The controversy around a randomised control trial study looking at nudge letters did not make it into the final report on the project.
The Department of Health, Disability and Ageing will likely continue to use so-called nudge letters to steer GP behaviour, with a new project report on a pathology requesting intervention failing to mention the ethical concerns it raised.
Published by DoHDA on Tuesday and dated August 2026, the GP Pathology Requesting Project Report rehashed the results of a randomised control trial which sought to evaluate how to best encourage GPs to request fewer pathology tests.
The research was conducted by the department in partnership with leading evidence-based medicine researchers Professor Denise O’Connor, Professor Paul Glasziou, and Professor Rachelle Buchbinder.
The study itself was published by The Lancet Primary Care in April.
Under the randomised control trial, roughly 6000 GPs who were in the top 10% of requesters for certain pathology tests were assigned to either a control group or received one of eight interventions.
Half of the interventions were delivered in letter format, and half were delivered in pamphlet format. Some contained cost data, some an invitation to a CPD course on pathology requesting, and some both.
There were no meaningful differences between the reactions of the different intervention groups, and just 7% of doctors took the department up on its CPD offer.
But taken as a whole, the intervention group saw a sharp decline in the overall rate of pathology test combination requests over the ensuing 12 months, compared to the control group.
“Sending feedback letters to GPs who request high volumes of pathology test combinations is a simple, low-cost intervention which can significantly change GP pathology requesting behaviour,” the DoHDA report concluded.
“The project resulted in an estimated 41,925 fewer pathology test combinations performed nationwide over the study period.
“Receiving any feedback resulted in a 32% relative reduction in the overall rate of pathology test combination requests over 12 months compared to the control group.
“Taken together, these findings provide robust evidence to support the use of personalised feedback for promoting evidence-based care in general practice.”
But what DoHDA’s report did not mention was the controversy which had surrounded the trial since it was first published in April.
In July, The Lancet Primary Care published correspondence from GP researchers Professor Louise Stone, Associate Professor Oliver Frank, and Dr Michael Tam raising concern about the ethical implications of the patient consent waiver granted by the Bond University Human Research Ethics Committee.
“General practitioners were not informed that they were included in a trial and were not given the opportunity to withhold their consent,” Professor Stone and colleagues wrote.
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“The researchers argue that gaining specific consent would make the study unfeasible and that government endorsement made consent unnecessary.
“We disagree. Governments may intervene in clinical practice without specific consent, but researchers should not.”
A waiver of consent, they said, should only be granted “if specific consent is impracticable”.
“We believe that it was possible to disclose the nature of the study, include opt-out consent, and enable general practitioners to exercise their right to withhold their data from the study,” the GP-researchers wrote.
Speaking to The Medical Republic in August, Professor Stone argued that the paper had understated the potential harm of the intervention.
“Although the various programs emphasise that GPs need to ‘reflect’ on the letters and consider the clinical relevance of the advice, nudge letters use the language of influence and marketing to subconsciously change behaviour,” she said.
The correspondence from Professor Stone and colleagues was significant enough for the original author team to respond, arguing in turn that the trial “carried no more than minimal risk of discomfort or inconvenience to participants compared with usual feedback”.
Curiously, the DoHDA report – which was dated after both the Professor Stone correspondence and the author rebuttal had already been published – did not allude to any of this.
