JOURNAL CLUB: Predictors of Provider Response to Clinical Decision Support: Lessons Learned From the Medicare Imaging Demonstration

Appropriateness and imaging outcomes of ultrasound, CT, and MR in the emergency department: a retrospective analysis from an urban academic center

PURPOSE

To evaluate the appropriateness and outcomes of ultrasound (US), computed tomography (CT), and magnetic resonance (MR) orders in the ED.

METHODS

We retrospectively reviewed consecutive US, CT, and MR orders for adult ED patients at a tertiary care urban academic center from January to March 2019. The American College of Radiology Appropriateness Criteria (ACRAC) guidelines were primarily used to classify imaging orders as "appropriate" or "inappropriate". Two radiologists in consensus judged specific clinical scenarios that were unavailable in the ACRAC. Final imaging reports were compared with the initial clinical suspicion for imaging and categorized into "normal", "compatible with initial diagnosis", "alternative diagnosis", or "inconclusive". The sample was powered to show a prevalence of inappropriate orders of 30% with a margin of error of 5%.

RESULTS

The rate of inappropriate orders was 59.4% for US, 29.1% for CT, and 33.3% for MR. The most commonly imaged systems for each modality were neuro (130/330) and gastrointestinal (95/330) for CT, genitourinary (132/330) and gastrointestinal (121/330) for US, neuro (273/330) and gastrointestinal (37/330) for MR. Compared to inappropriately ordered tests, the final reports of appropriate orders were nearly three times more likely to demonstrate findings compatible with the initial diagnosis for all modalities: US (45.5 vs. 14.3%, p < 0.001), CT (46.6 vs. 14.6%, p < 0.001), and MR (56.3 vs. 21.8%, p < 0.001). Inappropriate orders were more likely to show no abnormalities compared to appropriate orders: US (65.8 vs. 38.8%, p < 0.001), CT (62.5 vs. 34.2%, p < 0.001), and MR (61.8 vs. 38.7%, p < 0.001).

CONCLUSION

The prevalence of inappropriate imaging orders in the ED was 59.4% for US, 29.1% for CT, and 33.3% for MR. Appropriately ordered imaging was three times more likely to yield findings compatible with the initial diagnosis across all modalities.

Retrospective analysis of the impact of electronic medical record alerts on low value care in a pediatric hospital

OBJECTIVES

Hospital costs continue to rise unsustainably. Up to 20% of care is wasteful including low value care (LVC). This study aimed to understand whether electronic medical record (EMR) alerts are effective at reducing pediatric LVC and measure the impact on hospital costs.

MATERIALS AND METHODS

Using EMR data over a 76-month period, we evaluated changes in 4 LVC practices following the implementation of EMR alerts, using time series analysis to control for underlying time-based trends, in a large pediatric hospital in Australia. The main outcome measure was the change in rate of each LVC practice. Balancing measures included the rate of alert adherence as a proxy measure for risk of alert fatigue. Hospital costs were calculated by the volume of LVC avoided multiplied by the unit costs. Costs of the intervention were calculated from clinician and analyst time required.

RESULTS

All 4 LVC practices showed a statistically significant reduction following alert implementation. Two LVC practices (blood tests) showed an abrupt change, associated with high rates of alert adherence. The other 2 LVC practices (bronchodilator use in bronchiolitis and electrocardiogram ordering for sleeping bradycardia) showed an accelerated rate of improvement compared to baseline trends with lower rates of alert adherence. Hospital savings were $325 to $180 000 per alert.

DISCUSSION AND CONCLUSION

EMR alerts are effective in reducing pediatric LVC practices and offer a cost-saving opportunity to the hospital. Further efforts to leverage EMR alerts in pediatric settings to reduce LVC are likely to support future sustainable healthcare delivery.

Features and functions of decision support systems for appropriate diagnostic imaging: a scoping review

BACKGROUND

Diagnostic imaging decision support (DI-DS) systems could be effective tools for reducing inappropriate diagnostic imaging examinations. Since effective design and evaluation of these systems requires in-depth understanding of their features and functions, the present study aims to map the existing literature on DI-DS systems to identify features and functions of these systems.

METHODS

The search was performed using Scopus, Embase, PubMed, Web of Science, and Cochrane Central Registry of Controlled Trials (CENTRAL) and was limited to 2000 to 2021. Analytical studies, descriptive studies, reviews and book chapters that explicitly addressed the functions or features of DI-DS systems were included.

RESULTS

A total of 6,046 studies were identified. Out of these, 55 studies met the inclusion criteria. From these, 22 functions and 22 features were identified. Some of the identified features were: visibility, content chunking/grouping, deployed as a multidisciplinary program, clinically valid and relevant feedback, embedding current evidence, and targeted recommendations. And, some of the identified functions were: displaying an appropriateness score, recommending alternative or more appropriate imaging examination(s), providing recommendations for next diagnostic steps, and providing safety alerts.

CONCLUSIONS

The set of features and functions obtained in the present study can provide a basis for developing well-designed DI-DS systems, which could help to improve adherence to diagnostic imaging guidelines, minimize unnecessary costs, and improve the outcome of care through appropriate diagnosis and on-time care delivery.

Development and implementation of a clinical decision support-based initiative to drive intravenous fluid prescribing

OBJECTIVE

Studies suggest superior outcomes with use of intravenous (IV) balanced fluids compared to normal saline (NS). However, significant fluid prescribing variability persists, highlighting the knowledge-to-practice gap. We sought to identify contributors to prescribing variation and utilize a clinical decision support system (CDSS) to increase institutional balanced fluid prescribing.

MATERIALS AND METHODS

This single-center informatics-enabled quality improvement initiative for patients hospitalized or treated in the emergency department included stepwise interventions of 1) identification of design factors within the computerized provider order entry (CPOE) of our electronic health record (EHR) that contribute to preferential NS ordering, 2) clinician education, 3) fluid stocking modifications, 4) re-design and implementation of a CDSS-integrated IV fluid ordering panel, and 5) comparison of fluid prescribing before and after the intervention. EHR-derived prescribing data was analyzed via single interrupted time series.

RESULTS

Pre-intervention (3/2019-9/2019), balanced fluids comprised 33% of isotonic fluid orders, with gradual uptake (1.4%/month) of balanced fluid prescribing. Clinician education (10/2019-2/2020) yielded a modest (4.4%/month, 95% CI 1.6-7.2, p = 0.01) proportional increase in balanced fluid prescribing, while CPOE redesign (3/2020) yielded an immediate (20.7%, 95% CI 17.7-23.6, p < 0.0001) and sustained increase (72% of fluid orders in 12/2020). The intervention proved most effective among those with lower baseline balanced fluids utilization, including emergency medicine (57% increase, 95% CI 0.7-1.8, p < 0.0001) and internal medicine/subspecialties (18% increase, 95% CI 14.4-21.3, p < 0.0001) clinicians and substantially reduced institutional prescribing variation.

CONCLUSION

Integration of CDSS into an EHR yielded a robust and sustained increase in balanced fluid prescribing. This impact far exceeded that of clinician education highlighting the importance of CDSS.

Retrospective Evaluation of Artificial Intelligence Leveraging Free-Text Imaging Order Entry to Facilitate Federally Required Clinical Decision Support

OBJECTIVE

The Protecting Access to Medicare Act mandates clinical decision support (CDS) at imaging order entry, necessitating the use of structured indications to map CDS scores. We evaluated the performance of a commercially available artificial intelligence (AI) tool leveraging free-text order entry to facilitate provider selection of the necessary structured indications.

METHODS

Our institution implemented an AI tool offering predicted structured indications based upon the ordering provider's entry of a free-text reason for examination. Providers remained able to order via the traditional direct search for structured indications. Alternatively, they could take the new free-text-AI approach allowing them to select from AI-predicted indications, perform additional direct searches, indicate no matching indication, or exit CDS workflow. We hypothesized the free-text-AI approach would be elected more often and the AI tool would be successful in facilitating selection of structured indications. We reviewed advanced imaging orders (n = 40,053) for the first 3 months (February to May 2020) since implementation.

RESULTS

Providers were more likely (P < .001) to choose the free-text-AI approach (23,580; 58.9%) to order entry over direct search for structured indications (16,473; 41.1%). The AI tool yielded alerts with predicted indications in 91.7% (n = 21,631) of orders with free text. Ultimately, providers chose AI-predicted indications in 57.7% (n = 12,490) of cases in which they were offered by the tool.

DISCUSSION

Providers significantly more often elected the new free-text-AI approach to order entry for CDS, suggesting provider preference over the traditional approach. The AI tool commonly predicted indications acceptable to ordering providers.

Interventions to reduce low-value imaging - a systematic review of interventions and outcomes

BACKGROUND

It is estimated that 20-50% of all radiological examinations are of low value. Many attempts have been made to reduce the use of low-value imaging. However, the comparative effectiveness of interventions to reduce low-value imaging is unclear. Thus, the objective of this systematic review was to provide an overview and evaluate the outcomes of interventions aimed at reducing low-value imaging.

METHODS

An electronic database search was completed in Medline - Ovid, Embase-Ovid, Scopus, and Cochrane Library for citations between 2010 and 2020. The search was built from medical subject headings for Diagnostic imaging/Radiology, Health service misuse or medical overuse, and Health planning. Keywords were used for the concept of reduction and avoidance. Reference lists of included articles were also hand-searched for relevant citations. Only articles written in English, German, Danish, Norwegian, Dutch, and Swedish were included. The Mixed Methods Appraisal Tool was used to appraise the quality of the included articles. A narrative synthesis of the final included articles was completed.

RESULTS

The search identified 15,659 records. After abstract and full-text screening, 95 studies of varying quality were included in the final analysis, containing 45 studies found through hand-searching techniques. Both controlled and uncontrolled before-and-after studies, time series, chart reviews, and cohort studies were included. Most interventions were aimed at referring physicians. Clinical practice guidelines (n = 28) and education (n = 28) were most commonly evaluated interventions, either alone or in combination with other components. Multi-component interventions were often more effective than single-component interventions showing a reduction in the use of low-value imaging in 94 and 74% of the studies, respectively. The most addressed types of imaging were musculoskeletal (n = 26), neurological (n = 23) and vascular (n = 16) imaging. Seventy-seven studies reported reduced low-value imaging, while 3 studies reported an increase.

CONCLUSIONS

Multi-component interventions that include education were often more effective than single-component interventions. The contextual and cultural factors in the health care systems seem to be vital for successful reduction of low-value imaging. Further research should focus on assessing the impact of the context in interventions reducing low-value imaging and how interventions can be adapted to different contexts.

Radiation concerns in frequent flyer patients: Should imaging history influence decisions about recurrent imaging?

Radiation risks from diagnostic imaging have captured the attention of patients and medical practitioners alike, yet it remains unclear how these considerations can best be incorporated into clinical decision making. This manuscript presents a framework to consider these issues in a potentially at-risk population, the so called "frequent flyer" patients undergoing a large amount of recurrent imaging over time. Radiation risks from the low-dose exposures of diagnostic imaging are briefly reviewed, as applied to recurrent exposures. Some scenarios are then explored in which it may be helpful to incorporate knowledge of a patient's imaging history. There is no simple or uniformly applicable approach to these challenging and often nuanced clinical decisions. The complexity and variability of the underlying disease states and trajectories argues against alerting mechanisms based on a simple cumulative dose threshold. Awareness of imaging history may instead be beneficial in encouraging physicians and patients to take the long view, and to identify those populations of frequent flyers that might benefit from alternative imaging strategies.

Assessment of Primary Care Clinician Concordance With Guidelines for Use of Magnetic Resonance Imaging in Patients With Nonspecific Low Back Pain in the Veterans Affairs Health System

IMPORTANCE

Magnetic responance imaging (MRI) of the lumbar spine that is not concordant with treatment guidelines for low back pain represents an unnecessary cost for US health plans and may be associated with adverse effects. Use of MRI in the US Department of Veterans Affairs (VA) primary care clinics remains unknown.

OBJECTIVE

To assess the use of MRI scans during the first 6 weeks (early MRI scans) of episodes of nonspecific low back pain in VA primary care sites and to determine if historical concordance can identify clinicians and sites that are the least concordant with guidelines.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study of electronic health records from 944 VA primary care sites from the 3 years ending in 2016. Data were analyzed between January 2017 and August 2019. Participants were patients with new episodes of nonspecific low back pain and the primary care clinicians responsible for their care.

EXPOSURES

MRI scans.

MAIN OUTCOMES AND MEASURES

The proportion of early MRI scans at VA primary care clinics was assessed. Clinician concordance with published guidelines over 2 years was used to select clinicians expected to have low concordance in a third year.

RESULTS

A total of 1 285 405 new episodes of nonspecific low back pain from 920 547 patients (mean [SD] age, 56.7 [15.8] years; 93.6% men) were attributed to 9098 clinicians (mean [SD] age, 52.1 [10.1] years; 55.7% women). An early MRI scan of the lumbar spine was performed in 31 132 of the episodes (2.42%; 95% CI, 2.40%-2.45%). Historical concordance was better than a random draw in selecting the 10% of clinicians who were subsequently the least concordant with published guidelines. For primary care clinicians, the area under the receiver operating characteristic curve was 0.683 (95% CI, 0.658-0.701). For primary care sites, the area was under this curve was 0.8035 (95% CI, 0.754-0.855). The 10% of clinicians with the least historical concordance were responsible for just 19.2% of the early MRI scans performed in the follow-up year.

CONCLUSIONS AND RELEVANCE

VA primary care clinics had low rates of use of early MRI scans. A history of low concordance with imaging guidelines was associated with subsequent low concordance but with limited potential to select clinicians most in need of interventions to implement guidelines.

Evaluating the alert appropriateness of clinical decision support systems in supporting clinical workflow

The overwhelming number of medication alerts generated by clinical decision support systems (CDSS) has led to inappropriate alert overrides, which may lead to unintended patient harm. This review highlights the factors affecting the alert appropriateness of CDSS and barriers to the fit of CDSS alert with clinical workflow. A literature review was conducted to identify features and functions pertinent to CDSS alert appropriateness using the five rights of CDSS. Moreover, a process improvement method, namely, Lean, was used as a tool to optimise clinical workflows, and the appropriate design for CDSS alert using a human automation interaction (HAI) model was recommended. Evaluating the appropriateness of CDSS alert and its impact on workflow provided insights into how alerts can be designed and triggered effectively to support clinical workflow. The application of Lean methods and tools to analyse alert efficiencies in supporting workflow in this study provides an in-depth understanding of alert-workflow fit problems and their root cause, which is required for improving CDSS design. The application of the HAI model is recommended in the design of CDSS alerts to support various levels and stages of alert automations, namely, information acquisition and analysis, decision action and action implementation.

Clinical Decision Support: The Law, the Future, and the Role for Radiologists

Clinical Decision Support (CDS) was designed as an interactive, electronic tool for use by clinicians that communicates Appropriate Use Criteria (AUC) information to the user and assists them in making the most appropriate treatment decision for a patient's specific clinical condition. Policymakers recognized AUC as a potential solution to control inappropriate utilization of imaging and made CDS mandatory in the Protecting Access to Medicare Act of 2014. In the years since Protecting Access to Medicare Act, data on the potential impact of CDS has been mixed and much of the physician community has expressed concern about the logistics of the program. This article aims to review the legislation behind the AUC program, the events that have transpired since, and some of the challenges and opportunities facing radiologists in the current environment.

Impact of Radiologist-Driven Change-Order Requests on Outpatient CT and MRI Examinations

PURPOSE

To assess impact of electronic medical record-embedded radiologist-driven change-order request on outpatient CT and MRI examinations.

METHODS

Outpatient CT and MRI requests where an order change was requested by the protocoling radiologist in our tertiary care center, from April 11, 2017, to January 3, 2018, were analyzed. Percentage and categorization of requested order change, provider acceptance of requested change, patient and provider demographics, estimated radiation exposure reduction, and cost were analyzed. P < .05 was used for statistical significance.

RESULTS

In 79,310 outpatient studies in which radiologists determined protocol, change-order requests were higher for MRI (5.2%, 1,283 of 24,553) compared with CT (2.9%, 1,585 of 54,757; P < .001). Provider approval of requested change was equivalent for CT (82%, 1,299 of 1,585) and MRI (82%, 1,052 of 1,283). Change requests driven by improper contrast media utilization were most common and different between CT (76%, 992 of 1,299) and MRI (65%, 688 of 1,052; P < .001). Changing without and with intravenous contrast orders to with contrast only was most common for CT (39%, 505 of 1,299) and with and without intravenous contrast to without contrast only was most common for MRI (26%, 274 of 1,052; P < .001). Of approved changes in CT, 51% (661 of 1,299) resulted in lower radiation exposure. Approved changes frequently resulted in less costly examinations (CT 67% [799 of 1,198], MRI 48% [411 of 863]).

CONCLUSION

Outpatient CT and MRI orders are deemed incorrect in 2.9% to 5% of cases. Radiologist-driven change-order request for CT and MRI are well accepted by ordering providers and decrease radiation exposure associated with imaging.

Joint Design with Providers of Clinical Decision Support for Value-Based Advanced Shoulder Imaging

BACKGROUND

Provider orders for inappropriate advanced imaging, while rarely altering patient management, contribute enough to the strain on available health care resources, and therefore the United States Congress established the Appropriate Use Criteria Program.

OBJECTIVES

To examine whether co-designing clinical decision support (CDS) with referring providers will reduce barriers to adoption and facilitate more appropriate shoulder ultrasound (US) over magnetic resonance imaging (MRI) in diagnosing Veteran shoulder pain, given similar efficacies and only 5% MRI follow-up rate after shoulder US.

METHODS

We used a theory-driven, convergent parallel mixed-methods approach to prospectively (1) determine medical providers' reasons for selecting MRI over US in diagnosing shoulder pain and identify barriers to ordering US, (2) co-design CDS, informed by provider interviews, to prompt appropriate US use, and (3) assess CDS impact on shoulder imaging use. CDS effectiveness in guiding appropriate shoulder imaging was evaluated through monthly monitoring of ordering data at our quaternary care Veterans Hospital. Key outcome measures were appropriate MRI/US use rates and transition to ordering US by both musculoskeletal specialist and generalist providers. We assessed differences in ordering using a generalized estimating equations logistic regression model. We compared continuous measures using mixed effects analysis of variance with log-transformed data.

RESULTS

During December 2016 to March 2018, 569 (395 MRI, 174 US) shoulder advanced imaging examinations were ordered by 111 providers. CDS "co-designed" in collaboration with providers increased US from 17% (58/335) to 50% (116/234) of all orders (p < 0.001), with concomitant decrease in MRI. Ordering appropriateness more than doubled from 31% (105/335) to 67% (157/234) following CDS (p < 0.001). Interviews confirmed that generalist providers want help in appropriately ordering advanced imaging.

CONCLUSION

Partnering with medical providers to co-design CDS reduced barriers and prompted appropriate transition to US from MRI for shoulder pain diagnosis, promoting evidence-based practice. This approach can inform the development and implementation of other forms of CDS.

Characteristics of knowledge content in a curated online evidence library

Objective

To describe types of recommendations represented in a curated online evidence library, report on the quality of evidence-based recommendations pertaining to diagnostic imaging exams, and assess underlying knowledge representation.

Materials and Methods

The evidence library is populated with clinical decision rules, professional society guidelines, and locally developed best practice guidelines. Individual recommendations were graded based on a standard methodology and compared using chi-square test. Strength of evidence ranged from grade 1 (systematic review) through grade 5 (recommendations based on expert opinion). Finally, variations in the underlying representation of these recommendations were identified.

Results

The library contains 546 individual imaging-related recommendations. Only 15% (16/106) of recommendations from clinical decision rules were grade 5 vs 83% (526/636) from professional society practice guidelines and local best practice guidelines that cited grade 5 studies (P < .0001). Minor head trauma, pulmonary embolism, and appendicitis were topic areas supported by the highest quality of evidence. Three main variations in underlying representations of recommendations were "single-decision," "branching," and "score-based."

Discussion

Most recommendations were grade 5, largely because studies to test and validate many recommendations were absent. Recommendation types vary in amount and complexity and, accordingly, the structure and syntax of statements they generate. However, they can be represented in single-decision, branching, and score-based representations.

Conclusion

In a curated evidence library with graded imaging-based recommendations, evidence quality varied widely, with decision rules providing the highest-quality recommendations. The library may be helpful in highlighting evidence gaps, comparing recommendations from varied sources on similar clinical topics, and prioritizing imaging recommendations to inform clinical decision support implementation.

Clinical Decision Support for Ordering CTA-PE Studies in the Emergency Department-A Pilot on Feasibility and Clinical Impact in a Tertiary Medical Center

PURPOSE

To determine the feasibility and impact of Clinical Decision Support for imaging ordering.

METHODS

A survey of 231 emergency providers identified Computed tomography angiography (CTA)-Pulmonary embolism (PE) as an overutilized study. We developed an algorithm that combined established risk scores to stratify patients for PE work-up (recommendations: CTA, D-dimer or no further testing); the algorithm was integrated into the Epic Radiology Information Ordering System.

RESULTS

Among 872 studies requested, 479 (55%) received a recommendation to change their order: 6 (1.3%) were cancelled; 13 (2.7%) changed to a D-dimer, and 460 (96%) proceeded with CTA. Of the 853 studies conducted, 8.2% were positive for PE. The algorithm had good discriminatory power with positivity rates of 12.0% (CT), 10.0% (D-dimer), and 2.6% (no further testing). Compliance with the recommendation ranged from 12%-68% (mean 45%) with 10% correlation between compliance and positivity rates.

CONCLUSION

While the CDS algorithm was accurate, it had only a minimal impact on ordering practices, in part due to heterogeneity in physician adherence.

What Physicians and Health Organizations Should Know About Mandated Imaging Appropriate Use Criteria

The Appropriate Use Criteria Program, enacted by the Centers for Medicare & Medicaid Services in response to the Protecting Access to Medicare Act of 2014 (PAMA), aims to reduce inappropriate and unnecessary imaging by mandating use of clinical decision support (CDS) by all providers who order advanced imaging examinations (magnetic resonance imaging; computed tomography; and nuclear medicine studies, including positron emission tomography). Beginning 1 January 2020, documentation of an interaction with a certified CDS system using approved appropriate use criteria will be required on all Medicare claims for advanced imaging in all emergency department patients and outpatients as a prerequisite for payment. The Appropriate Use Criteria Program will initially cover 8 priority clinical areas, including several (such as headache and low back pain) commonly encountered by internal medicine providers. All providers and organizations that order and provide advanced imaging must understand program requirements and their options for compliance strategies. Substantial resources and planning will be needed to comply with PAMA regulations and avoid unintended negative consequences on workflow and payments. However, robust evidence supporting the desired outcome of reducing inappropriate use of advanced imaging is lacking.

Communication Practices of Mammography Facilities and Timely Follow-up of a Screening Mammogram with a BI-RADS 0 Assessment

RATIONALE AND OBJECTIVES

The objective of this study was to evaluate the association of communication practices with timely follow-up of screening mammograms read as Breast Imaging Reporting and Data Systems (BI-RADS) 0 in the Population-based Research Optimizing Screening through Personalized Regimens (PROSPR) consortium.

MATERIALS AND METHODS

A radiology facility survey was conducted in 2015 with responses linked to screening mammograms obtained in 2011-2014. We considered timely follow-up to be within 15 days of the screening mammogram. Generalized estimating equation models were used to evaluate the association between modes of communication with patients and providers and timely follow-up, adjusting for PROSPR site, patient age, and race and ethnicity.

RESULTS

The analysis included 34,680 mammography examinations with a BI-RADS 0 assessment among 28 facilities. Across facilities, 85.6% of examinations had a follow-up within 15 days. Patients in a facility where routine practice was to contact the patient by phone if follow-up imaging was recommended were more likely to have timely follow-up (odds ratio [OR] 4.63, 95% confidence interval [CI] 2.76-7.76), whereas standard use of mail was associated with reduced timely follow-up (OR 0.47, 95% CI 0.30-0.75). Facilities that had standard use of electronic medical records to report the need for follow-up imaging to a provider had less timely follow-up (OR 0.56, 95% CI 0.35-0.90). Facilities that routinely contacted patients by mail if they missed a follow-up imaging visit were more likely to have timely follow-up (OR 1.65, 95% CI 1.02-2.69).

CONCLUSIONS

Our findings support the value of telephone communication to patients in relation to timely follow-up. Future research is needed to evaluate the role of communication in completing the breast cancer screening episode.

Contributions from the 2017 Literature on Clinical Decision Support

Objectives:  To summarize recent research and select the best papers published in 2017 in the field of computerized clinical decision support for the Decision Support section of the International Medical Informatics Association (IMIA) yearbook.

Methods:  A literature review was performed by searching two bibliographic databases for papers referring to clinical decision support systems (CDSSs). The aim was to identify a list of candidate best papers from the retrieved bibliographic records, which were then peer-reviewed by external reviewers. A consensus meeting of the IMIA editorial team finally selected the best papers on the basis of all reviews and the section editors' evaluation.

Results:  Among the 1,194 retrieved papers, the entire review process resulted in the selection of four best papers. The first paper studies the impact of recency and of longitudinal extent of electronic health record (EHR) datasets used to train a data-driven predictive model of inpatient admission orders. The second paper presents a decision support tool for surgical team selection, relying on the history of surgical team members and the specific characteristics of the patient. The third paper compares three commercial drug-drug interaction knowledge bases, particularly against a reference list of highly-significant known interactions. The fourth paper focuses on supporting the diagnosis of postoperative delirium using an adaptation of the “anchor and learn” framework, which was applied in unstructured texts contained in EHRs.

Conclusions:  The conducted review illustrated also this year that research in the field of CDSS is very active. Of note is the increase in publications concerning data-driven CDSSs, as revealed by the review process and also reflected by the four papers that have been selected. This trend is in line with the current attention that “Big Data” and data-driven artificial intelligence have gained in the domain of health and CDSSs in particular.

Factors associated with imaging overuse in the emergency department: A systematic review

BACKGROUND

Emergency departments (ED) are sites of prevalent imaging overuse; however, determinants that drive imaging in this setting are not well-characterized. We systematically reviewed the literature to summarize the determinants of imaging overuse in the ED.

METHODS

We searched MEDLINE® and Embase® from January 1998 to March 2017. Studies were included if they were written in English, contained original data, pertained to a U.S. population, and identified a determinant associated with overuse of imaging in the ED.

RESULTS

Twenty relevant studies were included. Fourteen evaluated computerized tomography (CT) scanning in patents presenting to a regional ED who were then transferred to a level 1 trauma center; incomplete transfer of data and poor image quality were the most frequently described reasons for repeat scanning. Unnecessary pre-transfer scanning or repeated scanning after transfer, in multiple studies, was highest among older patients, those with higher Injury Severity Scores (ISS) and those being transferred further. Six studies explored determinants of overused imaging in the ED in varied conditions, with overuse greater in older patients and those having more comorbid diseases. Defensive imaging reportedly influenced physician behavior. Less integration of services across the health system also predisposed to overuse of imaging.

CONCLUSIONS

The literature is heterogeneous with surprisingly few studies of determinants of imaging in minor head injury or of spine imaging. Older patient age and higher ISS were the most consistently associated with ED imaging overuse. This review highlights the need for precise definitions of overuse of imaging in the ED.

Medicare Imaging Demonstration: Assessing Attributes of Appropriate Use Criteria and Their Influence on Ordering Behavior

OBJECTIVE

Persistent concern exists about the variable and possibly inappropriate utilization of high-cost imaging tests. The purpose of this study is to assess the influence of appropriate use criteria attributes on altering ambulatory imaging orders deemed inappropriate.

MATERIALS AND METHODS

This secondary analysis included Medicare Imaging Demonstration data collected from three health care systems in 2011-2013 via the use of clinical decision support (CDS) during ambulatory imaging order entry. The CDS system captured whether orders were inappropriate per the appropriate use criteria of professional societies and provided advice during the intervention period. For orders deemed inappropriate, we assessed the impact of the availability of alternative test recommendations, conflicts with local best practices, and the strength of evidence for appropriate use criteria on the primary outcome of cancellation or modification of inappropriate orders. Expert review determined conflicts with local best practices for 250 recommendations for abdominal and thoracic CT orders. Strength of evidence was assessed for the 15 most commonly triggered recommendations that were deemed inappropriate. A chi-square test was used for univariate analysis.

RESULTS

A total of 1691 of 63,222 imaging test orders (2.7%) were deemed inappropriate during the intervention period; this amount decreased from 364 of 11,675 test orders (3.1%) in the baseline period (p < 0.00001). Of 270 inappropriate recommendations with alternative test recommendations, 28 (10.4%) were modified, compared with four of 1024 inappropriate recommendations without alternatives (0.4%) (p < 0.0001). Seventy-eight of 250 recommendations (31%) conflicted with local best practices, but only six of 69 inappropriate recommendations (9%) conflicted (p < 0.001). No inappropriate recommendations that conflicted with local best practices were modified. All 15 commonly triggered recommendations had an Oxford Centre for Evidence-Based Medicine level of evidence of 5 (i.e., expert opinion).

CONCLUSION

Orders for imaging tests that were deemed inappropriate were modified infrequently, more often with alternative recommendations present and only for appropriate use criteria consistent with local best practices.