Effect of Clinical Decision Support on Appropriateness of Advanced Imaging Use Among Physicians-in-Training

A decision support system to increase the compliance of diagnostic imaging examinations with imaging guidelines: focused on cerebrovascular diseases

OBJECTIVES

Diagnostic imaging decision support (DI-DS) system has emerged as an innovative evidence-based solution to decrease inappropriate diagnostic imaging. The aim of the present study was to design and evaluate a DI-DS system for cerebrovascular diseases.

METHODS

The present study was an applied piece of research. First, the conceptual model of the DI-DS system was designed based on its functional and non-functional requirements. Afterwards, to create the system's knowledge base, cerebrovascular diseases diagnostic imaging algorithms were extracted from the American College of Radiology Appropriateness Criteria (ACR-AC). Subsequently, the system was developed based on the obtained conceptual model and the extracted algorithms. The software was programmed by means of the C#. After debugging the system, it was evaluated regarding its performance and also the users' satisfaction with it.

RESULTS

Assessing the users' satisfaction with the system demonstrated that all the evaluation criteria met the acceptable threshold (85 %). The retrospective evaluation of the system's performance indicated that from among 76 imaging examinations, which had previously been performed for 30 patients, 12 (15.78 %) were deemed inappropriate. And, the system accurately identified all the inappropriate physicians' decisions. The concurrent evaluation of the system's performance indicated that the system's recommendations helped the physicians remove 100 % (4 out of 4) of the inappropriate and 40 % (2 out of 5) of the inconclusive imaging examinations from their initial choices.

CONCLUSIONS

A DI-DS system could increase the compliance of the physicians' decisions with diagnostic imaging guidelines, and also improve treatment outcomes through correct diagnosis and providing timely care.

Impact and effect of imaging referral guidelines on patients and radiology services: a systematic review

OBJECTIVES

The objective of this systematic review was to offer a comprehensive overview and explore the associated outcomes from imaging referral guidelines on various key stakeholders, such as patients and radiologists.

MATERIALS AND METHODS

An electronic database search was conducted in Medline, Embase and Web of Science to retrieve citations published between 2013 and 2023. The search was constructed using medical subject headings and keywords. Only full-text articles and reviews written in English were included. The quality of the included papers was assessed using the mixed methods appraisal tool. A narrative synthesis was undertaken for the selected articles.

RESULTS

The search yielded 4384 records. Following the abstract, full-text screening, and removal of duplication, 31 studies of varying levels of quality were included in the final analysis. Imaging referral guidelines from the American College of Radiology were most commonly used. Clinical decision support systems were the most evaluated mode of intervention, either integrated or standalone. Interventions showed reduced patient radiation doses and waiting times for imaging. There was a general reduction in radiology workload and utilisation of diagnostic imaging. Low-value imaging utilisation decreased with an increase in the appropriateness of imaging referrals and ratings and cost savings. Clinical effectiveness was maintained during the intervention period without notable adverse consequences.

CONCLUSION

Using evidence-based imaging referral guidelines improves the quality of healthcare and outcomes while reducing healthcare costs. Imaging referral guidelines are one essential component of improving the value of radiology in the healthcare system.

CLINICAL RELEVANCE STATEMENT

There is a need for broader dissemination of imaging referral guidelines to healthcare providers globally in tandem with the harmonisation of the application of these guidelines to improve the overall value of radiology within the healthcare system.

KEY POINTS

The application of imaging referral guidelines has an impact and effect on patients, radiologists, and health policymakers. The adoption of imaging referral guidelines in clinical practice can impact healthcare costs and improve healthcare quality and outcomes. Implementing imaging referral guidelines contributes to the attainment of value-based radiology.

"My attending really wants it!" Manual clinical decision support adjudicating the "better look" inpatient MRI at an academic medical center

OBJECTIVE

MRI utilization in the United States is relatively higher than in other parts of the world and inpatient MRI utilization is particularly difficult to manage given the lack of direct reimbursement. Body MRI studies present an opportunity to reduce inpatient MRI utilization since they are generally the least emergent. Our objective was to use a targeted questionnaire to probe the necessity of inpatient body MRI orders and present an opportunity to either cancel them or transition them to the outpatient realm METHODS: A 9-item questionnaire was devised asking questions about the urgency of the inpatient MRI order including the urgent management question, an inpatient procedure or whether it was recommended by a consultant. Peer-to-peer discussion walking through each of the questions was conducted by radiology housestaff with the ordering clinicians and responses recorded.

RESULTS

845 recorded responses reported a lack of specific clinical question in 23.9% of orders, 68.9% were recommended by a non-radiology consulting service and 16.1% were recommended by radiology studies. 17.0% orders were felt to be outpatient appropriate and 23.3% were considered possibly appropriate for the outpatient setting. 3.9% were canceled and 4.9% were transitioned to outpatient orders.

DISCUSSION

Engaging in a focused discussion about the urgency and appropriateness of an inpatient MRI body order following a list of scripted questions has the potential to reduce utilization. This approach also highlights the relatively high rate of indication uncertainty among ordering clinicians and the central role of consultants in prompting orders.

Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report

Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging, are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.

Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report

Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging (MRI), are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.

The role of information systems in emergency department decision-making-a literature review

OBJECTIVES

Healthcare providers employ heuristic and analytical decision-making to navigate the high-stakes environment of the emergency department (ED). Despite the increasing integration of information systems (ISs), research on their efficacy is conflicting. Drawing on related fields, we investigate how timing and mode of delivery influence IS effectiveness. Our objective is to reconcile previous contradictory findings, shedding light on optimal IS design in the ED.

MATERIALS AND METHODS

We conducted a systematic review following PRISMA across PubMed, Scopus, and Web of Science. We coded the ISs' timing as heuristic or analytical, their mode of delivery as active for automatic alerts and passive when requiring user-initiated information retrieval, and their effect on process, economic, and clinical outcomes.

RESULTS

Our analysis included 83 studies. During early heuristic decision-making, most active interventions were ineffective, while passive interventions generally improved outcomes. In the analytical phase, the effects were reversed. Passive interventions that facilitate information extraction consistently improved outcomes.

DISCUSSION

Our findings suggest that the effectiveness of active interventions negatively correlates with the amount of information received during delivery. During early heuristic decision-making, when information overload is high, physicians are unresponsive to alerts and proactively consult passive resources. In the later analytical phases, physicians show increased receptivity to alerts due to decreased diagnostic uncertainty and information quantity. Interventions that limit information lead to positive outcomes, supporting our interpretation.

CONCLUSION

We synthesize our findings into an integrated model that reveals the underlying reasons for conflicting findings from previous reviews and can guide practitioners in designing ISs in the ED.

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.

What works for and what hinders deimplementation of low-value care in emergency medicine practice? A scoping review

OBJECTIVES

Low-value care can harm patients and healthcare systems. Despite a decade of global endeavours, low value care has persisted. Identification of barriers and enablers is essential for effective deimplementation of low-value care. This scoping review is an evidence summary of barriers, enablers and features of effective interventions for deimplementation of low-value care in emergency medicine practice worldwide.

DESIGN

A mixed-methods scoping review was conducted using the Arksey and O'Malley framework.

DATA SOURCES

Medline, CINAHL, Embase, EMCare, Scopus and grey literature were searched from inception to 5 December 2022.

ELIGIBILITY CRITERIA

Primary studies which employed qualitative, quantitative or mixed-methods approaches to explore deimplementation of low-value care in an EM setting and reported barriers, enablers or interventions were included. Reviews, protocols, perspectives, comments, opinions, editorials, letters to editors, news articles, books, chapters, policies, guidelines and animal studies were excluded. No language limits were applied.

DATA EXTRACTION AND SYNTHESIS

Study selection, data collection and quality assessment were performed by two independent reviewers. Barriers, enablers and interventions were mapped to the domains of the Theoretical Domains Framework. The Mixed Methods Appraisal Tool was used for quality assessment.

RESULTS

The search yielded 167 studies. A majority were quantitative studies (90%, 150/167) that evaluated interventions (86%, 143/167). Limited provider abilities, diagnostic uncertainty, lack of provider insight, time constraints, fear of litigation, and patient expectations were the key barriers. Enablers included leadership commitment, provider engagement, provider training, performance feedback to providers and shared decision-making with patients. Interventions included one or more of the following facets: education, stakeholder engagement, audit and feedback, clinical decision support, nudge, clinical champions and training. Multifaceted interventions were more likely to be effective than single-faceted interventions. Effectiveness of multifaceted interventions was influenced by fidelity of the intervention facets. Use of behavioural change theories such as the Theoretical Domains Framework in the published studies appeared to enhance the effectiveness of interventions to deimplement low-value care.

CONCLUSION

High-fidelity, multifaceted interventions that incorporated education, stakeholder engagement, audit/feedback and clinical decision support, were administered daily and lasted longer than 1 year were most effective in achieving deimplementation of low-value care in emergency departments. This review contributes the best available evidence to date, but further rigorous, theory-informed, qualitative and mixed-methods studies are needed to supplement the growing body of evidence to effectively deimplement low-value care in emergency medicine practice.

Measuring appropriateness of diagnostic imaging: a scoping review

In radiology, the justification of diagnostic imaging is a key performance indicator. To date, specific recommendations on the measurement of appropriateness in diagnostic imaging are missing. To map the study literature concerning the definition, measures, methods and data used for analyses of appropriateness in research of diagnostic imaging. We conducted a scoping review in Medline, EMBASE, Scopus and the Cochrane Central Register of Controlled Trials. Two independent reviewers undertook screening and data extraction. After screening 6021 records, we included 50 studies. National guidelines (n = 22/50) or American College of Radiology Appropriateness Criteria (n = 23/50) were used to define and rate appropriateness. 22/50 studies did not provide methodological details about the appropriateness assessment. The included studies varied concerning modality, amount of reviewed examinations (88-13,941) and body regions. Computed tomography (27 studies, 27,168 examinations) was the most frequently analyzed modality, followed by magnetic resonance imaging (17 studies, 6559 examinations) and radiography (10 studies, 7095 examinations). Heterogeneous appropriateness rates throughout single studies (0-100%), modalities, and body regions (17-95%) were found. Research on pediatric and outpatient imaging was sparse. Multicentric, methodologically robust and indication-oriented studies would strengthen appropriateness research in diagnostic imaging and help to develop reliable key performance indicators.

Ankle MRI and preceding radiographs: an evaluation of physician ordering practices

OBJECTIVE

Multiple guidelines have been published for appropriate imaging in patients with ankle-related symptoms which suggest radiographs as the initial imaging examination for both acute and chronic ankle abnormalities. Few studies have evaluated adherence to these imaging guidelines. This study retrospectively evaluated the utilization of ankle MRI and preceding radiographs based on ordering provider group and MRI indication.

MATERIALS AND METHODS

A total of 4186 ankle MRIs performed over a 9-year period at a single institution were evaluated for the presence of preceding ankle and/or foot radiographs at two time points, within 3 months and within 6 months of the MRI examination. Ankle MRIs were then categorized based on 6 ordering provider groups and 13 MRI indications.

RESULTS

Of the 4186 MRIs evaluated, 68% had preceding radiographs within 3 months and 77% had radiographs within 6 months. Primary care, sports medicine, and podiatry had the lowest rates of preceding radiographs (73%, 68%, and 64%, respectively, within 6 months). Eighty-six percent of ankle MRIs ordered by orthopedic surgery had preceding radiographs within 6 months and 89% of ankle MRIs ordered by emergency medicine and inpatient providers had preceding radiographs. MRIs intended for evaluation of Achilles tendon or plantar fascia abnormalities were among the least likely indications to have preceding radiographs.

CONCLUSION

Based on established clinical guidelines, there was a lower-than-expected rate of obtaining preceding radiographs for ankle MRIs among most provider groups, particularly non-orthopedic outpatient providers. Additional research is needed to address the lack of adherence to clinical imaging guidelines and ensure appropriate imaging.

Emergency Radiology: Evolution, Current Status, and Future Directions

Emergency Radiology is a clinical practice and an academic discipline that has rapidly gained increasing global recognition among radiology and emergency/critical care departments and trauma services around the world. As with other subspecialties, Emergency Radiology practice has a unique scope and purpose and presents with its own unique challenges. There are several advantages of having a dedicated Emergency Radiology section, perhaps most important of which is the broad clinical skillset that Emergency Radiologists are known for. This multi-society paper, representing the views of Emergency Radiology societies in Canada and Europe, outlines several value-oriented contributions of Emergency Radiologists and briefly discusses the current state of Emergency Radiology as a subspecialty.

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.

Justification des demandes de tomodensitométrie aux urgences

Introduction : La justification des demandes de tomodensitométrie (TDM) faites aux urgences est mal connue. Notre objectif était d’évaluer la justification des demandes de TDM dans un service d’urgences adultes.

Méthodes : La justification des demandes de scanner a été mesurée prospectivement de deux façons complémentaires. L’adéquation aux recommandations a été évaluée pour l’ensemble des demandes de TDM par confrontation à une liste préétablie de syndromes et d’hypothèses diagnostiques. La pertinence des demandes a été évaluée par un comité d’experts sur la base du dossier médical des urgences pour 100 de ces dossiers.

Résultats : Les 273 TDM incluses concernaient le crâne (52%), l’abdomen (17%), le thorax (11%) ou une autre localisation (20%). Elles étaient en adéquation avec les recommandations dans 215 cas (79%). Pour 100 dossiers analysés par le comité d’experts, la pertinence a été adjugée à l’unanimité pour 95 cas ; 67 TDM (71%) ont été jugées pertinentes. La concordance entre l’adéquation aux recommandations et la pertinence évaluée par le comité d’expert était faible (kappa, 0,27, intervalle de confiance à 95%, de 0,06 à 0,47). Le seul facteur associé significativement à la pertinence était l’opinion du clinicien en charge du patient que la TDM ne pouvait pas être reportée (OR=6,7 avec IC95% [1,6-28,1], p=0,01).

Conclusion : La proportion des demandes de TDM qui ne sont pas en adéquation avec les recommandations et la proportion de demandes non pertinentes sont élevées. Elles suggèrent que le nombre de TDM demandées par les services d’urgences pourrait être diminué.

Three Statistical Approaches for Assessment of Intervention Effects: A Primer for Practitioners

INTRODUCTION

Statistical methods to assess the impact of an intervention are increasingly used in clinical research settings. However, a comprehensive review of the methods geared toward practitioners is not yet available.

METHODS AND MATERIALS

We provide a comprehensive review of three methods to assess the impact of an intervention: difference-in-differences (DID), segmented regression of interrupted time series (ITS), and interventional autoregressive integrated moving average (ARIMA). We also compare the methods, and provide illustration of their use through three important healthcare-related applications.

RESULTS

In the first example, the DID estimate of the difference in health insurance coverage rates between expanded states and unexpanded states in the post-Medicaid expansion period compared to the pre-expansion period was 5.93 (95% CI, 3.99 to 7.89) percentage points. In the second example, a comparative segmented regression of ITS analysis showed that the mean imaging order appropriateness score in the emergency department at a tertiary care hospital exceeded that of the inpatient setting with a level change difference of 0.63 (95% CI, 0.53 to 0.73) and a trend change difference of 0.02 (95% CI, 0.01 to 0.03) after the introduction of a clinical decision support tool. In the third example, the results from an interventional ARIMA analysis show that numbers of creatinine clearance tests decreased significantly within months of the start of eGFR reporting, with a magnitude of drop equal to -0.93 (95% CI, -1.22 to -0.64) tests per 100,000 adults and a rate of drop equal to 0.97 (95% CI, 0.95 to 0.99) tests per 100,000 per adults per month.

DISCUSSION

When choosing the appropriate method to model the intervention effect, it is necessary to consider the structure of the data, the study design, availability of an appropriate comparison group, sample size requirements, whether other interventions occur during the study window, and patterns in the data.

Developing an Institute for Health Care Delivery Science: successes, challenges, and solutions in the first five years

Medical knowledge is increasing at an exponential rate. At the same time, unexplained variations in practice and patient outcomes and unacceptable rates of medical errors and inefficiencies in health care delivery have emerged. Our Institute for Health Care Delivery Science (I-HDS) began in 2014 as a novel platform to conduct multidisciplinary healthcare delivery research. We followed ten strategies to develop a successful institute with excellence in methodology and strong understanding of the value of team science. Our work was organized around five hubs: 1) Quality/Process Improvement and Systematic Review, 2) Comparative Effectiveness Research, Pragmatic Clinical Trials, and Predictive Analytics, 3) Health Economics and Decision Modeling, 4) Qualitative, Survey, and Mixed Methods, and 5) Training and Mentoring. In the first 5 years of the I-HDS, we have identified opportunities for change in clinical practice through research using our health system's electronic health record (EHR) data, and designed programs to educate clinicians in the value of research to improve patient care and recognize efficiencies in processes. Testing the value of several model interventions has guided prioritization of evidence-based quality improvements. Some of the changes in practice have already been embedded in the EHR workflow successfully. Development and sustainability of the I-HDS has been fostered by a mix of internal and external funding, including philanthropic foundations. Challenges remain due to the highly competitive funding environment and changes needed to adapt the EHR to healthcare delivery research. Further stakeholder engagement and culture change working with hospital leadership and I-HDS core and affiliate members continues.

Diagnostic imaging: Doing the right thing

Inappropriate diagnostic imaging (DI) is a burgeoning issue and embraces its overuse and its misapplication. The obverse problem is one of underuse - that is when patients who should undergo imaging fail to do so. This article attempts to define these problems, examines the causes and effects and suggests some potential solutions.

Use of Imaging During Emergency Department Visits for Low Back Pain

OBJECTIVE. Back pain is one of the most common reasons for adult patients 18-65 years old to seek emergency care. Use of imaging for patients without so-called red flags (trauma, malignancy, or infection) may result in potentially unnecessary costs and radiation exposure. The aim of this study was to investigate the use of imaging for patients with emergency visits for low back pain. MATERIALS AND METHODS. Emergency department visits for patients with low back pain billed to insurance were identified by querying a national commercial claims and encounters database for patients 18-64 years old. Patients with concomitant encounter diagnoses suggestive of trauma or those with prior visits for back pain were excluded. Imaging modalities (radiography, CT, and MRI) were identified by Current Procedural Terminology codes. RESULTS. A total of 134,624 encounters met inclusion criteria. Imaging was obtained in 44,405 (33.7%) visits and decreased from 34.4% to 31.9% between 2011 and 2016 (odds ratio per year, 0.98 [95% CI, 0.98-0.99]; p < 0.001). During the study period, 30.9% of patients underwent radiography, 2.7% of patients underwent CT, and 0.8% of patients underwent MRI for evaluation of low back pain. The use of imaging varied significantly by geographic region (p < 0.001), with patients in the southern United States undergoing 10% more imaging than patients in the western United States. CONCLUSION. The use of imaging for the initial evaluation of patients with low back pain in the emergency department continues to occur at a high rate, in approximately one in three new emergency visits for low back pain in the United States.