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Byerly SE, Filiberto DM, Lenart EK, Easterday T, Howley I, Nouer S, Tolley E, Magnotti LJ. Clinical decompensation after trauma laparotomy: It's probably not a pulmonary embolus. Injury 2024:111651. [PMID: 38849214 DOI: 10.1016/j.injury.2024.111651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 05/04/2024] [Accepted: 05/30/2024] [Indexed: 06/09/2024]
Abstract
Introduction Computed Tomography (CT) to rule out pulmonary embolus (PE) is often ordered during post-trauma laparotomy clinical decompensation (CD) involving fever, tachycardia, tachypnea, and/or leukocytosis. We hypothesize this diagnostic modality is low-yield in the postoperative period when surgery-related sequelae are more probable. Methods This is a single-center retrospective cohort study of patients who underwent trauma laparotomy and had subsequent CT for CD from March 19, 2019 to June 30, 2022. Descriptive statistics and multiple logistic regression were performed. The primary outcome was saddle and lobar PE incidence. Results 1032 adult patients underwent trauma laparotomy with 434 undergoing CT for CD: 137 CT abdomen and pelvis only, 30 CTPE, 265 both. The majority (80.2 %) was male, age 33[interquartile range (IQR) 24-45], suffered penetrating mechanism (57 %), and had ISS 23[IQR16-30]. Injuries at laparotomy included 47 % solid organ, 62 % GI tract, 7 % biliary, 11 % vascular, and 42 % other. 176 (41 %) required damage control laparotomy. Median time to CT post-laparotomy was 174 h [111-235] with saddle and lobar PE in 3 (1 %), peripheral PE 18 (5 %), and abdominal abscess, leak, fluid, or pseudoaneurysm in 222 (51 %). Clinical management was altered (40 %) by antibiotics, therapeutic anticoagulation, drainage, aspiration, filter, thrombectomy, or surgical operation. Patients for whom CT findings changed management were more likely to have had GI tract surgery (69% vs 57 %, p = 0.021), higher white blood cell (WBC) (16.4 [13.1-20.5] vs 15.1 [9.9-19.5], p = 0.002), more hours between CT and laparotomy (184 [141-245] vs 162 [89-230], p = 0.002), and lower mortality (2% vs 8 %, p = 0.008). In-hospital mortality was 5 %; none were PE-related. Predictors of clinical intervention required based on CT imaging were GI tract injury (AOR: 1.65, p = 0.0182), and elevated WBC (AOR: 1.038, p = 0.010 Conclusion Saddle and lobar PE incidence post-trauma laparotomy is low. SIRS-type symptoms prompting postoperative CT commonly have no procedural or antibiotic requirement. Postoperative decompensation is more likely related post-operative complications, and less likely a PE.
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Affiliation(s)
- Saskya E Byerly
- Department of Surgery, Division of Trauma & Surgical Critical Care, University of Tennessee Health Science Campus, 910 Madison Ave, #220, Memphis, TN 38163, USA.
| | - Dina M Filiberto
- Department of Surgery, Division of Trauma & Surgical Critical Care, University of Tennessee Health Science Campus, 910 Madison Ave, #220, Memphis, TN 38163, USA
| | - Emily K Lenart
- Department of Surgery, Division of Trauma & Surgical Critical Care, University of Tennessee Health Science Campus, 910 Madison Ave, #220, Memphis, TN 38163, USA
| | - Thomas Easterday
- Department of Surgery, Division of Trauma & Surgical Critical Care, University of Tennessee Health Science Campus, 910 Madison Ave, #220, Memphis, TN 38163, USA
| | - Isaac Howley
- Department of Surgery, Division of Trauma & Surgical Critical Care, University of Tennessee Health Science Campus, 910 Madison Ave, #220, Memphis, TN 38163, USA
| | - Simonne Nouer
- College of Medicine-Memphis, Department of Preventative Medicine, Division of Preventative Medicine, 66 North Pauline St, Memphis, TN 38193, USA
| | - Elizabeth Tolley
- College of Medicine-Memphis, Department of Preventative Medicine, Division of Preventative Medicine, 66 North Pauline St, Memphis, TN 38193, USA
| | - Louis J Magnotti
- Department of Surgery, Division of Trauma and Acute Care Surgery, University of Arizona, PO Box 245063, Tucson, AZ 85724, USA
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Fan CY, Chen CH, Chen JW, Chang JH, Huang EPC, Sung CW. Chief complaints and computed tomography results in the emergency department: a three-year retrospective cohort study. BMC Emerg Med 2024; 24:87. [PMID: 38764022 PMCID: PMC11103846 DOI: 10.1186/s12873-024-01003-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 05/10/2024] [Indexed: 05/21/2024] Open
Abstract
BACKGROUND Computed tomography (CT) is frequently performed in the patients who admitted to the emergency department (ED), discharged but returned to ED within 72 h. It is unknown whether the main complaints of patients assist physicians to use CT effectively. This study aimed to find the association between chief complaints and the CT results. METHODS This three-year retrospective cohort study was conducted in the ED of a tertiary medical center. Adult patients who returned to the ED after the index visit were included from 2019 to 2021. Demographics, pre-existing diseases, chief complaints, and CT region were recorded by independent ED physicians. A logistic regression model with an odds ratio (OR) and 95% confidence interval (CI) was used to determine the relationship between chief complaints and positive CT results. RESULTS In total, 7,699 patients revisited ED after the index visit; 1,202 (15.6%) received CT. The top chief complaints in patients who received CT were abdominal pain, dizziness, and muscle weakness. Patients with abdominal pain or gastrointestinal symptoms had a significantly higher rate of positive abdominopelvic CT than those without it (OR 2.83, 95% CI 1.98-4.05, p < 0.001), while the central nervous system and cardiopulmonary chief complaints were not associated (or negatively associated) with new positive CT findings. CONCLUSION Chief complaints of patients on revisit to the ED are associated with different yields of new findings when CT scans of the chest, abdomen and head are performed. Physicians should consider these differential likelihoods of new positive findings based on these data.
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Affiliation(s)
- Cheng-Yi Fan
- Department of Emergency Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, 300, Taiwan
| | - Chi-Hsin Chen
- Department of Emergency Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, 300, Taiwan
| | - Jiun-Wei Chen
- Department of Emergency Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, 300, Taiwan
| | - Jia-How Chang
- Department of Emergency Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, 300, Taiwan
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, 100, Taiwan
| | - Edward Pei-Chuan Huang
- Department of Emergency Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, 300, Taiwan
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, 100, Taiwan
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, 100, Taiwan
| | - Chih-Wei Sung
- Department of Emergency Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, 300, Taiwan.
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, 100, Taiwan.
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Rahimi F, Rabiei R, Seddighi AS, Roshanpoor A, Seddighi A, Moghaddasi H. Features and functions of decision support systems for appropriate diagnostic imaging: a scoping review. Diagnosis (Berl) 2024; 11:4-16. [PMID: 37795534 DOI: 10.1515/dx-2023-0083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 09/10/2023] [Indexed: 10/06/2023]
Abstract
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.
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Affiliation(s)
- Fatemeh Rahimi
- Department of Health Information Technology and Management, Medical Informatics, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Reza Rabiei
- Department of Health Information Technology and Management, Medical Informatics, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Amir Saied Seddighi
- Functional Neurosurgery Research Center, Shohada Tajrish Comprehensive Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Arash Roshanpoor
- Department of computer, Yadegar-e-Imam Khomeini (RAH), Janat-abad Branch, Islamic Azad University, Tehran, Iran
| | - Afsoun Seddighi
- Functional Neurosurgery Research Center, Shohada Tajrish Comprehensive Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hamid Moghaddasi
- Department of Health Information Technology and Management, Health Information Management & Medical Informatics, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Darband St., Tehran, Iran
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Gyftopoulos S, Simon E, Swartz JL, Smith SW, Martinez LS, Babb JS, Horwitz LI, Makarov DV. Efficacy and Impact of a Multimodal Intervention on CT Pulmonary Angiography Ordering Behavior in the Emergency Department. J Am Coll Radiol 2024; 21:309-318. [PMID: 37247831 DOI: 10.1016/j.jacr.2023.02.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 01/26/2023] [Accepted: 02/04/2023] [Indexed: 05/31/2023]
Abstract
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.
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Affiliation(s)
- Soterios Gyftopoulos
- Department of Radiology, NYU Grossman School of Medicine, New York, New York, and Department of Orthopedic Surgery, NYU Grossman School of Medicine, New York, New York; Chief of Radiology, NYU-Brooklyn.
| | - Emma Simon
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, and Center for Healthcare Innovation and Delivery Science, NYU Grossman School of Medicine, New York, New York
| | - Jordan L Swartz
- Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, New York
| | - Silas W Smith
- Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, New York; and Chief, Division of Quality, Safety, and Practice Innovation, Institute for Innovations in Medical Education, NYU Langone Health, New York, New York
| | - Leticia Santos Martinez
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, and Center for Healthcare Innovation and Delivery Science, NYU Grossman School of Medicine, New York, New York
| | - James S Babb
- Department of Radiology, NYU Grossman School of Medicine, New York, New York
| | - Leora I Horwitz
- Department of Population Health, NYU Grossman School of Medicine, New York, New York; Center for Healthcare Innovation and Delivery Science, NYU Grossman School of Medicine, New York, New York; and Department of Medicine, NYU Grossman School of Medicine, New York, New York. https://twitter.com/Leorahorwitzmd
| | - Danil V Makarov
- Department of Population Health, NYU Grossman School of Medicine, New York, New York; Department of Urology, NYU Grossman School of Medicine, New York, New York; and Department of Urology, VA New York Harbor Healthcare System, New York, New York. https://twitter.com/Dannymak76
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Gangathimmaiah V, Drever N, Evans R, Moodley N, Sen Gupta T, Cardona M, Carlisle K. What works for and what hinders deimplementation of low-value care in emergency medicine practice? A scoping review. BMJ Open 2023; 13:e072762. [PMID: 37945299 PMCID: PMC10649718 DOI: 10.1136/bmjopen-2023-072762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 10/26/2023] [Indexed: 11/12/2023] Open
Abstract
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.
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Affiliation(s)
- Vinay Gangathimmaiah
- Department of Emergency Medicine, Townsville University Hospital, Townsville, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Natalie Drever
- Department of Obstetrics and Gynaecology, Cairns Hospital, Cairns, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Cairns, Queensland, Australia
| | - Rebecca Evans
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Nishila Moodley
- Department of Emergency Medicine, Townsville University Hospital, Townsville, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Tarun Sen Gupta
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Magnolia Cardona
- A/Prof Implementation Science, Faculty of Health and Behavioural Sciences, School of Psychology, The University of Queensland, Brisbane, Queensland, Australia
- Honorary A/Prof of Research Translation, Institute for Evidence Based Healthcare, Bond University, Gold Coast, Queensland, Australia
| | - Karen Carlisle
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
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Ban JW, Perera R, Williams V. Influence of research evidence on the use of cardiovascular clinical prediction rules in primary care: an exploratory qualitative interview study. BMC PRIMARY CARE 2023; 24:194. [PMID: 37730553 PMCID: PMC10512575 DOI: 10.1186/s12875-023-02155-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 09/06/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND Cardiovascular clinical prediction rules (CPRs) are widely used in primary care. They accumulate research evidence through derivation, external validation, and impact studies. However, existing knowledge about the influence of research evidence on the use of CPRs is limited. Therefore, we explored how primary care clinicians' perceptions of and experiences with research influence their use of cardiovascular CPRs. METHODS We conducted an exploratory qualitative interview study with thematic analysis. Primary care clinicians were recruited from the WWAMI (Washington, Wyoming, Alaska, Montana and Idaho) region Practice and Research Network (WPRN). We used purposeful sampling to ensure maximum variation within the participant group. Data were collected by conducting semi-structured online interviews. We analyzed data using inductive thematic analysis to identify commonalities and differences within themes. RESULTS Of 29 primary care clinicians who completed the questionnaire, 15 participated in the interview. We identified two main themes relating to the influence of clinicians' perceptions of and experiences with cardiovascular CPR research on their decisions about using cardiovascular CPRs: "Seek and judge" and "be acquainted and assume." When clinicians are familiar with, trust, and feel confident in using research evidence, they might actively search and assess the evidence, which may then influence their decisions about using cardiovascular CPRs. However, clinicians, who are unfamiliar with, distrust, or find it challenging to use research evidence, might be passively acquainted with evidence but do not make their own judgment on the trustworthiness of such evidence. Therefore, these clinicians might not rely on research evidence when making decisions about using cardiovascular CPRs. CONCLUSIONS Clinicians' perceptions and experiences could influence how they use research evidence in decisions about using cardiovascular CPRs. This implies, when promoting evidence-based decisions, it might be useful to target clinicians' unfamiliarity, distrust, and challenges regarding the use of research evidence rather than focusing only on their knowledge and skills. Further, because clinicians often rely on evidence-unrelated factors, guideline developers and policymakers should recommend cardiovascular CPRs supported by high-quality evidence.
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Affiliation(s)
- Jong- Wook Ban
- Centre for Evidence-Based Medicine, University of Oxford, Oxford, UK.
- Department for Continuing Education, University of Oxford, Oxford, UK.
| | - Rafael Perera
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Mercurio L, Corwin D, Kaplan R, Ellison AM, Casper TC, Kuppermann N, Kline JA. Bedside exclusion of pulmonary embolism in children without radiation (BEEPER): a national study of the Pediatric Emergency Care Applied Research Network-Study protocol. Res Pract Thromb Haemost 2023; 7:100046. [PMID: 36865906 PMCID: PMC9971278 DOI: 10.1016/j.rpth.2023.100046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 10/18/2022] [Accepted: 10/23/2022] [Indexed: 01/15/2023] Open
Abstract
Background The Pulmonary Embolism Rule Out Criteria (PERC) Peds rule, derived from the PERC rule, was derived to estimate a low pretest probability for pulmonary embolism (PE) in children but has not been prospectively validated. Objective The objective of this study was to present a protocol for an ongoing multicenter prospective observational study that evaluates the diagnostic accuracy of the PERC-Peds rule. Methods This protocol is identified by the acronym, BEdside Exclusion of Pulmonary Embolism without Radiation in children. The study aims were designed to prospectively validate, or if necessary, refine, the accuracy of PERC-Peds and D-dimer in excluding PE among children with clinical suspicion or testing for PE. Multiple ancillary studies will examine clinical characteristics and epidemiology of the participants. Children aged 4 through 17 years were being enrolled at 21 sites through the Pediatric Emergency Care Applied Research Network (PECARN). Patients taking anticoagulant therapy are excluded. PERC-Peds criteria data, clinical gestalt, and demographic information are collected in real time. The criterion standard outcome is image-confirmed venous thromboembolism within 45 days, determined from independent expert adjudication. We assessed interrater reliability of the PERC-Peds, frequency of PERC-Peds use in routine clinical care, and descriptive characteristics of missed eligible and missed patients with PE. Results Enrollment is currently 60% complete with an anticipated data lock in 2025. Conclusions This prospective multicenter observational study will not only test whether a set of simple criteria can safely exclude PE without need for imaging but also provide a resource to fill a critical knowledge gap about clinical characteristics of children with suspected and diagnosed PE.
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Affiliation(s)
- Laura Mercurio
- Department of Emergency Medicine, Section of Pediatric Emergency Medicine, Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Daniel Corwin
- Division of Emergency Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Ron Kaplan
- Department of Pediatrics, Division of Emergency Medicine, University of Washington School of Medicine, Seattle Children’s Hospital, Seattle, Washington, USA
| | - Angela M. Ellison
- Division of Emergency Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Theron Charles Casper
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Nathan Kuppermann
- Departments of Emergency Medicine and Pediatrics, UC Davis School of Medicine and UC Davis Health, Sacramento, California
| | - Jeffrey A. Kline
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan
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The impact of performance feedback reports on physician ordering behavior in the use of computed tomography pulmonary angiography (CTPA). Emerg Radiol 2023; 30:63-69. [PMID: 36378395 PMCID: PMC9664050 DOI: 10.1007/s10140-022-02100-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 11/07/2022] [Indexed: 11/16/2022]
Abstract
PURPOSE The increased utilization, and potential overutilization, of computed tomography pulmonary angiography (CTPA) is a well-recognized issue within emergency departments (EDs). The objective of this study is to determine the impact of performance feedback reports on CTPA ordering behavior among ED physicians. METHODS We conducted a prospective study of the impact of individualized performance feedback reports on the ordering behavior of physicians working at two high-volume community EDs in Ontario, Canada. We generated individualized reports (or "Dashboards") for each ED physician containing detailed feedback and peer comparison for each physician's CTPA ordering. Our baseline pre-intervention period was January 1 to December 31, 2018, and our intervention period was January 1, 2019, to December 31, 2021. We tracked individual and group ordering behavior through the study period. Our primary outcomes are impact of feedback on (1) overall group ordering rate and (2) overall diagnostic yield. Secondary analysis was done to determine the impact of the intervention on those physicians with the highest CTPA utilization rate. RESULTS There was no statistically significant difference in the diagnostic yield of the included physicians in either of the years of the intervention period. There was a statically significant increase in the utilization rate for CTPA from 2018 to 2020 and 2021 from 5.9 to 7.9 and 11.4 CTPAs per 1000 ED visits respectively (p < 0.5). CONCLUSION Our study found no consistent significant impact of individualized feedback and peer comparison on physician ordering of CTPAs. This points to a potentially greater impact of environmental and institutional factors, as opposed to physician-targeted quality improvement measures, on physician ordering behavior.
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Lacson R, Eskian M, Cochon L, Gujrathi I, Licaros A, Zhao A, Vetrano N, Schneider L, Raja A, Khorasani R. Representing narrative evidence as clinical evidence logic statements. JAMIA Open 2022; 5:ooac024. [PMID: 35474718 PMCID: PMC9030217 DOI: 10.1093/jamiaopen/ooac024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 03/05/2022] [Accepted: 03/25/2022] [Indexed: 11/12/2022] Open
Abstract
Abstract
Objective
Clinical evidence logic statements (CELS) are shareable knowledge artifacts in a semistructured “If-Then” format that can be used for clinical decision support systems. This project aimed to assess factors facilitating CELS representation.
Materials and Methods
We described CELS representation of clinical evidence. We assessed factors that facilitate representation, including authoring instruction, evidence structure, and educational level of CELS authors. Five researchers were tasked with representing CELS from published evidence. Represented CELS were compared with the formal representation. After an authoring instruction intervention, the same researchers were asked to represent the same CELS and accuracy was compared with that preintervention using McNemar’s test. Moreover, CELS representation accuracy was compared between evidence that is structured versus semistructured, and between CELS authored by specialty-trained versus nonspecialty-trained researchers, using χ2 analysis.
Results
261 CELS were represented from 10 different pieces of published evidence by the researchers pre- and postintervention. CELS representation accuracy significantly increased post-intervention, from 20/261 (8%) to 63/261 (24%, P value < .00001). More CELS were assigned for representation with 379 total CELS subsequently included in the analysis (278 structured and 101 semistructured) postintervention. Representing CELS from structured evidence was associated with significantly higher CELS representation accuracy (P = .002), as well as CELS representation by specialty-trained authors (P = .0004).
Discussion
CELS represented from structured evidence had a higher representation accuracy compared with semistructured evidence. Similarly, specialty-trained authors had higher accuracy when representing structured evidence.
Conclusion
Authoring instructions significantly improved CELS representation with a 3-fold increase in accuracy. However, CELS representation remains a challenging task.
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Affiliation(s)
- Ronilda Lacson
- Department of Radiology, Center for Evidence-Based Imaging, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Mahsa Eskian
- Department of Radiology, Center for Evidence-Based Imaging, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Laila Cochon
- Department of Radiology, Center for Evidence-Based Imaging, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Isha Gujrathi
- Department of Radiology, Center for Evidence-Based Imaging, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Andro Licaros
- Department of Radiology, Center for Evidence-Based Imaging, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Anna Zhao
- Department of Radiology, Center for Evidence-Based Imaging, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Nicole Vetrano
- Department of Radiology, Center for Evidence-Based Imaging, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Louise Schneider
- Department of Radiology, Center for Evidence-Based Imaging, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Ali Raja
- Department of Radiology, Center for Evidence-Based Imaging, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ramin Khorasani
- Department of Radiology, Center for Evidence-Based Imaging, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Zhang NJ, Rameau P, Julemis M, Liu Y, Solomon J, Khan S, McGinn T, Richardson S. Automated Pulmonary Embolism Risk Assessment Using the Wells Criteria: Validation Study. JMIR Form Res 2022; 6:e32230. [PMID: 35225812 PMCID: PMC8922138 DOI: 10.2196/32230] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 12/05/2021] [Accepted: 12/27/2021] [Indexed: 01/23/2023] Open
Abstract
Background Computed tomography pulmonary angiography (CTPA) is frequently used in the emergency department (ED) for the diagnosis of pulmonary embolism (PE), while posing risk for contrast-induced nephropathy and radiation-induced malignancy. Objective We aimed to create an automated process to calculate the Wells score for pulmonary embolism for patients in the ED, which could potentially reduce unnecessary CTPA testing. Methods We designed an automated process using electronic health records data elements, including using a combinatorial keyword search method to query free-text fields, and calculated automated Wells scores for a sample of all adult ED encounters that resulted in a CTPA study for PE at 2 tertiary care hospitals in New York, over a 2-month period. To validate the automated process, the scores were compared to those derived from a 2-clinician chart review. Results A total of 202 ED encounters resulted in a completed CTPA to form the retrospective study cohort. Patients classified as “PE likely” by the automated process (126/202, 62%) had a PE prevalence of 15.9%, whereas those classified as “PE unlikely” (76/202, 38%; Wells score >4) had a PE prevalence of 7.9%. With respect to classification of the patient as “PE likely,” the automated process achieved an accuracy of 92.1% when compared with the chart review, with sensitivity, specificity, positive predictive value, and negative predictive value of 93%, 90.5%, 94.4%, and 88.2%, respectively. Conclusions This was a successful development and validation of an automated process using electronic health records data elements, including free-text fields, to classify risk for PE in ED visits.
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Affiliation(s)
| | | | | | - Yan Liu
- Northwell Health, Manhasset, NY, United States
| | | | - Sundas Khan
- Northwell Health, Manhasset, NY, United States
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11
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Kjelle E, Andersen ER, Soril LJJ, van Bodegom-Vos L, Hofmann BM. Interventions to reduce low-value imaging - a systematic review of interventions and outcomes. BMC Health Serv Res 2021; 21:983. [PMID: 34537051 PMCID: PMC8449221 DOI: 10.1186/s12913-021-07004-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 09/02/2021] [Indexed: 12/24/2022] Open
Abstract
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.
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Affiliation(s)
- Elin Kjelle
- Institute for the Health Sciences at the Norwegian University of Science and Technology (NTNU) at Gjøvik, NTNU Gjøvik, Postbox 191, 2802 Gjøvik, Norway
| | - Eivind Richter Andersen
- Institute for the Health Sciences at the Norwegian University of Science and Technology (NTNU) at Gjøvik, NTNU Gjøvik, Postbox 191, 2802 Gjøvik, Norway
| | - Lesley J. J. Soril
- Department of Community Health Sciences and The Health Technology Assessment Unit, O’Brien Institute for Public Health, University of Calgary, 3280 Hospital Dr NW, Calgary, Alberta T2N 4Z6 Canada
| | - Leti van Bodegom-Vos
- Medical Decision making, Department of Biomedical Data Sciences, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, the Netherlands
| | - Bjørn Morten Hofmann
- Institute for the Health Sciences at the Norwegian University of Science and Technology (NTNU) at Gjøvik, NTNU Gjøvik, Postbox 191, 2802 Gjøvik, Norway
- Centre of Medical Ethics, University of Oslo, Postbox 1130, Blindern, 0318 Oslo, Norway
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12
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Schwartz FR, Roth CJ, Boardwine B, Hardister L, Thomas-Campbell S, Lander K, Montoya C, Jaffe TA. Electronic Health Record Closed-Loop Communication Program for Unexpected Nonemergent Findings. Radiology 2021; 301:123-130. [PMID: 34374592 DOI: 10.1148/radiol.2021210057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background Reliance on examination reporting of unexpected imaging findings does not ensure receipt of findings or appropriate follow-up. A closed-loop communication system should include provider and patient notifications and be auditable through the electronic health record (EHR). Purpose To report the initial design of and results from using an EHR-integrated unexpected findings navigator (UFN) program that ensures closed-loop communication of unexpected nonemergent findings. Materials and Methods An EHR-integrated UFN program was designed to enable identification and communication of unexpected findings and aid in next steps in findings management. Three navigators (with prior training as radiologic technologists and sonographers) facilitated communication and documentation of results to providers and patients. Twelve months (October 2019 to October 2020) of results were retrospectively reviewed to evaluate patient demographics and program metrics. Descriptive statistics and correlation analysis were performed by using commercially available software. Results A total of 3542 examinations were reported within 12 months, representing 0.5% of all examinations performed (total of 749 649); the median patient age was 62 years (range, 1 day to 98 years; interquartile range, 23 years). Most patients were female (2029 of 3542 [57%]). Almost half of the examinations submitted were from chest radiography and CT (1618 of 3542 [46%]), followed by MRI and CT of the abdomen and pelvis (1123 of 3542 [32%]). The most common unexpected findings were potential neoplasms (391 of 3542 [11%]). The median time between examination performance and patient notification was 12 days (range, 0-136 days; interquartile range, 13 days). A total of 2127 additional imaging studies were performed, and 1078 patients were referred to primary care providers and specialists. Most radiologists (89%, 63 of 71 respondents) and providers (65%, 28 of 43 respondents) found the system useful and used it most frequently during regular business hours. Conclusion An electronic health record-integrated, navigator-facilitated, closed-loop communication program for unexpected radiologic findings led to near-complete success in notification of providers and patients and facilitated the next steps in findings management. © RSNA, 2021 See also the editorial by Safdar in this issue.
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Affiliation(s)
- Fides R Schwartz
- From the Duke University Medical Center, Department of Radiology, 2301 Erwin Rd, Box 3808, Durham, NC 27710
| | - Christopher J Roth
- From the Duke University Medical Center, Department of Radiology, 2301 Erwin Rd, Box 3808, Durham, NC 27710
| | - Brenda Boardwine
- From the Duke University Medical Center, Department of Radiology, 2301 Erwin Rd, Box 3808, Durham, NC 27710
| | - Lisa Hardister
- From the Duke University Medical Center, Department of Radiology, 2301 Erwin Rd, Box 3808, Durham, NC 27710
| | - Shannon Thomas-Campbell
- From the Duke University Medical Center, Department of Radiology, 2301 Erwin Rd, Box 3808, Durham, NC 27710
| | - Katherine Lander
- From the Duke University Medical Center, Department of Radiology, 2301 Erwin Rd, Box 3808, Durham, NC 27710
| | - Charlene Montoya
- From the Duke University Medical Center, Department of Radiology, 2301 Erwin Rd, Box 3808, Durham, NC 27710
| | - Tracy A Jaffe
- From the Duke University Medical Center, Department of Radiology, 2301 Erwin Rd, Box 3808, Durham, NC 27710
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13
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Andruchow JE, Grigat D, McRae AD, Innes G, Vatanpour S, Wang D, Taljaard M, Lang E. Decision support for computed tomography in the emergency department: a multicenter cluster-randomized controlled trial. CAN J EMERG MED 2021; 23:631-640. [PMID: 34351598 DOI: 10.1007/s43678-021-00170-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 06/17/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Clinical decision support may facilitate evidence-based imaging, but most studies to date examining the impact of decision support have used non-randomized designs which limit the conclusions that can be drawn from them. This randomized trial examines if decision support can reduce computed tomography (CT) utilization for patients with mild traumatic brain injuries and suspected pulmonary embolism in the emergency department. This study was funded by a competitive public research grant and registered on ClinicalTrials.gov (NCT02410941). METHODS Emergency physicians at five urban sites were assigned to voluntary decision support for CT imaging of patients with either head injuries or suspected pulmonary embolism using a cluster-randomized design over a 1-year intervention period. The co-primary outcomes were CT head and CT pulmonary angiography utilization. CT pulmonary angiography diagnostic yield (proportion of studies diagnostic for acute pulmonary embolism) was a secondary outcome. RESULTS A total of 225 physicians were randomized and studied over a 2-year baseline and 1-year intervention period. Physicians interacted with the decision support in 38.0% and 45.0% of eligible head injury and suspected pulmonary embolism cases, respectively. A mixed effects logistic regression model demonstrated no significant impact of decision support on head CT utilization (OR 0.93, 95% CI 0.79-1.10, p = 0.31), CT pulmonary angiography utilization (OR 0.98, 95% CI 0.88-1.11, p = 0.74) or diagnostic yield (OR 1.23, 95% CI 0.96-1.65, p = 0.10). However, overall CT pulmonary diagnostic yield (17.7%) was almost three times higher than that reported by a recent large US study, suggesting that selective imaging was already being employed. CONCLUSION Voluntary decision support addressing many commonly cited barriers to evidence-based imaging did not significantly reduce CT utilization or improve diagnostic yield but was limited by low rates of participation and high baseline rates of selective imaging. Demonstrating value to clinicians through interventions that improve workflow is likely necessary to meaningfully change imaging practices.
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Affiliation(s)
- James E Andruchow
- Department of Emergency Medicine, University of Calgary Cumming School of Medicine, Foothills Medical Centre Room C-231, 1403-29st NW, Calgary, AB, T2N 2T9, Canada. .,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.
| | | | - Andrew D McRae
- Department of Emergency Medicine, University of Calgary Cumming School of Medicine, Foothills Medical Centre Room C-231, 1403-29st NW, Calgary, AB, T2N 2T9, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Grant Innes
- Department of Emergency Medicine, University of Calgary Cumming School of Medicine, Foothills Medical Centre Room C-231, 1403-29st NW, Calgary, AB, T2N 2T9, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Shabnam Vatanpour
- Department of Emergency Medicine, University of Calgary Cumming School of Medicine, Foothills Medical Centre Room C-231, 1403-29st NW, Calgary, AB, T2N 2T9, Canada
| | - Dongmei Wang
- Department of Emergency Medicine, University of Calgary Cumming School of Medicine, Foothills Medical Centre Room C-231, 1403-29st NW, Calgary, AB, T2N 2T9, Canada
| | - Monica Taljaard
- Ottawa Hospital Research Institute, Ottawa, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Eddy Lang
- Department of Emergency Medicine, University of Calgary Cumming School of Medicine, Foothills Medical Centre Room C-231, 1403-29st NW, Calgary, AB, T2N 2T9, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
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14
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Bledsoe JR, Kelly C, Stevens SM, Woller SC, Haug P, Lloyd JF, Allen TL, Butler AM, Jacobs JR, Elliott CG. Electronic pulmonary embolism clinical decision support and effect on yield of computerized tomographic pulmonary angiography: ePE-A pragmatic prospective cohort study. J Am Coll Emerg Physicians Open 2021; 2:e12488. [PMID: 34263250 PMCID: PMC8254596 DOI: 10.1002/emp2.12488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 05/29/2021] [Accepted: 06/03/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Multiple professional societies recommend pre-test probability (PTP) assessment prior to imaging in the evaluation of patients with suspected pulmonary embolism (PE), however, PTP testing remains uncommon, with imaging occurring frequently and rates of confirmed PE remaining low. The goal of this study was to assess the impact of a clinical decision support tool embedded into the electronic health record to improve the diagnostic yield of computerized tomography pulmonary angiography (CTPA) in suspected patients with PE in the emergency department (ED). METHODS Between July 24, 2014 and December 31, 2016, 4 hospitals from a healthcare system embedded an optional electronic clinical decision support system to assist in the diagnosis of pulmonary embolism (ePE). This system employs the Pulmonary Embolism Rule-out Criteria (PERC) and revised Geneva Score (RGS) in series prior to CT imaging. We compared the diagnostic yield of CTPA) among patients for whom the physician opted to use ePE versus the diagnostic yield of CTPA when ePE was not used. RESULTS During the 2.5-year study period, 37,288 adult patients were eligible and included for study evaluation. Of eligible patients, 1949 of 37,288 (5.2%) were enrolled by activation of the tool. A total of 16,526 CTPAs were performed system-wide. When ePE was not engaged, CTPA was positive for PE in 1556 of 15,546 scans for a positive yield of 10.0%. When ePE was used, CTPA identified PE in 211 of 980 scans (21.5% yield) (P < 0.001). CONCLUSIONS ePE significantly increased the diagnostic yield of CTPA without missing 30-day clinically overt PE.
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Affiliation(s)
- Joseph R. Bledsoe
- Department of Emergency MedicineHealthcare Delivery InstituteIntermountain HealthcareMurrayUtahUSA
- Department of Emergency MedicineStanford MedicinePalo AltoCaliforniaUSA
| | - Christopher Kelly
- Department of SurgeryDivision of Emergency MedicineUniversity of Utah School of MedicineSalt Lake CityUtahUSA
| | - Scott M. Stevens
- Department of MedicineIntermountain Medical CenterMurrayUtahUSA
- Department of Internal MedicineUniversity of Utah School of MedicineSalt Lake CityUtahUSA
| | - Scott C. Woller
- Department of MedicineIntermountain Medical CenterMurrayUtahUSA
- Department of Internal MedicineUniversity of Utah School of MedicineSalt Lake CityUtahUSA
| | - Peter Haug
- Medical InformaticsIntermountain HealthcareMurrayUtahUSA
| | - James F. Lloyd
- Medical InformaticsIntermountain HealthcareMurrayUtahUSA
| | - Todd L. Allen
- Department of Emergency MedicineHealthcare Delivery InstituteIntermountain HealthcareMurrayUtahUSA
- Department of Emergency MedicineStanford MedicinePalo AltoCaliforniaUSA
| | | | | | - C. Gregory Elliott
- Department of MedicineIntermountain Medical CenterMurrayUtahUSA
- Department of Internal MedicineUniversity of Utah School of MedicineSalt Lake CityUtahUSA
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15
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Buk M, Rengier F, Mokry T, Riffel J, Giannitsis E, Kihm L, Malikova H, Kauczor HU, von Stackelberg O, Weber TF. Appropriateness of CT pulmonary angiograms according to current diagnostic guidelines based on risk stratification: A retrospective single-center study. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2020; 165:51-56. [PMID: 33087940 DOI: 10.5507/bp.2020.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 10/07/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND AND AIM Assessment of appropriateness of CT pulmonary angiograms (CTPA) in patients with suspected pulmonary embolism (PE) is based on risk stratification algorithms such as simplified the Geneva Score (sGS) in combination with D-dimer blood tests. The aim of this study was to validate the diagnostic yield and appropriateness of CTPA examinations in accordance with 2014 European Society of Cardiology (ESC) guidelines. MATERIALS AND METHODS Data from 155 outpatients who underwent CTPA for clinical suspicion of PE were gathered from the radiology information system (RIS) and the clinical information system (CIS). We assessed the presence of sGS items and D-dimer blood test results in RIS from CTPA request forms and from clinical documentation in CIS. RESULTS Based on the RIS, there were 2.6% patients with high (sGS≥3) and 97.4% patients with low pre-test PE probability (sGS<3), and CTPA indication was formally comprehendible in 75.5% using sGS and D-dimer blood tests. Based on RIS and CIS data in combination, there were 41.3% patients with high and 58.7% patients with low pre-test PE probability, and CTPA indication was formally comprehendible in 88.4%. Using RIS and CIS in combination, PE probability was upgraded from low to high probability in 39.7% compared with RIS alone. In 12.9%, there was a lack of data in RIS for CTPA justification. CONCLUSION There is a high diagnostic yield when applying current diagnostic guidelines to our data. There was however a notable discrepancy between the data transferred to the CTPA request forms from the full clinical documentation, therefore not readily available for clinical decision making.
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Affiliation(s)
- Michal Buk
- Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Germany.,Department of Radiology, Third Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Prague, Czech Republic.,Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Fabian Rengier
- Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), University of Heidelberg, Heidelberg, Germany
| | - Theresa Mokry
- Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Germany
| | - Johannes Riffel
- Department of Cardiology, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Lars Kihm
- Department of Endocrinology, University Hospital Heidelberg, Heidelberg, Germany
| | - Hana Malikova
- Department of Radiology, Third Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Prague, Czech Republic.,Institute of Anatomy, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Hans-Ulrich Kauczor
- Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), University of Heidelberg, Heidelberg, Germany
| | | | - Tim Frederik Weber
- Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Germany
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16
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Hategeka C, Ruton H, Karamouzian M, Lynd LD, Law MR. Use of interrupted time series methods in the evaluation of health system quality improvement interventions: a methodological systematic review. BMJ Glob Health 2020; 5:e003567. [PMID: 33055094 PMCID: PMC7559052 DOI: 10.1136/bmjgh-2020-003567] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/07/2020] [Accepted: 09/10/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND When randomisation is not possible, interrupted time series (ITS) design has increasingly been advocated as a more robust design to evaluating health system quality improvement (QI) interventions given its ability to control for common biases in healthcare QI. However, there is a potential risk of producing misleading results when this rather robust design is not used appropriately. We performed a methodological systematic review of the literature to investigate the extent to which the use of ITS has followed best practice standards and recommendations in the evaluation of QI interventions. METHODS We searched multiple databases from inception to June 2018 to identify QI intervention studies that were evaluated using ITS. There was no restriction on date, language and participants. Data were synthesised narratively using appropriate descriptive statistics. The risk of bias for ITS studies was assessed using the Cochrane Effective Practice and Organisation of Care standard criteria. The systematic review protocol was registered in PROSPERO (registration number: CRD42018094427). RESULTS Of 4061 potential studies and 2028 unique records screened for inclusion, 120 eligible studies assessed eight QI strategies and were from 25 countries. Most studies were published since 2010 (86.7%), reported data using monthly interval (71.4%), used ITS without a control (81%) and modelled data using segmented regression (62.5%). Autocorrelation was considered in 55% of studies, seasonality in 20.8% and non-stationarity in 8.3%. Only 49.2% of studies specified the ITS impact model. The risk of bias was high or very high in 72.5% of included studies and did not change significantly over time. CONCLUSIONS The use of ITS in the evaluation of health system QI interventions has increased considerably over the past decade. However, variations in methodological considerations and reporting of ITS in QI remain a concern, warranting a need to develop and reinforce formal reporting guidelines to improve its application in the evaluation of health system QI interventions.
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Affiliation(s)
- Celestin Hategeka
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Centre for Health Services and Policy Research, School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Hinda Ruton
- Centre for Health Services and Policy Research, School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada
- School of Public Health, University of Rwanda, Kigali, Rwanda
| | - Mohammad Karamouzian
- School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada
- HIV/STI Surveillance Research Centre, and WHO Collaborating Centre for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Larry D Lynd
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia, Canada
- Center for Health Evaluation and Outcome Sciences, Providence Health Research Institute, Vancouver, British Columbia, Canada
| | - Michael R Law
- Centre for Health Services and Policy Research, School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada
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17
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Predictors of Overtesting in Pulmonary Embolism Diagnosis. Acad Radiol 2020; 27:404-408. [PMID: 31155486 DOI: 10.1016/j.acra.2019.04.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 04/05/2019] [Accepted: 04/06/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND The benefits of computed tomography pulmonary angiography (CTPA) for pulmonary embolism (PE) diagnosis must be weighed against its risks, radiation-induced malignancy, and contrast-induced nephropathy. Appropriate use of CTPA can be assessed by monitoring yield, the percentage of tests positive for PE. We identify factors that are associated low CTPA yield, which may predict overtesting. METHODS This was a retrospective cohort study of six emergency departments between June 2014 and February 2017. The electronic health record was queried for CTPAs ordered for adult patients in the emergency department. We assessed the following patient factors: age, gender, body mass index, number of comorbidities, race, and ethnicity, provider factors: type (resident, fellow, attending, physician assistant) and environment factors: test time of day, season of visit, and crowdedness of the department. RESULTS A total of 14,782 CTPAs were reviewed, of which 1366 were found to be positive for PE, resulting in an overall CTPA yield of 9.24%. Provider type was not associated with a difference in yield. Testing was less likely to be positive in younger patients, females, those with lower body mass indexes and those identifying as Asian or Hispanic. Testing was also less likely to be positive when ordered during the overnight shift and during the winter and spring seasons. CONCLUSION Our study identified several patient and environmental factors associated with low CTPA yield suggesting potential targets for overtesting. Targeting education and clinical decision support to assist providers in these circumstances may meaningfully improve yields.
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18
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Hogan J, Frasso R, Hailu T, Tate A, Martin R, Sze R. Optimizing Imaging Clinical Decision Support: Perspectives of Pediatric Emergency Department Physicians. J Am Coll Radiol 2020; 17:262-267. [DOI: 10.1016/j.jacr.2019.08.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 08/14/2019] [Accepted: 08/25/2019] [Indexed: 11/25/2022]
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19
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Babaa A, Al-Hihi M, Abujudeh HH. An Overview of Strategies Targeting Inappropriate Advanced Diagnostic Imaging in the Setting of Acute Uncomplicated Low Back Pain. CURRENT RADIOLOGY REPORTS 2020. [DOI: 10.1007/s40134-020-0345-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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20
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Kline JA, Garrett JS, Sarmiento EJ, Strachan CC, Courtney DM. Over-Testing for Suspected Pulmonary Embolism in American Emergency Departments: The Continuing Epidemic. Circ Cardiovasc Qual Outcomes 2020; 13:e005753. [PMID: 31957477 DOI: 10.1161/circoutcomes.119.005753] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND No recent data have investigated rates of diagnostic testing for pulmonary embolism (PE) in US emergency departments (EDs), and no data have examined computed tomographic pulmonary angiography (CTPA) rates in subgroups at high risk for adverse imaging outcomes, including young women and children. We hypothesized that over-testing for PE remains a problem. METHODS AND RESULTS We used electronic health record and billing data for 16 EDs in Indiana and 11 hospitals in the Dallas-Fort Worth area from 2016 to 2019 to locate ED patients who had any of the following: D-dimer, CTPA, scintillation ventilation perfusion lung scanning or formal pulmonary angiography. The primary outcomes were ED encounter volume-adjusted CTPA rate, PE yield rate with subgroup reporting for children (<18 years) and women under 45 years. We also examined the most frequent diagnoses. From a total visit volume of 1 828 010 patient encounters, 97 125 (5.3% of the total volume) had a diagnostic test for PE, including 25 870 patients who had CTPA order without D-dimer (59% of all tests for PE). The yield rate for PE from CTPA scans was 1.3% (1.1%-1.5%) in Indiana and 4.8% (4.2%-5.1%) in Dallas-Fort Worth (pooled rate 3.1%). Linear regression showed that increased D-dimer ordering correlated with increased PE yield rate (Pearson's R2=0.43; P<0.001). From the pooled sample, 59% of CTPAs done were in women, with 21% of all CTPAs performed on women under 45 years of age, and 1.4% (1.3%-1.5%) on children. The most frequent diagnoses were symptom-based descriptions of chest pain (34%) and shortness of breath (6.5%) and the condition-based diagnosis of pneumonia (4.1%). CONCLUSIONS Over-testing for PE in American EDs remains a major public health problem. Centers with higher D-dimer ordering had higher yield of PE on CTPA. These data suggest the potential for implementation of D-dimer based protocols to reduce low-yield CTPA ordering.
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Affiliation(s)
- Jeffrey A Kline
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis (J.A.K., E.J.S., C.C.S.)
| | - John S Garrett
- Department of Emergency Medicine, Baylor University Medical Center, Dallas, TX (J.S.G.)
| | - Elisa J Sarmiento
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis (J.A.K., E.J.S., C.C.S.)
| | - Christian C Strachan
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis (J.A.K., E.J.S., C.C.S.)
| | - D Mark Courtney
- Department of Emergency Medicine, University of Texas Southwestern, Dallas, TX (D.M.C.)
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21
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Higher Imaging Yield When Clinical Decision Support Is Used. J Am Coll Radiol 2019; 17:496-503. [PMID: 31899178 DOI: 10.1016/j.jacr.2019.11.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 11/05/2019] [Accepted: 11/20/2019] [Indexed: 01/16/2023]
Abstract
OBJECTIVE Increased utilization of CT pulmonary angiography (CTPA) for the evaluation of pulmonary embolism has been associated with decreasing diagnostic yields and rising concerns about the harms of unnecessary testing. The objective of this study was to determine whether clinical decision support (CDS) use would be associated with increased imaging yields after controlling for selection bias. METHODS We performed a retrospective cohort study in the emergency departments of two tertiary care hospitals of all CTPAs performed between August 2015 and September 2018. Providers ordering a CTPA are routed to an optional CDS tool, which allows them to use Wells' Criteria for pulmonary embolism. After propensity score matching, CTPA yield was calculated for the CDS-use and CDS-dismissal groups and stratified by provider type. RESULTS A total of 7,367 CTPAs were ordered during the study period. Of those, providers used the CDS tool in 2,568 (35%) cases and did not use the tool in 4,799 (65%) of cases. After propensity score matching, CTPA yield was 11.99% in the CDS-use group and 8.70% in the CDS-dismissal group (P < .001). Attending physicians, residents, and physician assistant CDS users demonstrated a 56.5% (P = .006), 38.7% (P = .01), and 16.7% (P = .03) increased yield compared with those who dismissed the tool, respectively. DISCUSSION Diagnostic yield was 38% higher for CTPAs when the provider used the CDS tool, after controlling for selection bias. Yields were higher for every provider type. Further research is needed to discover successful strategies to increase provider use of these important tools.
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Rehani MM, Melick ER, Alvi RM, Doda Khera R, Batool-Anwar S, Neilan TG, Bettmann M. Patients undergoing recurrent CT exams: assessment of patients with non-malignant diseases, reasons for imaging and imaging appropriateness. Eur Radiol 2019; 30:1839-1846. [PMID: 31792584 DOI: 10.1007/s00330-019-06551-8] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 10/15/2019] [Accepted: 10/25/2019] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To determine percent of patients without malignancy and ≤ 40 years of age with high cumulative radiation doses through recurrent CT exams and assess imaging appropriateness. METHODS From the cohort of patients who received cumulative effective dose (CED) of ≥ 100 mSv over a 5-year period, a sub-set was identified with non-malignant disease. The top 50 clinical indications leading to multiple CTs were determined. Clinical decision support (CDS) system scores were analyzed using a widely adopted standard of 1-3 (red) as "not usually appropriate," 4-6 (yellow) "may or may not be appropriate," and 7-9 (green) "usually appropriate." Clinicians reviewed patient records to assess compliance with appropriate use criteria (AUC). RESULTS 9.6% of patients in our series were with non-malignant conditions and 1.4% with age ≤ 40 years. CDS scores (rounded) were 2% red, 38% yellow, 27% green, and 33% unscored CTs. Clinical society guidelines for CT exams, wherever available, were followed in 87.5 to 100% of cases. AUCs were not available for several clinical indications as also referral guidelines for serial CT imaging. More than half of CT exams were unrelated to follow-up of a primary chronic disease. CONCLUSIONS We are faced with a situation wherein patients in age ≤ 40 years require or are thought to require many CT exams over the course of a few years but the radiation risk creates concern. There is a fair number of conditions for which AUC are not available. Suggested solutions include development of CT scanners with lesser radiation dose and further development of appropriateness criteria. KEY POINTS We are faced with a situation wherein patients in age group 0-40 years and with non-malignant diagnosis require or are thought to require many CT exams over the course of a few years. More than half of CT exams were unrelated to follow-up of a primary chronic disease. Imaging guidelines and appropriateness use criteria are not available for many conditions. Wherever available, they are for initial work-up and diagnosis and there is a lack of guidance on serial CT imaging.
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Affiliation(s)
- Madan M Rehani
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.
| | - Emily R Melick
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Raza M Alvi
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Ruhani Doda Khera
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | | | - Tomas G Neilan
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Michael Bettmann
- Wake Forest University School of Medicine, Winston-Salem, NC, 27101, USA
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Hoonakker PLT, Carayon P, Salwei ME, Hundt AS, Wiegmann D, Kleinschmidt P, Pulia MS, Wang Y, Novak C, Patterson BW. The Design of PE Dx, a CDS to Support Pulmonary Embolism Diagnosis in the ED. Stud Health Technol Inform 2019; 265:134-140. [PMID: 31431589 DOI: 10.3233/shti190152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Designing and implementing clinical decision support (CDS) in health care has been challenging. Attempts have been made to design and implement CDS to support clinical procedures, but many of these CDSs have met user resistance. One possible explanation for the lack of acceptability can be the poor design of the CDS. In this study, we describe the design of PE Dx, a CDS built to support the diagnosis of pulmonary embolism (PE) in the emergency department (ED) using human factors methods.
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Affiliation(s)
| | | | | | - Ann S Hundt
- University of Wisconsin-Madison, Madison WI, 53726, USA
| | | | - Peter Kleinschmidt
- University of Wisconsin-Madison, Madison WI, 53726, USA.,UW Health, Madison WI, 53726, USA
| | - Michael S Pulia
- University of Wisconsin-Madison, Madison WI, 53726, USA.,UW Health, Madison WI, 53726, USA
| | - Yudi Wang
- University of Wisconsin-Madison, Madison WI, 53726, USA
| | | | - Brian W Patterson
- University of Wisconsin-Madison, Madison WI, 53726, USA.,UW Health, Madison WI, 53726, USA
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Hentel KD, Menard A, Mongan J, Durack JC, Johnson PT, Raja AS, Khorasani R. What Physicians and Health Organizations Should Know About Mandated Imaging Appropriate Use Criteria. Ann Intern Med 2019; 170:880-885. [PMID: 31181572 DOI: 10.7326/m19-0287] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
| | - Andrew Menard
- Johns Hopkins Medicine, Baltimore, Maryland (A.M., P.T.J.)
| | - John Mongan
- University of California, San Francisco, San Francisco, California (J.M.)
| | - Jeremy C Durack
- Memorial Sloan Kettering Cancer Center, New York, New York (J.C.D.)
| | | | - Ali S Raja
- Massachusetts General Hospital, Boston, Massachusetts (A.S.R.)
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Scope and Influence of Electronic Health Record-Integrated Clinical Decision Support in the Emergency Department: A Systematic Review. Ann Emerg Med 2019; 74:285-296. [PMID: 30611639 DOI: 10.1016/j.annemergmed.2018.10.034] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 10/08/2018] [Accepted: 10/29/2018] [Indexed: 01/19/2023]
Abstract
STUDY OBJECTIVE As electronic health records evolve, integration of computerized clinical decision support offers the promise of sorting, collecting, and presenting this information to improve patient care. We conducted a systematic review to examine the scope and influence of electronic health record-integrated clinical decision support technologies implemented in the emergency department (ED). METHODS A literature search was conducted in 4 databases from their inception through January 18, 2018: PubMed, Scopus, the Cumulative Index of Nursing and Allied Health, and Cochrane Central. Studies were included if they examined the effect of a decision support intervention that was implemented in a comprehensive electronic health record in the ED setting. Standardized data collection forms were developed and used to abstract study information and assess risk of bias. RESULTS A total of 2,558 potential studies were identified after removal of duplicates. Of these, 42 met inclusion criteria. Common targets for clinical decision support intervention included medication and radiology ordering practices, as well as more comprehensive systems supporting diagnosis and treatment for specific disease entities. The majority of studies (83%) reported positive effects on outcomes studied. Most studies (76%) used a pre-post experimental design, with only 3 (7%) randomized controlled trials. CONCLUSION Numerous studies suggest that clinical decision support interventions are effective in changing physician practice with respect to process outcomes such as guideline adherence; however, many studies are small and poorly controlled. Future studies should consider the inclusion of more specific information in regard to design choices, attempt to improve on uncontrolled before-after designs, and focus on clinically relevant outcomes wherever possible.
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Kubo T. Vendor free basics of radiation dose reduction techniques for CT. Eur J Radiol 2018; 110:14-21. [PMID: 30599851 DOI: 10.1016/j.ejrad.2018.11.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 10/19/2018] [Accepted: 11/04/2018] [Indexed: 11/16/2022]
Abstract
Although radiation dose in computed tomography (CT) decreased and CT became safer examinations than before, CT is the most significant source of the medical radiation exposure. Knowledge about available radiation dose reduction methods in CT is essential. Substantial improvement occurred regarding tube current selection (automatic exposure control) and image production method (iterative reconstruction). Optimizing the tube potential selection is expected to contribute to further CT radiation dose reduction. This review article summarizes the principles of radiation dose reduction in CT, principal methods of radiation dose reduction, auxiliary measures of radiation dose saving and recent issues of low dose CT.
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Affiliation(s)
- Takeshi Kubo
- Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan.
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Kadom N, Zafar HM, Cook TS, Greene A, Durand DJ. Engaging Patients: Models for Patient- and Family-centered Care in Radiology. Radiographics 2018; 38:1866-1871. [DOI: 10.1148/rg.2018180018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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