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Aim: This study aimed to survey general practitioners' (GPs) and radiologists' perspectives on referrals, imaging justification, and unnecessary imaging in Norway. Materials and methods: The survey covered access to imaging, responsibilities, attitudes toward justification assessment, referral process, and demographics using multiple choice questions, statements to report agreement with using the Likert scale and one open question. Results: Forty radiologists and 58 GPs attending national conferences completed a web-based survey, with a 20/15% response rate, respectively. Both radiologists (97%) and GPs (100%) considered avoiding unnecessary examinations essential to their role in the healthcare service. Still, 91% of GPs admitted that they referred to imaging they thought was not helpful, while about 60% of the radiologists agreed that unnecessary imaging was conducted in their workplace. GPs reported pressure from patients and patients having private insurance as the most common reasons for doing unnecessary examinations. In contrast, radiologists reported a lack of clinical information and the inability to discuss patient cases with the GPs as the most common reasons. Conclusion: This study adds to our understanding of radiologists' and GPs' perspectives on unnecessary imaging and referrals. Better guidelines and, even more importantly, better communication between the referrer and the radiologist are needed. Addressing these issues can reduce unnecessary imaging and improve the quality and safety of care. [ABSTRACT FROM AUTHOR]

Rational: Low‐value radiological imaging threatens patient safety and efficient use of limited health resources. It is important to evaluate measures for reducing low‐value utilisation, to learn and to improve. Accordingly, the objective of this study was to qualitatively evaluate a pilot intervention for reducing low‐value imaging in Norway. Methods: Semi‐structured interviews were conducted aimed at describing stakeholders' experience with a multicomponent pilot intervention consisting of a standardised procedure for referral assessment, a standardised return letter, and information about the value and possible risks of magnetic resonance imaging‐examinations to the public. Data were analysed in line with qualitative content analysis with a deductive approach. Results: Seven healthcare providers were interviewed, including two radiologists, two radiographers, one manual therapist, one practice consultant and one general practitioner. Data analysis yielded four categories: (1) information and reception, (2) referral‐ and assessment processes, (3) suggestions for improvement and facilitation and (4) outcomes of the pilot intervention. Conclusions: The pilot intervention was deemed acceptable, feasible, engaging and relevant. Specific training in the use of the new procedure was suggested to improve the intervention. The simple design, as well as the positive acceptance demonstrated and the few resources needed, make the pilot intervention and methodology highly relevant for other settings or when aiming to reduce the number of other low‐value radiology examinations. [ABSTRACT FROM AUTHOR]

Background: Unwarranted temporal and geographical variations are acknowledged as a profound problem for equal access and justice in the provision of health services. Even more, they challenge the quality, safety, and efficiency of such services. This is highly relevant for imaging services. Objective: To analyse the temporal and geographical variation in the number of diagnostic images in Norway from 2013 to 2021. Methods: Data on outpatient imaging provided by the Norwegian Health Economics Administration (HELFO) and inpatient data afforded by fourteen hospital trusts and hospitals in Norway. Data include the total number of imaging examinations according to the Norwegian Classification of Radiological Procedures (NCRP). Analyses were performed with descriptive statistics. Results: More than 37 million examinations were performed in Norway during 2013–2021 giving an average of 4.2 million examinations per year. In 2021 there was performed and average of 0.8 examinations per person and 2.2 examinations per person for the age group > 80. There was a 9% increase in the total number of examinations from 2013 to 2015 and a small and stable decrease of 0.5% per year from 2015 to 2021 (with the exception of 2020 due to the pandemic). On average 71% of all examinations were outpatient examinations and 32% were conducted at private imaging centres. There were substantial variations between the health regions, with Region South-East having 53.1% more examinations per inhabitant than Region West. The geographical variation was even more outspoken when comparing catchment areas, where Oslo University Hospital Trust had twice as many examinations per inhabitant than Finnmark Hospital Trust. Conclusion: As the population in Norway is homogeneous it is difficult to attribute the variations to socio-economic or demographic factors. Unwarranted and supply-sensitive variations are challenging for healthcare systems where equal access and justice traditionally are core values. [ABSTRACT FROM AUTHOR]

Rationale: Increased attention to cancer care has instigated altered systems for screening, diagnosis, and management of various types of cancer, such as in the prostate. While such systems very likely have improved the quality of cancer care, they also result in the altered use of specific services, such as magnetic resonance imaging (MRI). Aims and Objective: To study the change in the use of prostate MRI in the Norwegian health care system from 2013 to 2021 and to investigate some reasons for and potential implications of this change. Method: Data from the Norwegian Health Economics Administration (HELFO), The Cancer Registry of Norway and Cause‐of‐death registry at the Norwegian Institute of public health and the health registry of Vestfold Hospital Trust were used for descriptive statistical analysis. Results: The number of MRIs of the prostate increased threefold from 2013 to 2021, representing an extra cost of 2 million USD in 2020. The incidence of prostate cancer was stable at about 5000 cases per year, corresponding to 178 per 100,000 men, indicating no increased overdiagnosis. However, the clinical staging has changed substantially during this period, indicating stage and grade migration. The number of negative biopsies was reduced, and there are three MRIs per reduced negative biopsy. The number of persons on active surveillance increased during the period. However, these changes are partly independent of the increase in the number of MRIs. Conclusion: There was a substantial increase in the number of prostate MRIs and thus an increase in costs. This appears to have contributed to the reduction of negative biopsies, improved staging and increased active surveillance. However, as these effects are partly independent of the increase in MRIs, we need to document the outcomes for patients from prostate MRIs as their opportunity costs are substantial. [ABSTRACT FROM AUTHOR]

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Background: One kind of overutilization of diagnostic imaging is low-value imaging, i.e., imaging that does not lead to altered clinical pathways or improved health outcomes. Despite having well-documented extension and consequences, low-value imaging is still widespread. The objective of this study was to identify the drivers for the use of low-value imaging in the Norwegian healthcare services. Methods: We conducted individual, semi-structured interviews among representatives from the health authorities, general practitioners, specialists working in hospitals, radiologists, radiographers, and managers of imaging departments. Data analysis was carried out in line with framework analysis consisting of five steps: Familiarization, indexing, charting, mapping, and interpretation. Results: The analysis included 27 participants and resulted in two themes. The stakeholders identified drivers in the healthcare system and in the interaction between radiologists, referrers, and patients. The identified drivers were categorized in sub-themes, such as organization, communication, competence, expectations, defensive medicine, roles and responsibilities, and referral quality and time constraints. The drivers interact with each other and may strengthen the effect of other drivers. Conclusions: Several drivers for low-value imaging in Norway were identified at all levels of the healthcare system. The drivers work simultaneously and synergistically. To free resources for high-value imaging, drivers should be targeted by appropriate measures at several levels to reduce low-value imaging. [ABSTRACT FROM AUTHOR]

Background: Even though imaging is essential to modern medicine, some examinations are of low value as they do not lead to any change in the management of the patient. The Choosing Wisely (CW) campaign aims to reduce the use of such services. In the Norwegian version of CW, specific magnetic resonance imaging (MRI) of the head, lower back, and knee are amongst others identified as potential low-value examinations. However, referral practice and access to imaging may drive low-value utilisation. By using registry data from 2019 and descriptive analysis, this study aimed to examine the role of referral practice and access to imaging on the use of specific CW-examinations in one representative area in Norway. Results: A total of 237,554 examinations were performed by four public and two private imaging facilities located within the area. Forty-two percent (19,210/45,289) of all MRI examinations were related to CW. Private imaging centres performed most of the CW-imaging. A total of 3700 referrers were identified, and 2.3% were identified as "high-referrers," accounting for 33% of all CW-examinations. Referrers' experience did not influence imaging utilisation. A subset of referrers ("super-referrers," 0.5%) accounted for 10% of CW-examinations. Distance to service had no impact on the use of CW-examinations. Conclusions: This study provides valuable insight into the use of imaging and referral practice in one representative area in Norway. A great variation in referral practice was observed. Therefore, targeting referrers with high referral rates may be a promising strategy for reducing the use of low-value imaging. Key points: MRI is frequently used, and a substantial proportion of MRIs are potential of low value. A small number of referrers account for a large proportion of potential low-value imaging. The use of imaging is not associated with travel distance to imaging facilities or referrers' experience. Targeting "high-referrers" may be a promising strategy for reducing low-value imaging. [ABSTRACT FROM AUTHOR]

This study mapped existing health-promotion provisions targeting adults in professional football clubs across England, the Netherlands, Norway, and Portugal, and explored motives behind the clubs' adoption of the European Fans in Training (EuroFIT) programme. We surveyed top-tier football clubs in the four countries and interviewed representatives from football clubs and the clubs' charitable foundation who delivered EuroFIT. The findings showed large between-country differences, with football clubs in England reporting far greater healthy lifestyle provision than other countries. Relatively few health-promotion programmes targeted adults, particularly in the Netherlands, Portugal, and Norway. Club representatives reported that the motives for adopting the EuroFIT programme often involved adhering to both the social objectives of the football club or club's foundation and business-related objectives. They viewed the scientific evidence and evaluation underpinning EuroFIT as helpful in demonstrating the value and potential future impact of both the programme and the clubs' wider corporate social responsibility provision. [ABSTRACT FROM AUTHOR]

Background: The SARS-COV-2 pandemic provides a natural intervention to assess practical priority setting and internal evaluation of specific health services, such as radiological services. Norway makes an excellent case as it had a very low infection rate and very few cases of COVID-19. Accordingly, the objective of this study is to use the changes in performed outpatient radiological examinations during the first stages of the SARS-COV-2 pandemic to assess the practical evaluation of specific radiological examinations in Norway. Methods: Data was collected retrospectively from the Norwegian Health Economics Administration (HELFO) in the years 2015–2020. Data included the number of performed outpatient imaging examinations at public hospitals and private imaging centers in Norway and was divided in to three periods based on the level of restrictions on elective health services. Results were analyzed with descriptive statistics. Results: In the first period there was a 45% reduction in outpatient radiology compared to the same time period in 2015–2019 while in period 2 and 3 there was a 25 and 6% reduction respectively. The study identified a list of specific potential low-value radiological examinations. While some of these are covered by the Choosing Wisely campaign, others are not. Conclusion: By studying the priority setting practice during the initial phases of the pandemic this study identifies a set of potential low value radiological examinations during the initial phases of the SARS-COV-2 pandemic. These examinations are candidates for closer assessments for health services quality improvement. [ABSTRACT FROM AUTHOR]

Background: Lifestyle interventions targeting physical activity, sedentary time and dietary behaviours have the potential to initiate and support behavioural change and result in public health gain. Although men have often been reluctant to engage in such lifestyle programs, many are at high risk of several chronic conditions. We have developed an evidence and theory-based, gender sensitised, health and lifestyle program (European Fans in Training (EuroFIT)), which is designed to attract men through the loyalty they feel to the football club they support. This paper describes the study protocol to evaluate the effectiveness and cost-effectiveness of the EuroFIT program in supporting men to improve their level of physical activity and reduce sedentary behaviour over 12 months.Methods: The EuroFIT study is a pragmatic, two-arm, randomised controlled trial conducted in 15 football clubs in the Netherlands, Norway, Portugal and the UK (England). One-thousand men, aged 30 to 65 years, with a self-reported Body Mass Index (BMI) ≥27 kg/m(2) will be recruited and individually randomised. The primary outcomes are objectively-assessed changes in total physical activity (steps per day) and total sedentary time (minutes per day) at 12 months after baseline assessment. Secondary outcomes are weight, BMI, waist circumference, resting systolic and diastolic blood pressure, cardio-metabolic blood biomarkers, food intake, self-reported physical activity and sedentary time, wellbeing, self-esteem, vitality and quality of life. Cost-effectiveness will be assessed and a process evaluation conducted. The EuroFIT program will be delivered over 12 weekly, 90-minute sessions that combine classroom discussion with graded physical activity in the setting of the football club. Classroom sessions provide participants with a toolbox of behaviour change techniques to initiate and sustain long-term lifestyle changes. The coaches will receive two days of training to enable them to create a positive social environment that supports men in engaging in sustained behaviour change.Discussion: The EuroFIT trial will provide evidence on the effectiveness and cost-effectiveness of the EuroFIT program delivered by football clubs to their male fans, and will offer insight into factors associated with success in making sustained changes to physical activity, sedentary behaviour, and secondary outcomes, such as diet.Trial Registration: Isrctn: 81935608 . Registered 16 June 2015. [ABSTRACT FROM AUTHOR]

Background: The focus in recent years on physical inactivity and metabolic disturbances in individuals with schizophrenia raises the question of potential effects of physical activity. Physical activity has shown beneficial effects on cognition in healthy older individuals as well as on symptom severity in depression. However, opinions diverge regarding whether aerobic high-intensity interval training reduces cognition and key symptoms in schizophrenia. The main objective for the trial is to investigate the potential effects of aerobic high-intensity interval training on neurocognitive function and mental symptoms in outpatients with schizophrenia.Methods/design: The trial is designed as a randomized controlled, observer-blinded clinical trial. Patients are randomized to 1 of 2 treatment arms with 12-week duration: aerobic high-intensity interval training or computer gaming skills training. All participants also receive treatment as usual. Primary outcome measure is neurocognitive function. Secondary outcome measures will be positive and negative symptoms, wellbeing, tobacco-smoking patterns and physiological/metabolic parameters. Patient recruitment takes place in catchment area-based outpatient clinics.Trial Registration: ClinicalTrials.gov NCT02205684 . Registered 29 July 2014. [ABSTRACT FROM AUTHOR]

Purpose: This study aimed to examine the association between changes in objectively measured overall physical activity (PA) and changes in fasting and postprandial plasma insulin, C-peptide, and glucose concentrations in type 2 diabetes-prone immigrant Pakistani men living in Norway and to examine whether this association is explained by changes in moderate and vigorous PA (MVPA) or changes in sedentary time. Methods: The current study is a secondary cohort analysis on data collected from the Physical Activity and Minority Health study, a randomized controlled trial aimed at increasing the PA level, and not sedentary time per se, in a group of sedentary immigrant Pakistani men (n = 150). For the present analyses, the two groups were merged and a cohort analysis was performed. Overall PA (counts per minute) and its subcomponents, sedentary time and MVPA, were measured with accelerometry. Outcome variables were measured after a 2-h standardized glucose tolerance test. Results: Change in overall PA was significantly associated with postprandial log-transformed plasma insulin (β = -0.002; 95% confidence interval (CI), -0.003 to 0.000; P = 0.008), C-peptide (β = -2.7; 95% CI, -4.9 to -0.5; P = 0.01), and glucose concentration (β = -0.006; 95% CI, -0.01 to -0.002; P = 0.002). Change in sedentary time was significantly and beneficially associated with changes in postprandial log-transformed plasma insulin (β = 0.002; 95% CI, 0.001-0.003; P = 0.001), C-peptide (β = 3.7; 95% CI, 1.5-6.0; P = 0.001), and glucose concentration (β = 0.006; 95% CI, 0.002-0.1; P = 0.002), independent of changes in MVPA, waist circumference, and other confounders. Conclusions: Increasing overall PA by reducing sedentary time seems as important as increasing time spent at MVPA in relation to postprandial plasma insulin and glucose levels in diabetes-prone immigrant men. [ABSTRACT FROM AUTHOR]

High prevalence of type 2 diabetes (T2D) is seen in some immigrant groups in Western countries, particularly in those from the Indian subcontinent. Our aims were to increase the physical activity (PA) level in a group of Pakistani immigrant men, and to see whether any increase was associated with reduced serum glucose and insulin concentrations. The intervention was developed in collaboration with the Pakistani community. It used a social cognitive theory framework and consisted of structured supervised group exercises, group lectures, individual counselling and telephone follow-up. One- hundred and fifty physically inactive Pakistani immigrant men living in Oslo, Norway, were randomised to either a control group or an intervention group. The 5-month intervention focused on increasing levels of PA, which were assessed by use of accelerometer (Actigraph MTI 7164) recordings. Risk of diabetes was assessed by serum glucose and insulin concentrations determined in a fasted state, and after an oral glucose tolerance test (OGTT). ANCOVA was used to assess differences between groups. There was a mean difference in PA between the two groups of 49 counts per minute per day, representing a 15 % (95 % CI = 8.7-21.2; P = 0.01) higher increase in total PA level in the intervention group than in the control group. Insulin values taken 2 h after an OGTT were reduced in the intervention group by 27 % (95 % CI = 18.9-35.0; P = 0.02) more than those in the control group. There were no differences in fasting or postprandial glucose values between the groups at the follow-up test. This type of intervention can increase PA and reduce serum insulin in Pakistani immigrant men, thereby presumably reducing their risk of T2D. [ABSTRACT FROM AUTHOR]

Physical activity (PA) is thought to prevent the metabolic syndrome (MetS), which is prevalent among south Asian immigrants in Western countries. The purpose of this study was to explore whether increasing PA improves the MetS and associated components in a group of Pakistani immigrant men living in Norway. One- hundred and fifty physically inactive Pakistani immigrant men were randomized to either a control group (CG) or an intervention group (IG). The 5 months intervention focused on increasing PA level, which was assessed using accelerometer recordings. Total PA level (counts min) increased significantly more in the IG than in the CG. The mean difference between the two groups was 49 counts min, which translates into a 15% (95% CI = 8.7% to 21.2%; P = 0.01) greater increase in total PA level in the IG than in the CG. Serum insulin concentration and waist circumference decreased more in the IG compared with the CG. Other MetS related factors and the prevalence of the MetS did not differ between the groups after the intervention. A five- month intervention program can increase PA level and cardiorespiratory fitness, and reduce insulin concentration and waist circumference. However this intervention program may not lower the prevalence of the complete MetS in Pakistani immigrant men. [ABSTRACT FROM AUTHOR]

Background: Reject analysis can be used as a quality indicator, and is an important tool in localizing areas where optimization is required. Reducing number of rejects is important yielding reduced patient exposure and increased cost-effectiveness. Purpose: To determine rejection rates and causes in direct digital radiography. Material and Methods: Data were collected during a three-month period in spring 2010 at two direct digital laboratories in Norway. All X-ray examinations, types, numbers, and reasons for rejections were obtained using automatic reject analysis software. Thirteen causes for rejection could be selected. Results: Out of the 27,284 acquired images, 3206 were rejected, yielding an overall rejection rate of 12%. Highest rejection rates were found for examination of knees, shoulders, and wrist. In all, 77% of the rejected images arose from positioning errors. Conclusion: An overall rejection rate of 12% indicates a need for optimizing radiographic practice in the department. [ABSTRACT FROM AUTHOR]

Background: To our knowledge, no studies have aimed at improving the PA level in south Asian immigrant men residing in Western countries, and few studies have considered the relevance of SCT constructs to the PA behaviour of this group in the long term. The observed low physical activity (PA) level among south Asian immigrants in Western countries may partly explain the high prevalence of cardiovascular diseases (CVD) and type 2 diabetes (T2D) in this group. We have shown previously in a randomised controlled trial, the Physical Activity and Minority Health study (PAMH) that a social cognitive based intervention can beneficially influence PA level and subsequently reduce waist circumference and insulin resistance in the short-term. In an extended follow-up of the PAMH study: we aimed 1) to determine if the intervention produced long-term positive effects on PA level six months after intervention (follow-up 2 (FU2)), and 2) to identify the social cognitive mediators of any intervention effects. Methods: Physically inactive Pakistani immigrant men (n = 150) who were free of CVD and T2D were randomly assigned to a five months PA intervention or a control group. Six months after the intervention ended, we telephoned all those who attended FU1 and invited them for a second follow-up test (FU2) (n = 133). PA was measured using ActiGraph accelerometers. Statistical differences between groups were determined by use of ANCOVA. Results: Significant differences (baseline to FU2) between the groups were found for all PA variables (e.g., total PA level, sedentary time, PA intensity). Support from family and outcome expectancies increased more in the intervention group compared with the control group. Self-efficacy did not differ significantly between groups. Conclusions: Our results show that a multi component PA programme can increase PA over the short and long term in a group of immigrant Pakistani men. However, we could not identify the factors that mediated these changes in PA. Protocol ID: 07112001326, NCT ID: NCT00539903 [ABSTRACT FROM AUTHOR]

Background: The level of physical fitness in south Asian immigrants living in Norway is largely unknown, but the level of physical activity seems to be low, possibly in part explaining their high prevalence of diabetes and cardiovascular diseases. However, previous studies have used self-reported measures of physical activity, and it might be questioned whether the previous data reflect the true physical activity level. Aim: To describe objectively measured physical activity level, cardiorespiratory fitness and diabetes risk in a group of Pakistani immigrant men living in Oslo, Norway. Methods: One hundred and fifty Pakistani immigrant men in the age group 25-60 years were included. Physical activity level was assessed with an accelerometer. Cardiorespiratory fitness was measured until exhaustion on a treadmill, and diabetes risk was evaluated with an oral glucose tolerance test. Results: Mean age was 37.3 years (SD=7.7). Total physical activity level was 308 counts/min (SD=131), and peak oxygen uptake was 34.2 ml⋅kg-1⋅min-1 (SD=5.6). Fifty percent of the participants had the metabolic syndrome, and 76% were obese. Physical activity level and cardiorespiratory fitness level were lower, and prevalence of the metabolic syndrome higher in a subgroup of taxi drivers as compared with those in other occupations (P<0.05). Conclusions: Physical activity and cardiorespiratory fitness levels are low and diabetes risk high among Pakistani immigrant men living in Oslo, especially in taxi drivers. [ABSTRACT FROM AUTHOR]

The European Fans in Training (EuroFIT) program integrated need-supportive motivational strategies from Self-Determination Theory (SDT) in the design of a healthy lifestyle program delivered to overweight or obese male football fans (n = 1113; mean age of 45.9 [SD = 9.0] years old and BMI of 33.2 kg/m2 [SD = 4.6]) in professional football club settings in the UK, Portugal, Norway and the Netherlands. With a critical realist approach, we developed a structured thematic framework analysis based on Self-Determination Theory (SDT) to investigate the process of change in men who participated in the EuroFIT randomized controlled trial (RCT). We examined whether men's experiences of the social context of EuroFIT, and whether their engagement with the program's motivational strategies supported or frustrated their basic psychological needs while attempting to change their lifestyle behaviours. We found that men in all countries perceived the social contexts of the EuroFIT program as mostly needs-supportive, and that they found engagement with most of the program components helpful in supporting their psychological needs when initiating health behaviour changes. However, some of the program elements in the EuroFIT program were perceived as needs-frustrating by some participants and need-supportive by others. Implications for the use of need-supportive motivational strategies in designing future lifestyle interventions in sport settings to promote health behaviour change among male football fans are discussed. • The EuroFIT program used motivational strategies from Self-Determination Theory. • Men perceived the social contexts of EuroFIT as mostly needs-supportive. • Men's changes were supported through a toolbox of self-regulatory skills. • Being with 'other-men-like-me' supported perceptions of relatedness. • Use of competition fostered controlling motives towards PA adoption for some. [ABSTRACT FROM AUTHOR]

Purpose: This study aimed to assess adherence to the Scandinavian guidelines, the justification of referrals, and the quality of referrals of patients with mild, minimal, and moderate head injuries in a selection of Norwegian hospitals., Methods: We collected 283 head CT referrals for head trauma patients at one hospital trust in Norway in 2022. The data included the patients' sex, age, and the referral text. Six radiologists independently assessed all referrals using a registration form developed based on the Scandinavian guidelines for patients with mild, minimal, and moderate head injuries and general referral guidelines. Descriptive statistics was used to analyze data on adherence to guidelines, while Gwet's AC1/2 was used to test the agreement between the raters., Results: This study found that 65% of referrals were assessed to be justified according to the guideline by at least one rater, while 17% were rated justified outside the guideline. In 52%, at least one rater required more information. There was good to moderate interrater agreement., Conclusions: Adherence to the Scandinavian guidelines and the quality of referrals of patients with mild, minimal, and moderate head injuries are low. Training and using S100B is recommended to improve the justification rate and quality of patient care., Competing Interests: Declarations. Ethics approval: The Regional Committees for Medical and Health Research Ethics ​approved the anonymous data collection, ref no.268688. Consent to participate: Informed consent was obtained from all individual participants included in the study. Consent for publication: All participants have consented to publication. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Background: Substantial overuse of health care services is identified and intensified efforts are incited to reduce low-value services in general and in imaging in particular., Objective: To report crucial success factors for developing and implementing interventions to reduce specific low-value imaging examinations based on a case study in Norway., Materials and Methods: Mixed methods design including one systematic review, one scoping review, implementation science, qualitative interviews, content analysis of stakeholders' input, and stakeholder deliberations., Results: The description and analysis of an intervention to reduce low-value imaging in Norway identifies six general success factors: 1) Acknowledging complexity: advanced knowledge synthesis, competence of the context, and broad and strong stakeholder involvement is crucial to manage de-implementation complexity. 2) Clear consensus-based criteria for selecting low-value imaging procedures are key. 3) Having a clear target group is critical. 4) Stakeholder engagement is essential to ascertain intervention relevance and compliance. 5) Active and well-motivated intervention collaborators is imperative. 6) Paying close attention to the mechanisms of low-value imaging and the barriers to reduce it is decisive., Conclusion: Reducing low-value imaging is crucial to increase the quality, safety, efficiency, and sustainability of the health services. Reducing low-value imaging is a complex task and paying attention to specific practical success factors is key., Competing Interests: Competing interests The authors declare that they have no competing interests., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: An intervention to reduce low-value magnetic resonance imaging (MRI) was designed and implemented in private imaging centres in Norway in October 2022. The intervention used return letters for poor referrals of MRI of the lower back, brain and knee at private imaging centres in Norway. The study aimed to investigate key stakeholders' experiences and assessment of the intervention and the specific research questions were: • How many return letters were sent during the study period? • What were the medical directors' and managers' experiences with and reflection on success factors for the intervention implementation and using return letters?, Methods: The number of return letters sent was collected directly from Norway's two main private imaging providers. Two semi-structured individual interviews were conducted with the medical directors of the imaging providers, as well as two focus group interviews with nine managers from the various private imaging centres operated by the two imaging providers., Results: In total, 1,182 return letters were sent for patients undergoing one of the three types of MRI examinations, and the number of return letters was highest at the beginning of the intervention. The interview analysis resulted in five categories: general experience, anchoring, organisation, return letter procedure and outcome. Sufficient information, anchoring and support were identified as crucial success factors., Conclusions: This study provides insights into the practical and crucial details of implementing interventions to reduce low-value imaging. The intervention was generally well received, and the high initial number of return letters decreased rapidly over the course of the study. Several key success factors were identified., (© 2024. The Author(s).)

Objectives: The objective of this study is to investigate the proportion of potentially low-value knee MRI in Norway and to provide an estimate of the related costs., Design: Register study based on conditional data extraction and analysis of data from Control and Reimbursement of Healthcare Claims registry in Norway., Setting: MRI in public specialist healthcare with universal health coverage (Norway)., Participants: 48 212 MRIs for 41 456 unique patients and 45 946 reimbursement claims., Outcome Measures: Proportion of MRIs of the knee that (1) did not have a relevant tentative diagnosis prior to the knee MRI, (2) did not have a relevant alternative image of the knee before the MRI or (3) did not have a relevant code from the specialist care within 6 months after the MRI, and those that had combinations of 1, 2 and 3. Estimated costs for those that had combinations of 1, 2 and 3., Results: Very few patients (6.4%) had a relevant diagnosis code or prior imaging examination when having the MRI and only 14.6% got a knee-related diagnosis code from the specialist care within 6 months after the MRI. 21.8% of the patients had knee X-ray, CT or ultrasound within 6 months before the MRI. Between 58% and 85% of patients having knee MRIs in Norway have no relevant examinations or diagnoses six months prior to or after the MRI examination. These examinations are unlikely to benefit patients and they correspond to between 24 108 and 35 416 MRIs at a cost of €6.7-€9.8 million per year., Conclusion: A substantial proportion of MRIs of the knee in Norway have no relevant examinations or diagnoses before or after the MRI and are potentially of low value. Reducing low-value MRIs could free resources for high-value imaging, reduce waiting times, improve the quality of care and increase patient safety and professional integrity., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Background: A growing body of evidence suggest that the children's physical activity (PA) level in early childhood education and care (ECEC) settings are insufficient. Since most children attend ECEC settings for many hours on most days of the week, and these institutions reach children across the socioeconomic spectrum, the ECEC settings may serve as an ideal avenue for increasing physical activity level, reduce sedentary time and enhance the overall health of young children. This paper investigates the effectiveness of the "Active Kindergarten - Active Children" study to increase children's PA level and reduce sedentary time within the ECEC setting., Methods: Accelerometers were used to asses PA and sedentary time. A total of 116 three to four-year olds took part in a randomised controlled trial in 11 ECEC settings. Participants were cluster-randomised, by ECEC setting, to either a 12 week staff-led and expert-supported intervention or a waiting list control group., Results: The intervention group increased time spent in moderate- and vigorous intensity PA by 10 min/day (95% CI = 3, 18; P = 0.01), took 1909 more steps per day (95% CI = 1130, 2688; P < 0.01) and reduced sedentary time with 14 min/day (95% CI = - 27, - 1; P = 0.04) compared to the control group. The intervention group had a 2.4 higher odds (95% CI = 1.05, 5.7; P = 0.04) of meeting the PA recommendations compared to the control group at follow-up., Conclusions: Our results show that a flexible staff-led and expert-supported multicomponent PA intervention can increase total PA level, moderate- and vigorous intensity PA and reduce time spent sedentary in three to four-year old children during their stay in ECEC settings., Trial Registration: The trial was retrospectively registered on September 19, 2020 and available online at ClinicalTrials.gov: No. NCT04555746 .