Use and impact of point-of-care ultrasonography in general practice: a prospective observational study

Camilla Aakjær Andersen, John Brodersen, Annette Sofie Davidsen, Ole Graumann, Martin Bach B Jensen, Camilla Aakjær Andersen, John Brodersen, Annette Sofie Davidsen, Ole Graumann, Martin Bach B Jensen

Abstract

Objectives: To describe how general practitioners (GPs) use point-of-care ultrasonography (POCUS) and how it influences the diagnostic process and treatment of patients.

Design: Prospective observational study using an online questionnaire before and after POCUS.

Setting: Office-based general practice.

Participants: Twenty GPs consecutively recruited all patients examined with POCUS in 1 month.

Primary and secondary outcome measures: We estimated the use of POCUS through the indication for use, the frequency of use, the time consumption, the extent of modification of the examination and the findings.The influence on the diagnostic process was estimated through change in the tentative diagnoses, change in confidence, the ability to produce ultrasound images and the relationship between confidence and organs scanned or tentative diagnoses.The influence of POCUS on patient treatment was estimated through change in plan for the patient, change in patient's treatment and the relationship between such changes and certain findings.

Results: The GPs included 574 patients in the study. POCUS was used in patient consultations with a median frequency of 8.6% (IQR: 4.9-12.6). Many different organs were scanned covering more than 100 different tentative diagnoses. The median time taken to perform POCUS was 5 min (IQR: 3-8). Across applications and GPs, POCUS entailed a change in diagnoses in 49.4% of patients; increased confidence in a diagnosis in 89.2% of patients; a change in the management plan for 50.9% of patients including an absolute reduction in intended referrals to secondary care from 49.2% to 25.6%; and a change in treatment for 26.5% of patients.

Conclusions: The clinical utilisation of POCUS was highly variable among the GPs included in this study in terms of the indication for performing POCUS, examined scanning modalities and frequency of use. Overall, using POCUS altered the GPs' diagnostic process and clinical decision-making in nearly three out of four consultations.

Trial registration number: NCT03375333.

Keywords: change management; organisation of health services; primary care; ultrasonography.

Conflict of interest statement

Competing interests: None declared.

© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Figures

Figure 1
Figure 1
Patient flow diagram.*Time-log

Figure 2

Ultrasound competences of the participating…

Figure 2

Ultrasound competences of the participating general practitioners (GPs). *A teacher in point-of-care ultrasonography…

Figure 2
Ultrasound competences of the participating general practitioners (GPs). *A teacher in point-of-care ultrasonography (PoC-US) and radiology specialist (OG) assessed 19 of the GPs’ performances in a standardised setting using an adapted version of ageneric ultrasound rating scale (The Objective Structured Assessment of Ultrasound Skills (OSAUS)17) and asked questions about the examination according to an objective structured clinical examination (OSCE) evaluation sheet. The GPs were asked to demonstrate PoC-US according to their usual routine and they were only assessed in the applications that they normally used. One GPs declined to participate in this evaluation. ** OSAUS assessed on a scale from 0 to 40. Abd, abdomen; DVT, deep venous thrombosis; MSK, musculoskeletal; Ob/Gyn, obstetric and gynaecological.

Figure 3

Use of ultrasonography in general…

Figure 3

Use of ultrasonography in general practice. *After registrations of scanning modalities (N= 834).…

Figure 3
Use of ultrasonography in general practice. *After registrations of scanning modalities (N= 834). **Number of exams with an after registration of scanning modalities (N=574). The registered scanning modalities are categorised according to application: Upper abd.= upper abdominal organs (including liver, gall bladder, pancreas), urinary tract (including kidney, and bladder); OB/Gyn=obstetric and gynaecological (including uterus, ovaries, placenta, fetus and fossa douglasi); Ascites= scans for abdominal flee fluid; DVT= scans fordeep venous thrombosis; MSK= musculoskeletal (including joints, muscle, tendon, bone and joint puncture); Sub.P.= Subcutaneous process. The others category includes free text answers and registered applications with a frequency below five examinations: intestines incl. appendix andrectum (N=7), bursa (N=6), unclassified abdominal structures (N=6), testis (N=5), amnion fluid (N=4), lymph nodes (N=4), breast (N=3), soft tissue (N=2), hernia (N=2), ureter (N=1), Larynx (N=1), varicose vein (N=1), unclassified abscess (N=1), carotid artery (N=1), blood vein for venous access (N=1) and unclassified structure on finger (N=1). ***Time registration if examination only included one application (N=486). Described as median time consumption, IQR and range.
Figure 2
Figure 2
Ultrasound competences of the participating general practitioners (GPs). *A teacher in point-of-care ultrasonography (PoC-US) and radiology specialist (OG) assessed 19 of the GPs’ performances in a standardised setting using an adapted version of ageneric ultrasound rating scale (The Objective Structured Assessment of Ultrasound Skills (OSAUS)17) and asked questions about the examination according to an objective structured clinical examination (OSCE) evaluation sheet. The GPs were asked to demonstrate PoC-US according to their usual routine and they were only assessed in the applications that they normally used. One GPs declined to participate in this evaluation. ** OSAUS assessed on a scale from 0 to 40. Abd, abdomen; DVT, deep venous thrombosis; MSK, musculoskeletal; Ob/Gyn, obstetric and gynaecological.
Figure 3
Figure 3
Use of ultrasonography in general practice. *After registrations of scanning modalities (N= 834). **Number of exams with an after registration of scanning modalities (N=574). The registered scanning modalities are categorised according to application: Upper abd.= upper abdominal organs (including liver, gall bladder, pancreas), urinary tract (including kidney, and bladder); OB/Gyn=obstetric and gynaecological (including uterus, ovaries, placenta, fetus and fossa douglasi); Ascites= scans for abdominal flee fluid; DVT= scans fordeep venous thrombosis; MSK= musculoskeletal (including joints, muscle, tendon, bone and joint puncture); Sub.P.= Subcutaneous process. The others category includes free text answers and registered applications with a frequency below five examinations: intestines incl. appendix andrectum (N=7), bursa (N=6), unclassified abdominal structures (N=6), testis (N=5), amnion fluid (N=4), lymph nodes (N=4), breast (N=3), soft tissue (N=2), hernia (N=2), ureter (N=1), Larynx (N=1), varicose vein (N=1), unclassified abscess (N=1), carotid artery (N=1), blood vein for venous access (N=1) and unclassified structure on finger (N=1). ***Time registration if examination only included one application (N=486). Described as median time consumption, IQR and range.

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