‘Nudge’ letters to take supportive tone following RACGP push

Anastasia Tsirtsakis

5/11/2020 7:15:59 PM

More than 1000 GPs who were sent a letter regarding musculoskeletal diagnostic imaging requests are set to receive a more educative follow-up.

An envelope
The RACGP has reiterated its concerns to the Department of Health, claiming the nudge letters could increase the stress already faced by many GPs in the current environment.

‘Your musculoskeletal diagnostic imaging request rate is higher than 80% of general practitioners practicing in a similar geographical region in Australia.’
That was the opening line of a compliance letter, issued by the Department of Health (DoH) in November 2019, to 3055 GPs with the highest volume of requests for Medicare Benefits Schedule (MBS) musculoskeletal diagnostic imaging services.
The letter called on recipients to reflect on their requesting data and endeavor to limit their requests to ‘only those clinical situations where imaging will change your patient’s treatment plan and improve their health outcomes’.
Now, 1300 of those GPs are set to receive a follow-up letter in the coming weeks with updated feedback, but this time with a more supportive tone following a number of recommendations made by the RACGP.
In its correspondence on the DoH’s ‘Reducing unnecessary diagnostic imaging’ project, the college reiterated its concerns with the ‘ongoing approach of identifying general practitioners to target with nudge letters’ and the ‘Professional Services Review type language’ used in letters.
‘GPs and practices are presently under significant stress as a result of COVID-19. Sending these letters at this time will increase the stress already faced by many GPs in the current environment,’ the RACGP wrote.
Associate Professor Mark Morgan, Chair of the RACGP Expert Committee – Quality Care (REC–QC), welcomed the DoH’s decision to accept the college’s input.
While he agrees that low-value imaging is wasteful and can actually be harmful, he told newsGP an educational approach is important – and something the nudge-letter approach is lacking.
‘The problem with nudge letters is they are poorly targeted based on volume of testing, not appropriateness of testing,’ he said. ‘So there’s not much specific learning involved in receiving a nudge letter.
‘Whereas if you use computer decision support or a guideline, then the act of following or thinking about that prompt or thinking about the content of the guideline is something that you learn from and can apply in the future.
‘That’s why we made some suggestions for the wording.’
Among the issues raised by the RACGP is the use of raw data on the quantum of diagnostic imaging.
By simply comparing a GPs’ request rate to others in similar geographical locations, the college noted a lack of consideration for influences on requesting behaviours, such as a specialist interests.
‘The problem with this approach is that some doctors may have a skewed population because of a specialist interest,’ the RACGP wrote. 
‘In the past, GPs were informed regularly about why their practices were discordant in a collaborative and educational manner, and were not assessed according to their peers.
‘Providing feedback according to where each GP fits individually is more beneficial.’
The nudge letter is one of many sent to GPs to ensure compliance.
While the approach has proven effective for antibiotic prescribing, Associate Professor Morgan says it can cause unnecessary anxiety and should not be viewed as a ‘panacea’.
‘When used for opioid use, not accounting for the type of practice that GPs had and the variation in practice, it led to some access problems for patients for whom opioids were entirely appropriate,’ he said.
‘The GPs felt threatened by being highlighted as high opiate prescribing GPs, and that led to the unintended consequences of patients not getting treatments that were appropriate.
‘So I don’t want to see the Department of Health using nudge letters willy-nilly for all sorts of perceived problems.’
In the lead up to the release of the second letter, the DoH advised that GPs ‘are not being contacted as part of an audit or practitioner review compliance activity, and are not required to provide information to the department about their imaging requests’.
As a consequence, Associate Professor Morgan noted that, anecdotally, nudge letters can cause doctors to reduce inappropriate and appropriate care.
He said it is important to keep patient-centred care at the forefront.
‘The letters shouldn’t be there to scare GPs or to be threatening to GPs,’ Associate Professor Morgan said.
‘They’re really, if anything, just to encourage some reflection and to highlight that there might or might not be overuse of diagnostic imaging requests.
‘GPs can use it as an opportunity to reflect, but still maintain clinical autonomy and think about the person in front of them.’
GPs who have any questions or feedback regarding the letters can email the DoH.
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Dr Muhammad Hafizei Muhammad Nasir   6/11/2020 10:08:26 AM

Side issue - I noticed that RACGP is referring GPs as “GPs”, perhaps it is time for us to be referred as “GP specialists” consistently in the media statements, especially.

Dr Muhammad Shihab Rahman   6/11/2020 3:30:52 PM

I agree with you Dr Nasir. And we need to change the GP title. The adjective 'general' makes us look 'not special'.

Dr Felix Bisterbosch   8/11/2020 10:07:19 AM

I appreciate to get feedback on my work as a GP; it gives us the opportunity to reflect on our way of working and improve ourselves if needed. The nudge letters should be presented in a positive way.

Dr Thomas Anthony Shashian   9/11/2020 7:29:48 AM

Firstly I agree with my colleagues above in then replaced the college should start calling fellows either consultant general practitioners or specialist GPs however I prefer primary care physicians. If the college start using that sort of language in all of their press releases then perhaps other associated media God forbid even mainstream media may start picking up that sort of language as well.

Dr Thomas Anthony Shashian   9/11/2020 7:32:52 AM

In response to all of the hubbub around such letters. Surely my colleagues have enough insight into their own practice demographic to understand why they may be outside of the norm when prescribing opioids or requesting musculoskeletal imaging. Is part of your main focus in your practice is sports medicine or emergency medicine or work cover then you will absolutely be in the top percenttile for pain relief prescribing as well as imaging requests

A.Prof Christopher David Hogan   14/11/2020 9:16:17 PM

What wonderful result not only for RACGP advocacy but also the effectiveness of the impact of multiple multiple pieces of correspondence from grass root GPs

Dr Maureen Anne Fitzsimon   14/11/2020 11:12:33 PM

After receiving one of Brendan Murphy’s threatening letters about my opioid use, I’ve moved house, given up my large load of palliative care patients , quit seeing nursing home patients, work part time, instead of ridiculous hours, and now have a wonderful opioid profile. I’m relaxed, no longer take anti hypertensive medication, but am sad that there is one less GP available to care for those in real need of opioids. Thanks, Brendan.