General Practitioners’ Perspectives on Appropriate Use of Ultrasonography in Primary Care in Denmark: A Multistage Mixed Methods Study

The article for discussion is Andersen CA, Guetterman TC, Fetters MD, Brodersen J, Davidsen AS, Graumann O, et al. General Practitioners' Perspectives on Appropriate Use of Ultrasonography in Primary Care in Denmark: A Multistage Mixed Methods Study. Ann Fam Med. 2022;20(3):211-9.
The scope of this article is to assess Danish general practitioners’ (GPs’) understanding of what is considered appropriate use of point-of-care ultrasonography (POCUS) in general practice and to investigate differences between GPs’ attitudes and their actual practices (1). Andersen and her colleagues used an exploratory sequential approach combining both qualitative and quantitative methods to elucidate this topic.
What is POCUS? The term was introduced by Moore in 2011 (2). POCUS is used in many fields of medicine both as a diagnostic aid and for procedural support. Screening programs may utilize POCUS as well. GPs use POCUS as part of the patient examination in addition to the patient’s history, physical examination and laboratory tests. Several organs can be scanned: Heart, lungs, aorta, abdominal organs, and gynecological/obstetrics or musculoskeletal scans can be done among others (3-8). POCUS has been part of GPs’ toolbox since the early 1980-ies (9-11). The use of POCUS in general practice has increased in the recent years (6, 12). GPs do not perform a comprehensive check like radiologists do, but rather a focused examination to rule-in or rule-out a suspected clinical condition (1). In that aspect, POCUS does not differ from the use of an ECG for assessing arrhythmias or HbA1c as a part of diabetes follow-up.
In this article, the participants all agreed that POCUS in general practice ought to be a “focused examination with a clear clinical purpose aimed to address specific clinical questions in symptomatic patients”. I totally agree to this principle. As an example is when a patient comes with a localized red, warm swollen mass suspicious of an abscess. A quick scan with a linear transducer can verify a hypoechoic cyst with hyperechoic debris prior to incision. When the next patient comes with a painful, swollen red leg, this may be due to erysipelas or to venous thromboembolism. Used in addition to the patient’s history, Wells score, CRP and D-dimer, the same linear transducer can reveal compressible or non-compressible veins, or maybe a cobblestone pattern as seen in case of erysipelas, and thus be helpful for making the correct diagnosis.
Applying POCUS in general practice, Andersen et al found the participants to agree upon that GPs ought to do some examinations, but there was no agreement upon which (1). GPs meet people in all phases of their lives, from antenatal care via childhood, adolescence and adulthood into old age and terminal care. GPs meet people throughout their lives with varying symptoms scattered all over White’s square in Figure 1 (13). Some of them are severely ill, but most are not. In general practice, the pre-test probability of serious illness is low. This, in addition to the low frequency of scans made by many GPs (12) may lead to frequent experiences of uncertainty. How GPs handle such uncertainty, is not known. It is an interesting finding that non-users of POCUS describe a clear distinction between appropriate and inappropriate use, users are less distinctive and describe a stepwise inclusion of procedures based on the GP’s interests and patient population (1). There are differences to the organisation of primary care between countries, as can be read in table 8.7 in the last OECD rapport (14). Gynecological scans, as an example, are commonly performed by GPs in Denmark (8) and Norway (12), whereas in Switzerland and Austria GPs do not perform these (5). These factors will affect what are considered appropriate use of POCUS in each country.
Andersen et al suggest guidelines for POCUS in general practice. At present, no such guidelines are internationally recognized. The American Academy of Family Physicians has recently updated its recommended curriculum guidelines for family medicine residents (15), and included a practical guide for GPs who use POCUS (16). There Government of Western Australia, department of Health provides recommendations for the use of imaging modalities (17, 18). The Society for ultrasonography in general practice in Norway provides some recommendations (19), but only available in Norwegian and the last update was in 2013. Lokkegaard et al published an article in 2020, where 60 Scandinavian GPs were invited to a Delphi process to establish a basic curriculum for POCUS (20). This may serve as a source for future guidelines.
The wide scope of general practice is known to create challenges for implementation of guidelines in general (21, 22). GPs for example prescribe drugs with an addictive potential and antibiotics that do not align with recommendations (23-28). Regarding POCUS, guidelines may be useful and easy to adhere to in the straightforward cases. However, for the many “shades of grey” in everyday practice for the common GP such guidelines and recommendations may be difficult to apply.
In Andersen’s study, the majority of clinicians opposed certification for the use of POCUS. They feared that this might lead to stricter regulations also in other fields of general practice. German GPs said something similar related to guidelines in a study by Wangler et al (22). Autonomy is a motivational factor for GPs (29).
Being a GP means balancing on a line in between over- and underdiagnosing patients. GPs must balance wise choices (30) and not missing out on those who are severely ill (31). Steinmetz and Lindgaard have previously shown that it is safe and beneficial for patients when GPs use POCUS of low to moderate complexity (32, 33). Diprose et al described how POCUS may be an accurate and cost-effective diagnostic tool compared to physical examination (34). Andersen et al found that the use of POCUS increases disease-specific diagnoses, reduces referrals to secondary care and implies a change in treatment in one of four patients (8). If the local GP performed the screening, Eggebo found that this could save pregnant women in rural areas from a 12-hour journey back and forth to the nearest hospital (11). Wordsworth found that POCUS used by GPs reduces healthcare expenses to a finite budget (35). POCUS has the potential to be an important and useful tool in general practice. The application of POCUS, and the required training and not least the indications, needs to be adapted to the unique properties of general practice and to the various health care systems.

References

1. Andersen CA, Guetterman TC, Fetters MD, Brodersen J, Davidsen AS, Graumann O, et al. General Practitioners' Perspectives on Appropriate Use of Ultrasonography in Primary Care in Denmark: A Multistage Mixed Methods Study. Ann Fam Med. 2022;20(3):211-9.
2. Moore CL, Copel JA. Point-of-care ultrasonography. N Engl J Med. 2011;364:749-57.
3. Andersen CA HS, Vela J, Rathleff MS, Jensen MB. Point-of-care ultrasound in general practice: A systematic review. Ann Fam Med. 2019;17:61-9.
4. Genc A, Ryk M, Suwala M, Zurakowska T, Kosiak W. Ultrasound imaging in the general practitioner's office - a literature review. Journal of ultrasonography. 2016;16:78-86.
5. Mengel-Jorgensen T, Jensen MB. Variation in the use of point-of-care ultrasound in general practice in various European countries. Results of a survey among experts. Eur J Gen Pract. 2016;22:274-7.
6. Myhr K, Sandvik H, Morken T, Hunskaar S. Point-of-care ultrasonography in Norwegian out-of-hours primary health care. Scand J Prim Health Care. 2017;35:120-5.
7. Sorensen B, Hunskaar S. Point-of-care ultrasound in primary care: a systematic review of generalist performed point-of-care ultrasound in unselected populations. Ultrasound J. 2019;11(1):31.
8. Aakjær Andersen C, Brodersen J, Davidsen AS, Graumann O, Jensen MBB. Use and impact of point-of-care ultrasonography in general practice: a prospective observational study. BMJ open. 2020;10(9):e037664.
9. Bratland SZ. [Ultrasonic diagnosis in general practice. An evaluation study]. Tidsskr Nor Laegeforen. 1985;105:1939-40.
10. Johansen I, Grimsmo A, Nakling J. [Ultrasonography in primary health care--experiences within obstetrics 1983-99]. Tidsskr Nor Laegeforen. 2002;122(20):1995-8.
11. Eggebo TM, Dalaker K. Ultralydundersøkelser av gravide i allmennpraksis [Ultrasonic diagnosis of pregnant women performed in general practice]. Tidsskr Nor Laegeforen. 1989;109:2979-81.
12. Myklestul HC, Skonnord T, Brekke M. Point-of-care ultrasound (POCUS) in Norwegian general practice. Scand J Prim Health Care. 2020:1-7.
13. White KL, Williams TF, Greenberg BG. The ecology of medical care. N Engl J Med. 1961;265:885-92.
14. Development OfEC-oa. Health at a Glance 2021 : OECD Indicators 2021 [Available from: https://www.oecd-ilibrary.org/sites/ae3016b9-en/1/3/8/3/index.html?itemI....
15. Physicians AAoF. Recommended Curriculum Guidelines for Family Medicine Residents Point-of-Care Ultrasound 2016 [Available from: https://www.aafp.org/dam/AAFP/documents/medical_education_residency/prog....
16. Shen-Wagner J, Deutchman M. Point-of-Care Ultrasound: A Practical Guide for Primary Care. Fam Pract Manag. 2020;27(6):33-40.
17. Mendelson RM, Montgomery BD. Towards appropriate imaging: Tips for practice. Aust Fam Physician. 2016;45(6):391-5.
18. Government of Western Australia DoH. Diagnostic Imaging Pathways 2015 [updated July 2019. Available from: http://www.imagingpathways.health.wa.gov.au/.
19. Norway F-SfUiGPi. Indikasjoner for ultralydundersøkelser i allmennpraksis - Indications for ultrasonography in general practice 2013 [Available from: http://fuanorge.no/files/Ultralydindikasjoner.pdf.
20. Lokkegaard T, Todsen T, Nayahangan LJ, Andersen CA, Jensen MB, Konge L. Point-of-care ultrasound for general practitioners: a systematic needs assessment. Scand J Prim Health Care. 2020:1-9.
21. Austad B, Hetlevik I, Mjølstad BP, Helvik AS. Applying clinical guidelines in general practice: a qualitative study of potential complications. BMC Fam Pract. 2016;17:92.
22. Wangler J, Jansky M. What is the significance of guidelines in the primary care setting? : Results of an exploratory online survey of general practitioners in Germany. Wien Med Wochenschr. 2021;171(13-14):321-9.
23. Siriwardena AN, Qureshi Z, Gibson S, Collier S, Latham M. GPs' attitudes to benzodiazepine and 'Z-drug' prescribing: a barrier to implementation of evidence and guidance on hypnotics. Br J Gen Pract. 2006;56(533):964-7.
24. Neves IT, Oliveira JSS, Fernandes MCC, Santos OR, Maria VAJ. Physicians' beliefs and attitudes about Benzodiazepines: a cross-sectional study. BMC Fam Pract. 2019;20(1):71.
25. Punwasi R, de Kleijn L, Rijkels-Otters JBM, Veen M, Chiarotto A, Koes B. General practitioners' attitudes towards opioids for non-cancer pain: a qualitative systematic review. BMJ open. 2022;12(2):e054945.
26. Zetts RM, Stoesz A, Garcia AM, Doctor JN, Gerber JS, Linder JA, et al. Primary care physicians' attitudes and perceptions towards antibiotic resistance and outpatient antibiotic stewardship in the USA: a qualitative study. BMJ open. 2020;10(7):e034983.
27. Karasneh RA, Al-Azzam SI, Ababneh M, Al-Azzeh O, Al-Batayneh OB, Muflih SM, et al. Prescribers' Knowledge, Attitudes and Behaviors on Antibiotics, Antibiotic Use and Antibiotic Resistance in Jordan. Antibiotics (Basel). 2021;10(7).
28. Biezen R, Roberts C, Buising K, Thursky K, Boyle D, Lau P, et al. How do general practitioners access guidelines and utilise electronic medical records to make clinical decisions on antibiotic use? Results from an Australian qualitative study. BMJ open. 2019;9(8):e028329.
29. Gronseth IM, Malterud K, Nilsen S. Why do doctors in Norway choose general practice and remain there? A qualitative study about motivational experiences. Scand J Prim Health Care. 2020;38(2):184-91.
30. Choosing wisely Clinician lists keyword=ultrasound: Choosing Wisely; [Available from: https://www.choosingwisely.org/clinician-lists/#keyword=ultrasound.
31. Gikas A, Triantafillidis JK. The role of primary care physicians in early diagnosis and treatment of chronic gastrointestinal diseases. Int J Gen Med. 2014;7:159-73.
32. Steinmetz P, Oleskevich S. The benefits of doing ultrasound exams in your office. J Fam Pract. 2016;65(8):517-23.
33. Lindgaard K, Riisgaard L. 'Validation of ultrasound examinations performed by general practitioners'. Scand J Prim Health Care. 2017;35:256-61.
34. Diprose W, Verster F, Schauer C. Re-examining physical findings with point-of-care ultrasound: a narrative review. N Z Med J. 2017;130:46-51.
35. Wordsworth S, Scott A. Ultrasound scanning by general practitioners: is it worthwhile? J Public Health Med. 2002;24:88-94.