Efficacy and Impact of a Multimodal Intervention on CT Pulmonary Angiography Ordering Behavior in the Emergency Department

OBJECTIVE

To evaluate the efficacy of a multimodal intervention in reducing CT pulmonary angiography (CTPA) overutilization in the evaluation of suspected pulmonary embolism in the emergency department (ED).

METHODS

Previous mixed-methods analysis of barriers to guideline-concordant CTPA ordering results was used to develop a provider-focused behavioral intervention consisting of a clinical decision support tool and an audit and feedback system at a multisite, tertiary academic network. The primary outcome (guideline concordance) and secondary outcomes (yield and CTPA and D-dimer order rates) were compared using a pre- and postintervention design. ED encounters for adult patients from July 5, 2017, to January 3, 2019, were included. Fisher's exact tests and statistical process control charts were used to compare the pre- and postintervention groups for each outcome.

RESULTS

Of the 201,912 ED patient visits evaluated, 3,587 included CTPA. Guideline concordance increased significantly after the intervention, from 66.9% to 77.5% (P < .001). CTPA order rate and D-dimer order rate also increased significantly, from 17.1 to 18.4 per 1,000 patients (P = .035) and 30.6 to 37.3 per 1,000 patients (P < .001), respectively. Percent yield showed no significant change (12.3% pre- versus 10.8% postintervention; P = .173). Statistical process control analysis showed sustained special-cause variation in the postintervention period for guideline concordance and D-dimer order rates, temporary special-cause variation for CTPA order rates, and no special-cause variation for percent yield.

CONCLUSION

Our success in increasing guideline concordance demonstrates the efficacy of a mixed-methods, human-centered approach to behavior change. Given that neither of the secondary outcomes improved, our results may demonstrate potential limitations to the guidelines directing the ordering of CTPA studies and D-dimer ordering.

Inappropriate CT examinations: how much, who and where? Insights from a clinical decision support system (CDSS) analysis

OBJECTIVE

To assess the appropriateness of Computed Tomography (CT) examinations, using the ESR-iGuide.

MATERIAL AND METHODS

A retrospective study was conducted in 2022 in a medium-sized acute care teaching hospital. A total of 278 consecutive cases of CT referral were included. For each imaging referral, the ESR-iGuide provided an appropriateness score using a scale of 1-9 and the Relative Radiation Level using a scale of 0-5. These were then compared with the appropriateness score and the radiation level of the recommended ESR-iGuide exam.

DATA ANALYSIS

Pearson's chi-square test or Fisher exact test was used to explore the correlation between ESR-iGuide appropriateness level and physician, patients, and shift characteristics. A stepwise logistic regression model was used to capture the contribution of each of these factors.

RESULTS

Most of exams performed were CT head (63.67%) or CT abdominal pelvis (23.74%). Seventy percent of the actual imaging referrals resulted in an ESR-iGuide score corresponding to "usually appropriate." The mean radiation level for actual exam was 3.2 ± 0.45 compared with 2.16 ± 1.56 for the recommended exam. When using a stepwise logistic regression for modeling the probability of non-appropriate score, both physician specialty and status were significant (p = 0.0011, p = 0.0192 respectively). Non-surgical and specialist physicians were more likely to order inappropriate exams than surgical physicians.

CONCLUSIONS

ESR-iGuide software indicates a substantial rate of inappropriate exams of CT head and CT abdominal-pelvis and unnecessary radiation exposure mainly in the ED department. Inappropriate exams were found to be related to physicians' specialty and seniority.

CLINICAL RELEVANCE STATEMENT

These findings underscore the urgent need for improved imaging referral practices to ensure appropriate healthcare delivery and effective resource management. Additionally, they highlight the potential benefits and necessity of integrating CDSS as a standard medical practice. By implementing CDSS, healthcare providers can make more informed decisions, leading to enhanced patient care, optimized resource allocation, and improved overall healthcare outcomes.

KEY POINTS

• The overall mean of appropriateness for the actual exam according to the ESR-iGuide was 6.62 ± 2.69 on a scale of 0-9. • Seventy percent of the actual imaging referrals resulted in an ESR-iGuide score corresponding to "usually appropriate." • Inappropriate examination is related to both the specialty of the physician who requested the exam and the seniority status of the physician.

Decreasing Duplicative Imaging: Inpatient and Emergency Medicine Abdominal Ultrasound Within 72 Hours of Abdominal CT

PURPOSE

The aim of this project was to reduce abdominal ultrasound examinations in patients who had undergone abdominal CT within 72 hours previously.

METHODS

A best practice advisory (BPA) was created in the electronic medical record to advise against the use of abdominal ultrasound in adult inpatients and emergency department patients who had undergone abdominal CT within the preceding 72 hours. Acceptable acknowledgment reasons to proceed with the order were made available if providers chose to override. Frequency of BPA firing and subsequent ordering behavior were evaluated 6 months after integration of the BPA into the electronic medical record. Chart review was conducted for 100 patients whose orders were placed through an override of the alert to determine if the ultrasound study added value and for all patients whose ultrasound studies were canceled to confirm that patient care was not compromised by omitting the ultrasound study.

RESULTS

In the first 6 months, a total of 614 inpatient and emergency department abdominal ultrasound orders triggered the BPA. A total of 16% of orders (n = 96) were canceled by the provider after the BPA, reflecting 518 overrides. The majority of retained orders were to evaluate the gallbladder (44% [227 of 518]). Chart review confirmed utility for gallbladder imaging and that the canceled ultrasound examinations would not have contributed value to patients' care.

CONCLUSIONS

A recently performed abdominal CT scan may obviate the need for inpatient and emergency department abdominal ultrasound, particularly in the setting of hospital-acquired acute kidney injury. A BPA resulted in only 16% of orders' being canceled, whereas chart review revealed a much larger opportunity to avoid duplicative imaging.

European Society of Radiology (ESR). Methodology for ESR iGuide content

The European Society of Radiology (ESR) considers the use of evidence-based referral guidelines in clinical practice essential to ensure the appropriate utilisation of medical imaging for patients. Since 2014, the ESR has been working with the American College of Radiology (ACR) to develop referral guidelines for Europe, based on the ACR Appropriateness Criteria (AC) and appropriate use criteria developed by the ACR Rapid Response Committee.

This paper sets out the methodology used by the ESR’s Referral Guidelines Subcommittee to adapt the ACR criteria for use in the European clinical decision support (CDS) platform ESR iGuide. The ESR adheres to the ACR’s original methodology as far as applicable, and has established additional methodological guidance for its experts, establishing several key principles:

Any changes to existing recommendations, and any additional guidelines, should be based on evidence as far as possible

Expert opinion, judgement, European practice standards, should only function as a supplement when necessary

Appropriateness recommendations should give no consideration to national or institutional circumstances, costs, or availability of equipment.

The cooperation between the ACR and ESR on appropriate use criteria and imaging referral guidelines provides added value to both societies as European studies and guidelines from European subspecialty societies of radiology are fed into the process and the exchange of views among the experts makes the guideline development and review process more robust.

The ESR’s aim is to ensure referrers and patients benefit from the best possible guidance for appropriate imaging.

Magnetic resonance imaging of the lumbar spine: determining clinical impact and potential harm from overuse

BACKGROUND

Lumbar spine magnetic resonance imaging is frequently said to be "overused" in the evaluation of low back pain, yet data concerning the extent of overuse and the potential harmful effects are lacking.

PURPOSE

The objective of this study was to determine the proportion of examinations with a detectable impact on patient care (actionable outcomes).

STUDY DESIGN

This is a retrospective cohort study.

PATIENT SAMPLE

A total of 5,365 outpatient lumbar spine magnetic resonance (MR) examinations were conducted.

OUTCOME MEASURES

Actionable outcomes included (1) findings leading to an intervention making use of anatomical information such as surgery; (2) new diagnoses of cancer, infection, or fracture; or (3) following known lumbar spine pathology. Potential harm was assessed by identifying examinations where suspicion of cancer or infection was raised but no positive diagnosis made.

METHODS

A medical record aggregation/search system was used to identify lumbar spine MR examinations with positive outcome measures. Patient notes were examined to verify outcomes. A random sample was manually inspected to identify missed positive outcomes.

RESULTS

The proportion of actionable lumbar spine magnetic resonance imaging was 13%, although 93% were appropriate according to the American College of Radiology guidelines. Of 36 suspected cases of cancer or infection, 81% were false positives. Further investigations were ordered on 59% of suspicious examinations, 86% of which were false positives.

CONCLUSIONS

The proportion of lumbar spine MR examinations that inform management is small. The false-positive rate and the proportion of false positives involving further investigation are high. Further study to improve the efficiency of imaging is warranted.

Collaboration, campaigns and champions for appropriate imaging: feedback from the Zagreb workshop

Abstract

Leading radiologists and representatives from national radiation protection regulatory authorities and health ministries from 19 countries of the European region worked together with five experts at the workshop on justification and appropriate use of imaging in Zagreb, Croatia, from 26 to 28 October 2017 jointly organised by the IAEA and the European Society of Radiology. The workshop served as a forum to exchange information on challenges and solutions for improving justification and the appropriate use of diagnostic imaging. Common barriers to improving the use of imaging referral guidelines were discussed and the need for increased collaboration identified. Examples of good practices were presented, including use of Clinical Decision Support (CDS) systems to facilitate rapid and good justification decisions. The workshop identified some of the needs of European countries for achieving more appropriate imaging proposing wider use of collaboration, campaigns and champions.

Main messages

• Drivers for appropriate imaging in Europe are similar to those elsewhere globally.

• Implementing imaging referral guidelines is the main barrier to more appropriate imaging.

• Clinical Decision Support systems (CDS) facilitates good referral practice and justification decisions.

• Collaboration, campaigns and champions may improve awareness, appropriateness and audit.

Adult intussusception: An 8 years institutional review

BACKGROUND

Intussusception is a rare cause of intestinal obstruction in adults. Its diagnosis could be elusive based solely on clinical features because of protean presentation. Supplementary imaging allows for preoperative diagnosis, early institution of definitive management, and a better clinical outcome.

PATIENTS AND METHODS

Records of adults managed for intestinal obstruction by laparotomy in a surgical unit of a tertiary health facility were retrospectively examined. The subgroup having an intraoperative diagnosis of intussusception was extracted and analyzed. Data obtained included age, sex, and primary symptom at presentation. Presence of intestinal perforation, the histology of the lead point of resected tissues, and the final disposition of the patients were documented.

RESULTS

Four hundred and three patients underwent surgical management of intestinal obstruction. Eight patients (2%) had an intraoperative diagnosis of intussusception at laparotomy; four males and four females (male: female = 1:1). Abdominal pain was the presentation in 7 (87.5%) and anal protrusion in 1 (12.5%). Four patients (50%) had bowel perforation with peritonitis. Seven of the resected intestines had lead points which were benign. Two patients (25%) died from sepsis. Resection and anastomosis were done for all the patients.

CONCLUSION

Intussusception in adults is uncommon but carries a high morbidity and mortality which can be reduced with a good clinical assessment, appropriate imaging, and early laparotomy.