• David J Halpern, Adrian Clark-Randall, Jonathan Woodall, John Anderson, and Kevin Shah.
• Duke University, Durham, NC, USA. david.halpern@duke.edu.
• J Gen Intern Med. 2021 Jan 1; 36 (1): 108-113.

BackgroundHigh clinical variation has been linked to decreased quality of care, increased costs, and decreased patient satisfaction. We present the implementation and analysis of a peer comparison intervention to reduce clinical variation within a large primary care network.ObjectiveEvaluate existing variation in radiology ordering within a primary care network and determine whether peer comparison feedback reduces variation or changes practice patterns.DesignRadiology ordering data was analyzed to evaluate baseline variation in imaging rates. A utilization dashboard was shared monthly with providers for a year, and imaging rates pre- and post-intervention were retrospectively analyzed.ParticipantsProviders within the primary care network spanning 1,358,644 outpatient encounters and 159 providers over a 3-year period.InterventionsThe inclusion of radiology utilization data as part of a provider's monthly quality and productivity dashboards. This information allows providers to compare their practice patterns with those of their colleagues.Main MeasuresWe measured provider imaging rates, stratified by modality, as well as order variation over time.Key ResultsWe observed significant variation in imaging rates among providers in the network, with the top decile ordering an average of 4.2 times more than the lowest decile in the two years prior to intervention. Provider experience and training were not significantly associated with imaging utilization. In the first year after sharing utilization data with providers, we saw a 17.3% decrease in median imaging rate (p < 0.001) and a 21.4% reduction in provider variation between top and bottom deciles. Median ordering rate for more costly cross-sectional imaging, including CT, MRI, and nuclear medicine studies, decreased by 30.4% (p < 0.001), 20.2% (p = 0.008), and 41.8% (p = 0.002), respectively.ConclusionsPeer comparison feedback can shape provider imaging behavior even in the absence of targets or financial incentives. Peer comparison is a low-touch, low-cost intervention for influencing provider ordering and may have applicability in other clinical areas.

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