BMJ. 1992 Mar 21;304(6829):740-3. doi: 10.1136/bmj.304.6829.740.
To measure the effect on hospital radiology referral practice of introducing a strategy for change involving guidelines of good practice, monitoring, and peer review.
Prospective data collection over a continuous 21-24 month period at each centre some time between January 1987 and December 1990.
Five district general hospitals and one district health authority.
314,663 inpatient discharges, deaths, and day cases and 1,706,781 outpatient attendances under the care of 722 consultants from 25 clinical specialties.
Number of referrals for x ray examination per 100 inpatient discharges, deaths, and day cases and per 100 new outpatient attenders.
Most doctors were prepared to accept standards of clinical practice set by peers and also the monitoring and review of their practice with respect to these standards by local colleagues. 18% of firms were identified before guidelines were instituted as having persistently high referral rates. Appreciable, and often dramatic reductions in referral rates for individual x ray examinations were recorded by a substantial number of firms in every centre and in every specialty after guidelines were instituted. The major part of this reduction was achieved by some of the firms whose initial practice did not meet "high referral" criteria. Important variations in compliance with agreed standards of good practice were observed.
The study offers strong experimental evidence to support a recent suggestion that at least a fifth of radiological examinations carried out in NHS hospitals are clinically unhelpful. The problem of how to assure compliance with agreed standards of practice needs to be resolved. Until this happens medical audit alone is unlikely to translate good practice into common practice.
评估引入一项变革策略（包括良好实践指南、监测和同行评审）对医院放射科转诊实践的影响。
在1987年1月至1990年12月期间的某个时间，在每个中心连续21至24个月进行前瞻性数据收集。
五家地区综合医院和一个地区卫生管理局。
314,663例住院患者出院、死亡及日间病例，以及来自25个临床专科的722名顾问医生所诊治的1,706,781例门诊患者。
每100例住院患者出院、死亡及日间病例以及每100例新门诊患者的X光检查转诊次数。
大多数医生愿意接受同行设定的临床实践标准，以及当地同事对其符合这些标准的实践进行的监测和评审。在制定指南之前，18%的科室被确定转诊率持续偏高。在制定指南后，每个中心和每个专科的大量科室记录到个别X光检查的转诊率有明显且常常是显著的降低。这种降低的主要部分是由一些最初实践不符合“高转诊”标准的科室实现的。观察到在遵守商定的良好实践标准方面存在重要差异。
该研究提供了有力的实验证据，支持最近的一项建议，即国民健康服务体系（NHS）医院进行的放射学检查中至少五分之一在临床上并无帮助。如何确保遵守商定的实践标准这一问题需要得到解决。在此之前，仅靠医疗审计不太可能将良好实践转化为普遍实践。
