Providing feedback on cost has been demonstrated to decrease drug demand from clinicians. We conducted a prospective study with a step-wise intervention to test the hypothesis that providing information on the cost of drugs to clinicians would modify total expenditure. Participants included individuals who were admitted to the Royal Derby Hospital from November 2013 to November 2015 under the care of physicians. The cost of all antibiotics and inhaled corticosteroids was added to the electronic prescribing system. The main outcome was the weekly cost for antibiotics and inhaled corticosteroids in the intervention period compared to baseline costs. Mean weekly expenditure on antibiotics per patient decreased by £3.75 (95% confi dence intervals [CI] -6.52 to -0.98) after the intervention from a pre-intervention mean of £26.44, and then slowly increased subsequently by £0.10/week (95% CI +0.02 to +0.18). Mean weekly expenditure on inhaled corticosteroids per patient did not substantially change after the intervention (-£0.03, 95% CI -0.06 to -0.01 after the intervention from a pre-intervention mean of £5.29 per person). New clinical guidelines for inhaled corticosteroids were associated with a decrease in weekly expenditure, but provision of feedback on drug costs resulted in no sustained change in institutional expenditure. However, clinical guidelines have the potential to modify clinical prescribing behaviour.

We report a case of venous intravasation of barium sulphate occurring during a routine barium enema examination for investigation of rectal bleeding. The patient suffered a cardiopulmonary arrest, but made a full recovery after organ support in intensive care. Review of radiographs from the examination showed intravasated barium in pelvic vessels. We review the literature on this rare, but serious, complication of barium enema examination and suggest measures by which intravasation can be prevented.

Computed tomography (CT) is readily available in developed countries. As one of the side effects includes an increased risk of cancer, interventions that may encourage more judicious use of CT are important. Behavioural economics theory includes the use of nudges that aim to help more informed decisions to be made, although these have been rarely used in hospitals to date. We aimed to evaluate the impact of a simple educational message appended to the CT report on subsequent numbers of CT completed using a controlled interrupted time series design based in two teaching hospitals in the UK. The intervention was the addition of a non-directional educational message on the risk of ionising radiation to all CT reports. There was a statistically significant reduction in the number of CT requested in the intervention hospital compared to the control hospital (-4.6%, 95% confidence intervals-7.4 to-1.7, p=0.002) in the 12 months after the intervention was implemented. We conclude that a simple, non-directional nudge intervention has the capacity to modify clinician use of CT. This approach is cheap, and has potential in helping support doctors make informed decisions.

IntroductionParkinson’s disease (PD) is the most common movement disorder in the elderly and is characterised clinically by bradykinesia, tremor and rigidity. Diagnosing Parkinson’s can be difficult especially in the early stages. High-resolution nigrosome MRI offers promising diagnostic accuracy of patients with established clinical symptoms; however, it is unclear whether this may help to establish the diagnosis in the early stages of PD, when there is diagnostic uncertainty. In this scenario, a single photon emission CT scan using a radioactive dopamine transporter ligand can help to establish the diagnosis, or clinical follow-up may eventually clarify the diagnosis. A non-invasive, cost-effective diagnostic test that could replace this would be desirable. We therefore aim to prospectively test whether nigrosome MRI is as useful as DaTSCAN to establish the correct diagnosis in people with minor or unclear symptoms suspicious for PD.Methods and analysisIn a prospective study we will recruit 145 patients with unclear symptoms possibly caused by Parkinson’s from three movement disorder centres in the UK to take part in the study. We will record the Movement Disorder Society - Unified Parkinson’s Disease Rating Scale, and participants will undergo DaTSCAN and high-resolution susceptibility weighted MRI at a field strength of 3T. DaTSCANs will be assessed visually and semiquantitatively; MRI scans will be visually assessed for signal loss in nigrosome-1 by blinded investigators. We will compare how the diagnosis suggested by MRI compares with the diagnosis based on DaTSCAN and will also validate the diagnosis based on the two tests with a clinical examination performed at least 1 year after the initial presentation as a surrogate gold standard diagnostic test.Ethics and disseminationThe local ethics commission (Health Research Authority East Midlands – Derby Research Ethics Committee) has approved this study (REC ref.: 16/EM/0229). The study is being carried out under the principles of the Declaration of Helsinki (64th, 2013) and Good Clinical Practice standards. We have included a number of 15 research-funded DaTSCAN in the research protocol. This is to compensate for study site-specific National Health Service funding for this investigation in affected patients. We therefore have also obtained approval from the Administration of Radioactive Substances Administration Committee (ARSAC Ref 253/3629/35864). All findings will be presented at relevant scientific meetings and published in peer-reviewed journals, on the study website, and disseminated in lay and social media where appropriate.Trial registration numberNCT03022357; Pre-results.

PROCESS AND SYSTEMS Does cost feedback modify demand for common blood tests in secondary care? A prospective controlled intervention study Background Behavioural insights or 'nudge' theory suggests that nondirectional interventions may be used to modify human behaviour. We have tested the hypothesis that the provision of the cost of common blood tests with their results may modify subsequent demand for blood assays. Methods The study design was a prospective controlled intervention study. The individual and annual institutional cost of full blood count (FBC), urea and electrolytes (U&E) and liver function test (LFT) blood assays were added to the electronic results system for inpatients at the intervention teaching hospital, but not the control hospital. Results In the 12 months after the intervention was implemented, demand for FBC dropped by 3% (95% confidence interval (CI) 1-5; p<0.001), U&E by 2% (95% CI 0-4; p=0.054) and there was no change in demand for LFT compared to the control institution. Conclusions Providing cost feedback to clinicians for commonly used blood tests is a viable intervention that is associated with small reductions in demand for some, but not all blood assays. As this is an easily scalable approach, this has potential to enable efficient healthcare delivery, while also minimising the morbidity experienced by the patient.