascades of further unnecessary tests and treatment.
 
‘This is a problem as well for society as it wastes finite health resources that could be directed to high-value care, and it also generates avoidable carbon emissions.’
 
In 2022–23 alone, Professor Buchbinder said 160 million pathology services were requested in Australia at a cost of $3.8 billion to Medicare, with most requests originating in general practice. 
 
She said a key message for GPs, and all clinicians who request tests, is to think about why they are requesting pathology tests.
 
Chair of the RACGP Expert Committee – Quality Care Professor Mark Morgan said this research demonstrates there is some benefit in providing targeted audits and feedback to reduce wasteful pathology testing, ‘but no discernible benefit of complicating the information with additional features’.
 
He added the RACGP’s First Do No Harm resources have information for GPs and patients about when to consider vitamin D testing and when not to.
 
‘Similarly, there is a resource aimed at reducing harms from inappropriate management of subclinical hypothyroidism,’ Professor Morgan said.
 
A spokesperson for DoHDA said the Department is responsible for ensuring the integrity and sustainability of payments made under the Medicare Benefits Schedule.
 
This is done through ‘prevention, early identification, and treatment of incorrect claiming, inappropriate practice and fraud’.
 
‘Supporting practitioners through education, engagement and consultation is our preferred method for achieving compliance,’ the spokesperson said.
 
‘GPs provide a key role in the selection of pathology tests used to diagnose medical conditions and manage patient treatment.
 
‘Using available research, data analysis and consultation with peak bodies, the research project aimed to promote the importance of clinically relevant use of pathology tests by providing data and resources from peak medical bodies to help reduce unintended patient harm.’
 
There are no current plans to re-run this specific project, the Government confirmed.
 
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