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Chaban YV, Vosshenrich J, McKee H, Gunasekaran S, Brown MJ, Atalay MK, Heye T, Markl M, Woolen SA, Simonetti OP, Hanneman K. Environmental Sustainability and MRI: Challenges, Opportunities, and a Call for Action. J Magn Reson Imaging 2024; 59:1149-1167. [PMID: 37694980 DOI: 10.1002/jmri.28994] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 08/18/2023] [Accepted: 08/21/2023] [Indexed: 09/12/2023] Open
Abstract
The environmental impact of magnetic resonance imaging (MRI) has recently come into focus. This includes its enormous demand for electricity compared to other imaging modalities and contamination of water bodies with anthropogenic gadolinium related to contrast administration. Given the pressing threat of climate change, addressing these challenges to improve the environmental sustainability of MRI is imperative. The purpose of this review is to discuss the challenges, opportunities, and the need for action to reduce the environmental impact of MRI and prepare for the effects of climate change. The approaches outlined are categorized as strategies to reduce greenhouse gas (GHG) emissions from MRI during production and use phases, approaches to reduce the environmental impact of MRI including the preservation of finite resources, and development of adaption plans to prepare for the impact of climate change. Co-benefits of these strategies are emphasized including lower GHG emission and reduced cost along with improved heath and patient satisfaction. Although MRI is energy-intensive, there are many steps that can be taken now to improve the environmental sustainability of MRI and prepare for the effects of climate change. On-going research, technical development, and collaboration with industry partners are needed to achieve further reductions in MRI-related GHG emissions and to decrease the reliance on finite resources. LEVEL OF EVIDENCE: 5 TECHNICAL EFFICACY: Stage 6.
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Affiliation(s)
- Yuri V Chaban
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jan Vosshenrich
- Department of Radiology, University Hospital Basel, Basel, Switzerland
| | - Hayley McKee
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Suvai Gunasekaran
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Maura J Brown
- Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Michael K Atalay
- Department of Diagnostic Imaging, Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Tobias Heye
- Department of Radiology, University Hospital Basel, Basel, Switzerland
| | - Michael Markl
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Department of Biomedical Engineering, Northwestern University, Evanston, Illinois, USA
| | - Sean A Woolen
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | | | - Kate Hanneman
- Department of Medical Imaging, University Medical Imaging Toronto, University of Toronto, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Rigney GH, King AH, Chung J, Ghoshal S, Jain A, Shi Z, Razak S, Hirsch JA, Lev MH, Buch K, Succi MD. Trends in non-focal neurological chief complaints and CT angiography utilization among adults in the emergency department. Intern Emerg Med 2024:10.1007/s11739-024-03569-9. [PMID: 38512433 DOI: 10.1007/s11739-024-03569-9] [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: 10/04/2023] [Accepted: 02/22/2024] [Indexed: 03/23/2024]
Abstract
Prudent imaging use is essential for cost reduction and efficient patient triage. Recent efforts have focused on head and neck CTA in patients with emergent concerns for non-focal neurological complaints, but have failed to demonstrate whether increases in utilization have resulted in better care. The objective of this study was to examine trends in head and neck CTA ordering and determine whether a correlation exists between imaging utilization and positivity rates. This is a single-center retrospective observational study at a quaternary referral center. This study includes patients presenting with headache and/or dizziness to the emergency department between January 2017 and December 2021. Patients who received a head and neck CTA were compared to those who did not. The main outcomes included annual head and neck CTA utilization and positivity rates, defined as the percent of scans with attributable acute pathologies. Among 24,892 emergency department visits, 2264 (9.1%) underwent head and neck CTA imaging. The percentage of patients who received a scan over the study period increased from 7.89% (422/5351) in 2017 to 13.24% (662/5001) in 2021, representing a 67.4% increase from baseline (OR, 1.14; 95% CI 1.11-1.18; P < .001). The positivity rate, or the percentage of scans ordered that revealed attributable acute pathology, dropped from 16.8% (71/422) in 2017 to 10.4% (69/662) in 2021 (OR, 0.86; 95% CI 0.79-0.94; P = .001), a 38% reduction in positive examinations. Throughout the study period, there was a 67.4% increase in head and neck CTA ordering with a concomitant 38.1% decrease in positivity rate.
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Affiliation(s)
- Grant H Rigney
- Harvard Medical School, Boston, USA
- Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, USA
| | - Alexander H King
- Harvard Medical School, Boston, USA
- Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, USA
| | - Janice Chung
- Harvard Medical School, Boston, USA
- Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, USA
| | - Soham Ghoshal
- Harvard Medical School, Boston, USA
- Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, USA
| | - Aditya Jain
- Harvard Medical School, Boston, USA
- Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, USA
| | - Zhuo Shi
- Harvard Medical School, Boston, USA
- Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, USA
| | - Shahaan Razak
- Harvard Medical School, Boston, USA
- Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, USA
| | - Joshua A Hirsch
- Harvard Medical School, Boston, USA
- Department of Radiology, Massachusetts General Hospital, Boston, USA
- Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, USA
| | - Michael H Lev
- Harvard Medical School, Boston, USA
- Department of Radiology, Massachusetts General Hospital, Boston, USA
- Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, USA
| | - Karen Buch
- Harvard Medical School, Boston, USA
- Department of Radiology, Massachusetts General Hospital, Boston, USA
- Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, USA
| | - Marc D Succi
- Harvard Medical School, Boston, USA.
- Department of Radiology, Massachusetts General Hospital, Boston, USA.
- Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, USA.
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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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Shreve LA, Fried JG, Liu F, Cao Q, Pakpoor J, Kahn CE, Zafar HM. Impact of Artificial Intelligence-Assisted Indication Selection on Appropriateness Order Scoring for Imaging Clinical Decision Support. J Am Coll Radiol 2023; 20:1258-1266. [PMID: 37390881 DOI: 10.1016/j.jacr.2023.04.016] [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: 02/08/2023] [Revised: 03/20/2023] [Accepted: 04/06/2023] [Indexed: 07/02/2023]
Abstract
PURPOSE The aim of this study was to assess appropriateness scoring and structured order entry after the implementation of an artificial intelligence (AI) tool for analysis of free-text indications. METHODS Advanced outpatient imaging orders in a multicenter health care system were recorded 7 months before (March 1, 2020, to September 21, 2020) and after (October 20, 2020, to May 13, 2021) the implementation of an AI tool targeting free-text indications. Clinical decision support score (not appropriate, may be appropriate, appropriate, or unscored) and indication type (structured, free-text, both, or none) were assessed. The χ2 and multivariate logistic regression adjusting for covariables with bootstrapping were used. RESULTS In total, 115,079 orders before and 150,950 orders after AI tool deployment were analyzed. The mean patient age was 59.3 ± 15.5 years, and 146,035 (54.9%) were women; 49.9% of orders were for CT, 38.8% for MR, 5.9% for nuclear medicine, and 5.4% for PET. After deployment, scored orders increased to 52% from 30% (P < .001). Orders with structured indications increased to 67.3% from 34.6% (P < .001). On multivariate analysis, orders were more likely to be scored after tool deployment (odds ratio [OR], 2.7, 95% CI, 2.63-2.78; P < .001). Compared with physicians, orders placed by nonphysician providers were less likely to be scored (OR, 0.80; 95% CI, 0.78-0.83; P < .001). MR (OR, 0.84; 95% CI, 0.82-0.87) and PET (OR, 0.12; 95% CI, 0.10-0.13) were less likely to be scored than CT (; P < .001). After AI tool deployment, 72,083 orders (47.8%) remained unscored, 45,186 (62.7%) with free-text-only indications. CONCLUSIONS Embedding AI assistance within imaging clinical decision support was associated with increased structured indication orders and independently predicted a higher likelihood of scored orders. However, 48% of orders remained unscored, driven by both provider behavior and infrastructure-related barriers.
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Affiliation(s)
- Lauren A Shreve
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Jessica G Fried
- Program Director, Abdominal Imaging, Associate Medical Director of Radiology Informatics, and Co-Director, Tumor Response Assessment Core, Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - Fang Liu
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Quy Cao
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jina Pakpoor
- Centre for Medical Imaging, University College London, London, United Kingdom
| | - Charles E Kahn
- Vice Chair, Department of Radiology, and Vice Chair of Informatics, Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania; Institute for Biomedical Informatics, University of Pennsylvania, Philadelphia, Pennsylvania; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Hanna M Zafar
- Vice Chair of Quality, Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
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Pierre K, Haneberg AG, Kwak S, Peters KR, Hochhegger B, Sananmuang T, Tunlayadechanont P, Tighe PJ, Mancuso A, Forghani R. Applications of Artificial Intelligence in the Radiology Roundtrip: Process Streamlining, Workflow Optimization, and Beyond. Semin Roentgenol 2023; 58:158-169. [PMID: 37087136 DOI: 10.1053/j.ro.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 02/14/2023] [Indexed: 04/24/2023]
Abstract
There are many impactful applications of artificial intelligence (AI) in the electronic radiology roundtrip and the patient's journey through the healthcare system that go beyond diagnostic applications. These tools have the potential to improve quality and safety, optimize workflow, increase efficiency, and increase patient satisfaction. In this article, we review the role of AI for process improvement and workflow enhancement which includes applications beginning from the time of order entry, scan acquisition, applications supporting the image interpretation task, and applications supporting tasks after image interpretation such as result communication. These non-diagnostic workflow and process optimization tasks are an important part of the arsenal of potential AI tools that can streamline day to day clinical practice and patient care.
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Affiliation(s)
- Kevin Pierre
- Radiomics and Augmented Intelligence Laboratory (RAIL), Department of Radiology and the Norman Fixel Institute for Neurological Diseases, University of Florida College of Medicine, Gainesville, FL; Department of Radiology, University of Florida College of Medicine, Gainesville, FL
| | - Adam G Haneberg
- Radiomics and Augmented Intelligence Laboratory (RAIL), Department of Radiology and the Norman Fixel Institute for Neurological Diseases, University of Florida College of Medicine, Gainesville, FL; Division of Medical Physics, Department of Radiology, University of Florida College of Medicine, Gainesville, FL
| | - Sean Kwak
- Radiomics and Augmented Intelligence Laboratory (RAIL), Department of Radiology and the Norman Fixel Institute for Neurological Diseases, University of Florida College of Medicine, Gainesville, FL
| | - Keith R Peters
- Radiomics and Augmented Intelligence Laboratory (RAIL), Department of Radiology and the Norman Fixel Institute for Neurological Diseases, University of Florida College of Medicine, Gainesville, FL; Department of Radiology, University of Florida College of Medicine, Gainesville, FL
| | - Bruno Hochhegger
- Radiomics and Augmented Intelligence Laboratory (RAIL), Department of Radiology and the Norman Fixel Institute for Neurological Diseases, University of Florida College of Medicine, Gainesville, FL; Department of Radiology, University of Florida College of Medicine, Gainesville, FL
| | - Thiparom Sananmuang
- Department of Diagnostic and Therapeutic Radiology and Research, Faculty of Medicine Ramathibodi Hospital, Ratchathewi, Bangkok, Thailand
| | - Padcha Tunlayadechanont
- Department of Diagnostic and Therapeutic Radiology and Research, Faculty of Medicine Ramathibodi Hospital, Ratchathewi, Bangkok, Thailand
| | - Patrick J Tighe
- Departments of Anesthesiology & Orthopaedic Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Anthony Mancuso
- Radiomics and Augmented Intelligence Laboratory (RAIL), Department of Radiology and the Norman Fixel Institute for Neurological Diseases, University of Florida College of Medicine, Gainesville, FL; Department of Radiology, University of Florida College of Medicine, Gainesville, FL
| | - Reza Forghani
- Radiomics and Augmented Intelligence Laboratory (RAIL), Department of Radiology and the Norman Fixel Institute for Neurological Diseases, University of Florida College of Medicine, Gainesville, FL; Department of Radiology, University of Florida College of Medicine, Gainesville, FL; Division of Medical Physics, Department of Radiology, University of Florida College of Medicine, Gainesville, FL.
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Medson K, Yu J, Liwenborg L, Lindholm P, Westerlund E. Comparing ‘clinical hunch’ against clinical decision support systems (PERC rule, wells score, revised Geneva score and YEARS criteria) in the diagnosis of acute pulmonary embolism. BMC Pulm Med 2022; 22:432. [DOI: 10.1186/s12890-022-02242-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 11/10/2022] [Indexed: 11/23/2022] Open
Abstract
Abstract
Background
Pulmonary embolism (PE) is a common and potentially life-threatening condition. Since it is considered a ‘do not miss’ diagnosis, PE tends to be over-investigated beyond the evidence-based clinical decision support systems (CDSS), which in turn subjects patients to unnecessary radiation and contrast agent exposure with no apparent benefits in terms of outcome.
The purpose of this study was to evaluate the yield of ‘clinical hunch’ (gestalt) and four CDSS: the PERC Rule, Wells score, revised Geneva score, and Years criteria.
Methods
A review was conducted on the Electronic Medical Records (EMR) of 1566 patients from the Emergency Department at a tertiary teaching hospital who underwent CTPA from the 1st of January 2018 to the 31st of December 2019. The scores for the four CDSS were calculated retrospectively from the EMR data. We considered that a CTPA had been ordered on a clinical hunch when there was no mention of CDSS in the EMR, and no D-dimer test. A bypass of CDSS was confirmed when any step of the diagnostic algorithms was not followed.
Results
Of the total 1566 patients who underwent CTPA, 265 (17%) were positive for PE. The diagnosis yield from the five decision groups (clinical hunch and four CDSS) was as follows—clinical hunch, 15%; PERC rule, 18% (6% when bypassed); Wells score, 19% (11% when bypassed); revised Geneva score, 26% (13% when bypassed); and YEARS criteria, 18% (6% when bypassed).
Conclusion
Clinicians should trust the evidence-based clinical decision support systems in line with the international guidelines to diagnose PE.
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Evaluation of the appropriate use of chest CT-Scans in the diagnosis of hospitalized patients in shiraz teaching hospitals, Southern Iran. Cost Eff Resour Alloc 2022; 20:44. [PMID: 35999543 PMCID: PMC9395783 DOI: 10.1186/s12962-022-00381-0] [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: 02/23/2022] [Accepted: 08/16/2022] [Indexed: 11/10/2022] Open
Abstract
PURPOSE During recent years, overuse of medical imaging especially computed tomography has become a serious concern. We evaluated the suitable usage of chest computed tomography (CT)-scan, in patients hospitalized in emergency and medical wards of two teaching hospitals of Shiraz University of Medical Science. METHODS Medical records of 216 patients admitted in two major teaching hospitals (Namazi and Shahid Faghihi), who had undergone chest radiography and at least one type of chest CT were investigated. The clinical and paraclinical manifestations were independently presented to three pulmonologists and their opinion regarding the necessity and type of CT prescription were documented. Also, the patient's history was presented to an expert chest radiologist and asked to rate the appropriateness of chest CT according to American colleague of radiologist (ACR) criteria. RESULTS In 127 cases (59%), at least 2 out of 3 pulmonologists had the same opinion on the necessity of performing CT scan regardless of CT scan type, in 89 cases (41%) the same CT type and in 38 (17.5%) cases other CT type was supposed. Based on ACR criteria, of total prescribed CTs, 49.5% were "usually not appropriate" and 31.5% of cases were "usually appropriate". Among 109 pulmonary CT angiography, 54 (49.5%) was usually not appropriate base on ACR criteria, which was the most frequent inappropriate requested CT type. CONCLUSION Considering the high rates of inappropriate utilization of chest CT scan in our teaching hospitals, implementation of the standard guideline at a different level and consulting with a pulmonologist, may prevent unnecessary chest CTs prescription and reduce harm to patients and the health system.
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Tadavarthi Y, Makeeva V, Wagstaff W, Zhan H, Podlasek A, Bhatia N, Heilbrun M, Krupinski E, Safdar N, Banerjee I, Gichoya J, Trivedi H. Overview of Noninterpretive Artificial Intelligence Models for Safety, Quality, Workflow, and Education Applications in Radiology Practice. Radiol Artif Intell 2022; 4:e210114. [PMID: 35391770 DOI: 10.1148/ryai.210114] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 12/17/2021] [Accepted: 01/11/2022] [Indexed: 12/17/2022]
Abstract
Artificial intelligence has become a ubiquitous term in radiology over the past several years, and much attention has been given to applications that aid radiologists in the detection of abnormalities and diagnosis of diseases. However, there are many potential applications related to radiologic image quality, safety, and workflow improvements that present equal, if not greater, value propositions to radiology practices, insurance companies, and hospital systems. This review focuses on six major categories for artificial intelligence applications: study selection and protocoling, image acquisition, worklist prioritization, study reporting, business applications, and resident education. All of these categories can substantially affect different aspects of radiology practices and workflows. Each of these categories has different value propositions in terms of whether they could be used to increase efficiency, improve patient safety, increase revenue, or save costs. Each application is covered in depth in the context of both current and future areas of work. Keywords: Use of AI in Education, Application Domain, Supervised Learning, Safety © RSNA, 2022.
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Affiliation(s)
- Yasasvi Tadavarthi
- Department of Medicine, Medical College of Georgia, Augusta, Ga (Y.T.); Department of Radiology and Imaging Sciences (V.M., W.W., H.Z., M.H., E.K., N.S., J.G., H.T.), School of Medicine (N.B.), and Department of Biomedical Informatics (I.B.), Emory University, 1364 E Clifton Rd NE, Atlanta, GA 30322; and Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea, UK (A.P.)
| | - Valeria Makeeva
- Department of Medicine, Medical College of Georgia, Augusta, Ga (Y.T.); Department of Radiology and Imaging Sciences (V.M., W.W., H.Z., M.H., E.K., N.S., J.G., H.T.), School of Medicine (N.B.), and Department of Biomedical Informatics (I.B.), Emory University, 1364 E Clifton Rd NE, Atlanta, GA 30322; and Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea, UK (A.P.)
| | - William Wagstaff
- Department of Medicine, Medical College of Georgia, Augusta, Ga (Y.T.); Department of Radiology and Imaging Sciences (V.M., W.W., H.Z., M.H., E.K., N.S., J.G., H.T.), School of Medicine (N.B.), and Department of Biomedical Informatics (I.B.), Emory University, 1364 E Clifton Rd NE, Atlanta, GA 30322; and Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea, UK (A.P.)
| | - Henry Zhan
- Department of Medicine, Medical College of Georgia, Augusta, Ga (Y.T.); Department of Radiology and Imaging Sciences (V.M., W.W., H.Z., M.H., E.K., N.S., J.G., H.T.), School of Medicine (N.B.), and Department of Biomedical Informatics (I.B.), Emory University, 1364 E Clifton Rd NE, Atlanta, GA 30322; and Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea, UK (A.P.)
| | - Anna Podlasek
- Department of Medicine, Medical College of Georgia, Augusta, Ga (Y.T.); Department of Radiology and Imaging Sciences (V.M., W.W., H.Z., M.H., E.K., N.S., J.G., H.T.), School of Medicine (N.B.), and Department of Biomedical Informatics (I.B.), Emory University, 1364 E Clifton Rd NE, Atlanta, GA 30322; and Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea, UK (A.P.)
| | - Neil Bhatia
- Department of Medicine, Medical College of Georgia, Augusta, Ga (Y.T.); Department of Radiology and Imaging Sciences (V.M., W.W., H.Z., M.H., E.K., N.S., J.G., H.T.), School of Medicine (N.B.), and Department of Biomedical Informatics (I.B.), Emory University, 1364 E Clifton Rd NE, Atlanta, GA 30322; and Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea, UK (A.P.)
| | - Marta Heilbrun
- Department of Medicine, Medical College of Georgia, Augusta, Ga (Y.T.); Department of Radiology and Imaging Sciences (V.M., W.W., H.Z., M.H., E.K., N.S., J.G., H.T.), School of Medicine (N.B.), and Department of Biomedical Informatics (I.B.), Emory University, 1364 E Clifton Rd NE, Atlanta, GA 30322; and Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea, UK (A.P.)
| | - Elizabeth Krupinski
- Department of Medicine, Medical College of Georgia, Augusta, Ga (Y.T.); Department of Radiology and Imaging Sciences (V.M., W.W., H.Z., M.H., E.K., N.S., J.G., H.T.), School of Medicine (N.B.), and Department of Biomedical Informatics (I.B.), Emory University, 1364 E Clifton Rd NE, Atlanta, GA 30322; and Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea, UK (A.P.)
| | - Nabile Safdar
- Department of Medicine, Medical College of Georgia, Augusta, Ga (Y.T.); Department of Radiology and Imaging Sciences (V.M., W.W., H.Z., M.H., E.K., N.S., J.G., H.T.), School of Medicine (N.B.), and Department of Biomedical Informatics (I.B.), Emory University, 1364 E Clifton Rd NE, Atlanta, GA 30322; and Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea, UK (A.P.)
| | - Imon Banerjee
- Department of Medicine, Medical College of Georgia, Augusta, Ga (Y.T.); Department of Radiology and Imaging Sciences (V.M., W.W., H.Z., M.H., E.K., N.S., J.G., H.T.), School of Medicine (N.B.), and Department of Biomedical Informatics (I.B.), Emory University, 1364 E Clifton Rd NE, Atlanta, GA 30322; and Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea, UK (A.P.)
| | - Judy Gichoya
- Department of Medicine, Medical College of Georgia, Augusta, Ga (Y.T.); Department of Radiology and Imaging Sciences (V.M., W.W., H.Z., M.H., E.K., N.S., J.G., H.T.), School of Medicine (N.B.), and Department of Biomedical Informatics (I.B.), Emory University, 1364 E Clifton Rd NE, Atlanta, GA 30322; and Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea, UK (A.P.)
| | - Hari Trivedi
- Department of Medicine, Medical College of Georgia, Augusta, Ga (Y.T.); Department of Radiology and Imaging Sciences (V.M., W.W., H.Z., M.H., E.K., N.S., J.G., H.T.), School of Medicine (N.B.), and Department of Biomedical Informatics (I.B.), Emory University, 1364 E Clifton Rd NE, Atlanta, GA 30322; and Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea, UK (A.P.)
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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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Bai L, Gao S, Burstein F, Kerr D, Buntine P, Law N. A systematic literature review on unnecessary diagnostic testing: The role of ICT use. Int J Med Inform 2020; 143:104269. [PMID: 32927268 DOI: 10.1016/j.ijmedinf.2020.104269] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 08/10/2020] [Accepted: 09/02/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND The negative impact of unnecessary diagnostic tests on healthcare systems and patients has been widely recognized. Medical researchers in various countries have been devoting effort to reduce unnecessary diagnostic tests by using different types of interventions, including information and communications technology-based (ICT-based) intervention, educational intervention, audit and feedback, the introduction of guidelines or protocols, and the reward and punishment of staff. We conducted a review of ICT based interventions and a comparative analysis of their relative effectiveness in reducing unnecessary tests. METHOD A systematic Boolean search in PubMed, EMBase and EBSCOhost research databases was performed. Keyword search and citation analysis were also conducted. Empirical studies reporting ICT based interventions, and their implications on relative effectiveness in reducing unnecessary diagnostic tests (pathology tests or medical imaging) were evaluated independently by two reviewers based on a rigorously developed coding protocol. RESULTS 92 research articles from peer-reviewed journals were identified as eligible. 47 studies involved a single-method intervention and 45 involved multi-method interventions. Regardless of the number of interventions involved in the studies, ICT-based interventions were utilized by 71 studies and 59 of them were shown to be effective in reducing unnecessary testing. A clinical decision support (CDS) tool appeared to be the most adopted ICT approach, with 46 out of 71 studies using CDS tools. The CDS tool showed effectiveness in reducing test volume in 38 studies and reducing cost in 24 studies. CONCLUSIONS This review investigated five frequently utilized intervention methods, ICT-based, education, introduction of guidelines or protocols, audit and feedback, and reward and punishment. It provides in-depth analysis of the efficacy of different types of interventions and sheds insights about the benefits of ICT based interventions, especially those utilising CDS tools, to reduce unnecessary diagnostic testing. The replicability of the studies is limited due to the heterogeneity of the studies in terms of context, study design, and targeted types of tests.
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Affiliation(s)
- Lu Bai
- Faculty of Information Technology, Monash University, Melbourne, VIC, Australia
| | - Shijia Gao
- Faculty of Information Technology, Monash University, Melbourne, VIC, Australia
| | - Frada Burstein
- Faculty of Information Technology, Monash University, Melbourne, VIC, Australia.
| | - Donald Kerr
- USC Business School, University of the Sunshine Coast, Sippy Downs, QLD, Australia
| | - Paul Buntine
- Emergency Department, Box Hill Hospital, Melbourne, VIC, Australia; Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
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Abstract
Costly proton pump inhibitors have been widely prescribed since the 1990s for prevention and treatment of ulcers and gastroesophageal reflux disease. Evidence published since 2012 demonstrates risks associated with taking proton pump inhibitors for longer than 8 weeks. Primary care providers mostly deprescribe proton pump inhibitors for persons not meeting criteria for long-term use. Many patients resist discontinuation.A 3-month evidence-based practice education project was conducted by a nurse practitioner to improve primary care provider peer deprescribing successes with appropriate patients in an outpatient California-based veteran primary care clinic. Fifteen primary care providers were pretested about usual care practices between 2 comparable clinics. Five primary care providers at the smaller clinic location were educated about long-term proton pump inhibitor use risks and introduced to 3 evidence-based practice guidelines using tapering techniques with follow-up care.A Canadian 2017 evidence-based practice proton pump inhibitor deprescribing guideline was proposed for translation into practice. Primary care providers voted to pilot this guideline, dependent upon nursing support. Primary care providers denied frustration with usual care practices, even as all were willing to try an evidence-based practice change between pre- and post-test surveys. Support for peer-led evidence-based practice on-site coaching increased from 87% to 100%. Tapering behavior increased from 67% to 100%, expediting improved long-term medication cessation.
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Adenaw N, Wen J, Pahwa AK, Sheth S, Johnson PT. Decreasing Duplicative Imaging: Inpatient and Emergency Medicine Abdominal Ultrasound Within 72 Hours of Abdominal CT. J Am Coll Radiol 2020; 17:590-596. [PMID: 32247697 DOI: 10.1016/j.jacr.2020.03.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 03/10/2020] [Accepted: 03/13/2020] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Nebiyu Adenaw
- The Russell H. Morgan Department of Radiology and Radiologic Science, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jessica Wen
- The Russell H. Morgan Department of Radiology and Radiologic Science, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Amit K Pahwa
- The Russell H. Morgan Department of Radiology and Radiologic Science, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sheila Sheth
- The Russell H. Morgan Department of Radiology and Radiologic Science, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Pamela T Johnson
- The Russell H. Morgan Department of Radiology and Radiologic Science, Johns Hopkins University School of Medicine, Baltimore, Maryland.
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Kobes KJ, Budau-Bymoen A, Thakur Y, Yong-Hing CJ. Multidisciplinary Development of Mobile Radiography Guidelines Reduced the Number of Inappropriate Mobile Exams in Patients Receiving Chest Radiographs in British Columbia. Can Assoc Radiol J 2020; 71:110-116. [PMID: 32063000 DOI: 10.1177/0846537119888357] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
AIM To decrease the number of mobile chest radiograph requests for inpatients in British Columbia who are medically able to tolerate transport to the main department by introducing and implementing request criteria. METHOD Concerns regarding inappropriate mobile exam requests in patients receiving chest radiography were surveyed at 28 medical imaging sites. In response, a multidisciplinary team composed a set of mobile radiography request guidelines incorporating feedback from all sites. These were successfully implemented along with in-person education to 21 sites. The number of adult annual mobile chest radiographs was tracked from 2014 to 2018, and informal feedback was obtained from participating sites. RESULTS The percentage of mobile chest radiographs of all chest radiographs performed between 2014 and 2018 decreased by 3.2%, while the total number of all chest radiographs performed during this time, including both departmental and mobile, increased by 1.9%. Sites reported positive engagement with the initiative and expressed need for ongoing education to optimize its effect. CONCLUSION Implementation of request guidelines with in-person education helped to reduce inappropriate mobile exams in patients receiving chest radiographs in British Columbia between 2014 and 2018. These guidelines promote patient safety through reduced radiation exposure, empower radiographers to mitigate inappropriate requests, and help to optimize use of limited hospital resources by reducing inappropriate mobile exams where routine departmental exams are more suitable.
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Affiliation(s)
- Kevin J Kobes
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Yogesh Thakur
- University of British Columbia, Vancouver, British Columbia, Canada.,Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada
| | - Charlotte J Yong-Hing
- University of British Columbia, Vancouver, British Columbia, Canada.,Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada.,BC Cancer, Vancouver Center, British Columbia, Canada
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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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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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Use of Imaging in the Emergency Department: Do Individual Physicians Contribute to Variation? AJR Am J Roentgenol 2019; 213:637-643. [DOI: 10.2214/ajr.18.21065] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Goehler A, Moore C, Manne-Goehler JM, Arango J, D'Amato L, Forman HP, Weinreb J. Clinical Decision Support for Ordering CTA-PE Studies in the Emergency Department-A Pilot on Feasibility and Clinical Impact in a Tertiary Medical Center. Acad Radiol 2019; 26:1077-1083. [PMID: 30389307 DOI: 10.1016/j.acra.2018.09.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 09/08/2018] [Accepted: 09/12/2018] [Indexed: 11/24/2022]
Abstract
PURPOSE To determine the feasibility and impact of Clinical Decision Support for imaging ordering. METHODS A survey of 231 emergency providers identified Computed tomography angiography (CTA)-Pulmonary embolism (PE) as an overutilized study. We developed an algorithm that combined established risk scores to stratify patients for PE work-up (recommendations: CTA, D-dimer or no further testing); the algorithm was integrated into the Epic Radiology Information Ordering System. RESULTS Among 872 studies requested, 479 (55%) received a recommendation to change their order: 6 (1.3%) were cancelled; 13 (2.7%) changed to a D-dimer, and 460 (96%) proceeded with CTA. Of the 853 studies conducted, 8.2% were positive for PE. The algorithm had good discriminatory power with positivity rates of 12.0% (CT), 10.0% (D-dimer), and 2.6% (no further testing). Compliance with the recommendation ranged from 12%-68% (mean 45%) with 10% correlation between compliance and positivity rates. CONCLUSION While the CDS algorithm was accurate, it had only a minimal impact on ordering practices, in part due to heterogeneity in physician adherence.
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The Increasing Use of Emergency Department Imaging in the United States: Is It Appropriate? AJR Am J Roentgenol 2019; 213:W180-W184. [PMID: 31237433 DOI: 10.2214/ajr.19.21386] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE. The purpose of this study was to study trends in utilization of imaging in emergency departments (ED) in relation to trends in ED visits and the specialties of the interpreting physicians. MATERIALS AND METHODS. This study was conducted with Medicare Part B Physician/Supplier Procedure Summary Master Files for 2004-2016 and Health Care Cost and Utilization Project (HCUP) data from 2006 to 2014. Yearly utilization was calculated per 1000 Medicare beneficiaries for different noninvasive imaging modalities performed during ED visits, and the specialties of the physicians making the interpretations were recorded. The number of ED visits by Medicare patients was obtained from the HCUP. RESULTS. The number of ED visits by Medicare fee-for-service patients increased 8.0% (from 20.0 million in 2006 to 21.6 million in 2014), and the total number of associated ED imaging examinations increased 38.4% (14.6 million to 20.2 million). The number of imaging examinations per ED visit was 0.73 in 2006, increasing to 0.94 by 2014. Utilization trends per 1000 Medicare fee-for-service enrollees in the ED for the major modalities were as follows: CT +153.0% (77.8 in 2004 to 196.7 in 2016), noncardiac ultrasound +134% (11.2 in 2004 to 26.2 in 2016), and radiography +30% (259 in 2004 to 336 in 2016). Utilization of MRI and nuclear medicine was very low. In 2016, radiologists interpreted 99.5% (CT), 99.2% (MRI), 98.0% (radiography), 87.6% (ultrasound), and 94.5% (nuclear medicine) of imaging examinations. CONCLUSION. Utilization of imaging in EDs is increasing not only in the Medicare population but also per ED visit. Radiologists strongly predominate in interpreting examinations in all modalities.
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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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Nishtar T, Ahmad T, Noor N, Muhammad F. Rational use of Computed Tomography Scan head in the Emergency Department of a high volume tertiary care public sector hospital. Pak J Med Sci 2019; 35:302-308. [PMID: 31086505 PMCID: PMC6500848 DOI: 10.12669/pjms.35.2.719] [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] [Indexed: 11/15/2022] Open
Abstract
Objective: To emphasize the rational use of Computed Tomography (CT) head in emergency department (ED) of a high volume tertiary care hospital. Methods: This retrospective observational study was conducted in Radiology Department of Medical Teaching Institute Lady Reading Hospital (MTI-LRH), Peshawar, Pakistan from November 1st 2017 to 31st January 2018. Patients of all ages and both genders presenting to the emergency department with post traumatic and non-traumatic indications for emergency CT head scan were included in the study. The imaging was performed on GE 16 multi slice Optima CT system. The imaging protocol included slice thickness of 3-5mm, non-contrast study for cases of head trauma or suspected stroke. Where needed intravenous contrast was administered e.g. to exclude meningitis in patients presenting with severe headache. Patients undergoing CT examination for regions of the body other than head and brain were excluded from the study as their number was insignificant. Reporting was done on PACS and results analyzed using latest SPSS version. Results: Out of 4284 CT scans performed in emergency department 90.8% were CT head (3893). Among 3893 CT scan head done in ED, 2581 cases were reported normal (66.29%), while 1312 cases had positive findings (33.7%), including post traumatic and non-traumatic. Conclusion: Misuse of CT head is common especially in an emergency setting. Emergency physicians should be encouraged to obtain a detailed history and perform a thorough physical examination with reference to internationally standardized guidelines, while ordering CT scan.
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Affiliation(s)
- Tahira Nishtar
- Dr. Tahira Nishtar, (FCPS), Associate Professor and Chairperson, Radiology Department, Medical Teaching Institute, Lady Reading Hospital, Peshawar, Pakistan
| | - Tabish Ahmad
- Dr. Tabish Ahmad, PGR-FCPS II, Radiology Department, Medical Teaching Institute, Lady Reading Hospital, Peshawar, Pakistan
| | - Nosheen Noor
- Dr. Nosheen Noor, (MCPS, FCPS), Assistant Professor, Radiology Department, Medical Teaching Institute, Lady Reading Hospital, Peshawar, Pakistan
| | - Fayaz Muhammad
- Dr. Fayaz Muhammad, PGR-FCPS II, Radiology Department, Medical Teaching Institute, Lady Reading Hospital, Peshawar, Pakistan
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Ahsen ME, Ayvaci MUS, Raghunathan S. When Algorithmic Predictions Use Human-Generated Data: A Bias-Aware Classification Algorithm for Breast Cancer Diagnosis. INFORMATION SYSTEMS RESEARCH 2019. [DOI: 10.1287/isre.2018.0789] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Mehmet Eren Ahsen
- Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York 10029
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Knee MRI Primary Care Ordering Practices for Nontraumatic Knee Pain: Compliance With ACR Appropriateness Criteria and Its Effect on Clinical Management. J Am Coll Radiol 2019; 16:289-294. [DOI: 10.1016/j.jacr.2018.10.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 08/27/2018] [Accepted: 10/11/2018] [Indexed: 12/31/2022]
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Hentel K, Menard A, Khorasani R. New CMS Clinical Decision Support Regulations: A Potential Opportunity with Major Challenges. Radiology 2018; 283:10-13. [PMID: 28318445 DOI: 10.1148/radiol.2017161560] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Keith Hentel
- From the Department of Radiology, Weill Cornell Medical College/New York Presbyterian Hospital, 525 E 68th St, Box 141, New York, NY 10065 (K.H.); and Center for Evidence Based Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass (A.M., R.K.)
| | - Andrew Menard
- From the Department of Radiology, Weill Cornell Medical College/New York Presbyterian Hospital, 525 E 68th St, Box 141, New York, NY 10065 (K.H.); and Center for Evidence Based Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass (A.M., R.K.)
| | - Ramin Khorasani
- From the Department of Radiology, Weill Cornell Medical College/New York Presbyterian Hospital, 525 E 68th St, Box 141, New York, NY 10065 (K.H.); and Center for Evidence Based Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass (A.M., R.K.)
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Net Revenue Analysis of Inpatient and Emergency Department Thyroid Ultrasound at a US Quaternary Care Center From 2012 to 2015. J Am Coll Radiol 2018; 15:75-81. [DOI: 10.1016/j.jacr.2017.08.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 08/15/2017] [Indexed: 11/20/2022]
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Tung M, Sharma R, Hinson JS, Nothelle S, Pannikottu J, Segal JB. Factors associated with imaging overuse in the emergency department: A systematic review. Am J Emerg Med 2017; 36:301-309. [PMID: 29100783 DOI: 10.1016/j.ajem.2017.10.049] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 10/17/2017] [Accepted: 10/18/2017] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Emergency departments (ED) are sites of prevalent imaging overuse; however, determinants that drive imaging in this setting are not well-characterized. We systematically reviewed the literature to summarize the determinants of imaging overuse in the ED. METHODS We searched MEDLINE® and Embase® from January 1998 to March 2017. Studies were included if they were written in English, contained original data, pertained to a U.S. population, and identified a determinant associated with overuse of imaging in the ED. RESULTS Twenty relevant studies were included. Fourteen evaluated computerized tomography (CT) scanning in patents presenting to a regional ED who were then transferred to a level 1 trauma center; incomplete transfer of data and poor image quality were the most frequently described reasons for repeat scanning. Unnecessary pre-transfer scanning or repeated scanning after transfer, in multiple studies, was highest among older patients, those with higher Injury Severity Scores (ISS) and those being transferred further. Six studies explored determinants of overused imaging in the ED in varied conditions, with overuse greater in older patients and those having more comorbid diseases. Defensive imaging reportedly influenced physician behavior. Less integration of services across the health system also predisposed to overuse of imaging. CONCLUSIONS The literature is heterogeneous with surprisingly few studies of determinants of imaging in minor head injury or of spine imaging. Older patient age and higher ISS were the most consistently associated with ED imaging overuse. This review highlights the need for precise definitions of overuse of imaging in the ED.
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Affiliation(s)
- Monica Tung
- Johns Hopkins University School of Medicine, Department of Medicine, United States
| | - Ritu Sharma
- Johns Hopkins University Bloomberg School of Public Health, United States
| | - Jeremiah S Hinson
- Johns Hopkins University School of Medicine, Department of Emergency Medicine, United States
| | - Stephanie Nothelle
- Johns Hopkins University School of Medicine, Department of Medicine, United States
| | - Jean Pannikottu
- Johns Hopkins University School of Medicine, Department of Medicine, United States; Northeastern Ohio Medical University, United States(1)
| | - Jodi B Segal
- Johns Hopkins University School of Medicine, Department of Medicine, United States; Johns Hopkins University Bloomberg School of Public Health, United States; Johns Hopkins University Center for Health Services and Outcomes Research, United States.
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Quaglini S, Sacchi L, Lanzola G, Viani N. Personalization and Patient Involvement in Decision Support Systems: Current Trends. Yearb Med Inform 2017; 10:106-18. [PMID: 26293857 DOI: 10.15265/iy-2015-015] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVES This survey aims at highlighting the latest trends (2012-2014) on the development, use, and evaluation of Information and Communication Technologies (ICT) based decision support systems (DSSs) in medicine, with a particular focus on patient-centered and personalized care. METHODS We considered papers published on scientific journals, by querying PubMed and Web of ScienceTM. Included studies focused on the implementation or evaluation of ICT-based tools used in clinical practice. A separate search was performed on computerized physician order entry systems (CPOEs), since they are increasingly embedding patient-tailored decision support. RESULTS We found 73 papers on DSSs (53 on specific ICT tools) and 72 papers on CPOEs. Although decision support through the delivery of recommendations is frequent (28/53 papers), our review highlighted also DSSs only based on efficient information presentation (25/53). Patient participation in making decisions is still limited (9/53), and mostly focused on risk communication. The most represented medical area is cancer (12%). Policy makers are beginning to be included among stakeholders (6/73), but integration with hospital information systems is still low. Concerning knowledge representation/management issues, we identified a trend towards building inference engines on top of standard data models. Most of the tools (57%) underwent a formal assessment study, even if half of them aimed at evaluating usability and not effectiveness. CONCLUSIONS Overall, we have noticed interesting evolutions of medical DSSs to improve communication with the patient, consider the economic and organizational impact, and use standard models for knowledge representation. However, systems focusing on patient-centered care still do not seem to be available at large.
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Affiliation(s)
- S Quaglini
- Silvana Quaglini, Department of Electrical, Computer, and Biomedical Engineering, University of Pavia, Via Ferrata 5, 27100 Pavia, Italy, Tel: +39 0382 985058, Fax: +39 0382 985060, E-mail:
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Bellolio MF, Heien HC, Sangaralingham LR, Jeffery MM, Campbell RL, Cabrera D, Shah ND, Hess EP. Increased Computed Tomography Utilization in the Emergency Department and Its Association with Hospital Admission. West J Emerg Med 2017; 18:835-845. [PMID: 28874935 PMCID: PMC5576619 DOI: 10.5811/westjem.2017.5.34152] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 05/05/2017] [Accepted: 05/26/2017] [Indexed: 12/17/2022] Open
Abstract
Introduction Our goal was to investigate trends in computed tomography (CT) utilization in emergency departments (EDs) and its association with hospitalization. Methods We conducted an analysis of an administrative claims database of U.S. privately insured and Medicare Advantage enrollees. We identified ED visits from 2005 through 2013 and assessed for CT use, associated factors, and hospitalization after CT, along with patient demographics. We used both descriptive methods and regression models adjusted for year, age, sex, race, geographic region, and Hwang comorbidity score to explore associations among CT use, year, demographic characteristics, and hospitalization. Results We identified 33,144,233 ED visits; 5,901,603 (17.8%) involved CT. Over time, CT use during ED visits increased 59.9%. CT use increased in all age groups but decreased in children since 2010. In propensity-matching analysis, odds of hospitalization increased with age, comorbidities, male sex, and CT use (odds ratio, 2.38). Odds of hospitalization over time decreased more quickly for patients with CT. Conclusion CT utilization in the ED has increased significantly from 2005 through 2013. For children, CT use after 2010 decreased, indicating caution about CT use. Male sex, older age, and higher number of comorbidities were predictors of CT in the ED. Over time, odds of hospitalization decreased more quickly for patients with CT.
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Affiliation(s)
- M Fernanda Bellolio
- Mayo Clinic, Department of Emergency Medicine, Rochester, Minnesota.,Mayo Clinic, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota.,Mayo Clinic, Division of Health Care Policy and Research, Rochester, Minnesota
| | - Herbert C Heien
- Mayo Clinic, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota
| | - Lindsey R Sangaralingham
- Mayo Clinic, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota
| | - Molly M Jeffery
- Mayo Clinic, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota.,Mayo Clinic, Division of Health Care Policy and Research, Rochester, Minnesota
| | - Ronna L Campbell
- Mayo Clinic, Department of Emergency Medicine, Rochester, Minnesota
| | - Daniel Cabrera
- Mayo Clinic, Department of Emergency Medicine, Rochester, Minnesota
| | - Nilay D Shah
- Mayo Clinic, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota.,Mayo Clinic, Division of Health Care Policy and Research, Rochester, Minnesota.,OptumLabs, Cambridge, Massachusetts
| | - Erik P Hess
- Mayo Clinic, Department of Emergency Medicine, Rochester, Minnesota.,Mayo Clinic, Division of Health Care Policy and Research, Rochester, Minnesota
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A snapshot of patients' awareness of radiation dose and risks associated with medical imaging examinations at an Australian radiology clinic. Radiography (Lond) 2017; 23:94-102. [DOI: 10.1016/j.radi.2016.10.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 10/18/2016] [Accepted: 10/31/2016] [Indexed: 11/18/2022]
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Goldschmiedt J, Levsky JM, Bellin EY, Mizrachi E, Esses D, Haramati LB. Prospective study of a non-restrictive decision rule for acute aortic syndrome. Am J Emerg Med 2017; 35:1309-1313. [PMID: 28427782 DOI: 10.1016/j.ajem.2017.04.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Revised: 04/04/2017] [Accepted: 04/05/2017] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVES To determine the impact of a non-restrictive clinical decision rule on CT utilization for Emergency Department patients suspected of having an acute aortic syndrome (AAS). METHODS We prospectively assessed the performance of a previously described, collaboratively designed, non-restrictive clinical decision rule for AAS. Emergency Department patients with suspected AAS were stratified into low and high-risk groups based on decision rule results, from July 2013-August 2014. Patients with acute trauma, prior AAS or aortic surgery were excluded. CT dose reduction protocols were concurrently implemented as a quality improvement measure. Bivariate analysis was performed to compare the prospective cohort with the historical derivation cohort for CT utilization rates, results of CT, AAS incidence and radiation exposure. The performance of the clinical decision rule was evaluated. RESULTS Compared with the historic cohort, the study cohort demonstrated a lower CT utilization rate [0.344% (427/124,093) versus 0.477% (1465/306,961), (p<0.001)], a trend toward higher CT diagnostic yield [4.4% (19/427) versus 2.7% (40/1465), (p=0.08)]. AAS incidence was similar [0.015% (19/124,093) versus 0.013% (40/306,961), (p=0.57)]. The mean effective radiation dose was markedly lower [12±5.5mSv versus 43±20mSv, (p<0.0001)]. The clinical decision rule correctly stratified only 56% (10/18) of patients with AAS as high-risk. CONCLUSIONS A non-restrictive, collaboratively designed, clinical decision rule for Emergency Department patients with suspected AAS performed poorly in risk-stratifying patients for AAS. However, its implementation was associated with a significant and safe decrease in CT utilization.
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Affiliation(s)
- Judah Goldschmiedt
- Department of Radiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY 10467, United States
| | - Jeffrey M Levsky
- Department of Radiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY 10467, United States; Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY 10467, United States
| | - Eran Y Bellin
- Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY 10467, United States; Department of Epidemiology, Population Health, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY 10467, United States
| | - Esther Mizrachi
- Department of Radiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY 10467, United States; Department of Emergency Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY 10467, United States
| | - David Esses
- Department of Emergency Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY 10467, United States
| | - Linda B Haramati
- Department of Radiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY 10467, United States; Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY 10467, United States.
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Brink JA, Arenson RL, Grist TM, Lewin JS, Enzmann D. Bits and bytes: the future of radiology lies in informatics and information technology. Eur Radiol 2017; 27:3647-3651. [PMID: 28280932 DOI: 10.1007/s00330-016-4688-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Revised: 11/01/2016] [Accepted: 11/29/2016] [Indexed: 11/30/2022]
Abstract
Advances in informatics and information technology are sure to alter the practice of medical imaging and image-guided therapies substantially over the next decade. Each element of the imaging continuum will be affected by substantial increases in computing capacity coincident with the seamless integration of digital technology into our society at large. This article focuses primarily on areas where this IT transformation is likely to have a profound effect on the practice of radiology. KEY POINTS • Clinical decision support ensures consistent and appropriate resource utilization. • Big data enables correlation of health information across multiple domains. • Data mining advances the quality of medical decision-making. • Business analytics allow radiologists to maximize the benefits of imaging resources.
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Affiliation(s)
- James A Brink
- Massachusetts General Hospital, 55 Fruit St., Boston, MA, 02114, USA.
| | - Ronald L Arenson
- UCSF Medical Center, 505 Parnassus Avenue, #391, San Francisco, CA, 94143, USA
| | - Thomas M Grist
- Department of Radiology, University of Wisconsin School of Medicine & Public Health, 600 Highland Avenue, E3/366 Clinical Science Center, Madison, WI, 53792-3252, USA
| | - Jonathan S Lewin
- Emory Healthcare, 1440 Clifton Road NE, Ste 400, Atlanta, GA, 30322, USA
| | - Dieter Enzmann
- Department of Radiological Sciences, UCLA Medical Center, 924 Westwood Blvd., Ste. 805, Los Angeles, CA, 90095, USA
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Medicare Imaging Demonstration: Assessing Attributes of Appropriate Use Criteria and Their Influence on Ordering Behavior. AJR Am J Roentgenol 2017; 208:1051-1057. [PMID: 28267371 DOI: 10.2214/ajr.16.17169] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Persistent concern exists about the variable and possibly inappropriate utilization of high-cost imaging tests. The purpose of this study is to assess the influence of appropriate use criteria attributes on altering ambulatory imaging orders deemed inappropriate. MATERIALS AND METHODS This secondary analysis included Medicare Imaging Demonstration data collected from three health care systems in 2011-2013 via the use of clinical decision support (CDS) during ambulatory imaging order entry. The CDS system captured whether orders were inappropriate per the appropriate use criteria of professional societies and provided advice during the intervention period. For orders deemed inappropriate, we assessed the impact of the availability of alternative test recommendations, conflicts with local best practices, and the strength of evidence for appropriate use criteria on the primary outcome of cancellation or modification of inappropriate orders. Expert review determined conflicts with local best practices for 250 recommendations for abdominal and thoracic CT orders. Strength of evidence was assessed for the 15 most commonly triggered recommendations that were deemed inappropriate. A chi-square test was used for univariate analysis. RESULTS A total of 1691 of 63,222 imaging test orders (2.7%) were deemed inappropriate during the intervention period; this amount decreased from 364 of 11,675 test orders (3.1%) in the baseline period (p < 0.00001). Of 270 inappropriate recommendations with alternative test recommendations, 28 (10.4%) were modified, compared with four of 1024 inappropriate recommendations without alternatives (0.4%) (p < 0.0001). Seventy-eight of 250 recommendations (31%) conflicted with local best practices, but only six of 69 inappropriate recommendations (9%) conflicted (p < 0.001). No inappropriate recommendations that conflicted with local best practices were modified. All 15 commonly triggered recommendations had an Oxford Centre for Evidence-Based Medicine level of evidence of 5 (i.e., expert opinion). CONCLUSION Orders for imaging tests that were deemed inappropriate were modified infrequently, more often with alternative recommendations present and only for appropriate use criteria consistent with local best practices.
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Tajmir S, Raja AS, Ip IK, Andruchow J, Silveira P, Smith S, Khorasani R. Impact of Clinical Decision Support on Radiography for Acute Ankle Injuries: A Randomized Trial. West J Emerg Med 2017; 18:487-495. [PMID: 28435501 PMCID: PMC5391900 DOI: 10.5811/westjem.2017.1.33053] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 12/31/2016] [Accepted: 01/16/2017] [Indexed: 12/26/2022] Open
Abstract
Introduction While only 15–20% of patients with foot and ankle injuries presenting to urgent care centers have clinically significant fractures, most undergo radiography. We examined the impact of electronic point-of-care clinical decision support (CDS) on adherence to the Ottawa Ankle Rules (OAR), as well as use and yield of foot and ankle radiographs in patients with acute ankle injury. Methods We obtained institutional review board approval for this randomized controlled study performed April 18, 2012—December 15, 2013. All ordering providers credentialed at an urgent care affiliated with a quaternary care academic hospital were randomized to either receive or not receive CDS, based on the OAR and integrated into the physician order-entry system, with feedback at the time of imaging order. If the patient met OAR low-risk criteria, providers were advised against imaging and could either cancel the order or ignore the alert. We identified patients with foot and ankle complaints via ICD-9 billing codes and electronic health records and radiology reports reviewed for those who were eligible. Chi-square was used to compare adherence to the OAR (primary outcome), radiography utilization rate and radiography yield of foot and ankle imaging (secondary outcomes) between the intervention and control groups. Results Of 14,642 patients seen at urgent care during the study period, 613 (4.2%, representing 632 visits) presented with acute ankle injury and were eligible for application of the OAR; 374 (59.2%) of these were seen by control-group providers. In the intervention group, CDS adherence was higher for both ankle (239/258=92.6% vs. 231/374=61.8%, p=0.02) and foot radiography (209/258=81.0% vs. 238/374=63.6%; p<0.01). However, ankle radiography use was higher in the intervention group (166/258=64.3% vs. 183/374=48.9%; p<0.01), while foot radiography use (141/258=54.6% vs. 202/374=54.0%; p=0.95) was not. Radiography yield was also higher in the intervention group (26/307=8.5% vs. 18/385=4.7%; p=0.04). Conclusion Clinical decision support, previously demonstrated to improve guideline adherence for high-cost imaging, can also improve guideline adherence for radiography – as demonstrated by increased OAR adherence and increased imaging yield.
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Affiliation(s)
- Shahein Tajmir
- Harvard Medical School, Boston, Massachusetts.,Brigham and Women's Hospital, Center for Evidence-Based Imaging, Boston, Massachusetts.,Brigham and Women's Hospital, Department of Radiology, Boston, Massachusetts.,Massachusetts General Hospital, Department of Radiology, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Ali S Raja
- Brigham and Women's Hospital, Center for Evidence-Based Imaging, Boston, Massachusetts.,Brigham and Women's Hospital, Department of Radiology, Boston, Massachusetts.,Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Ivan K Ip
- Brigham and Women's Hospital, Center for Evidence-Based Imaging, Boston, Massachusetts.,Brigham and Women's Hospital, Department of Radiology, Boston, Massachusetts.,Brigham and Women's Hospital, Department of Medicine, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - James Andruchow
- Brigham and Women's Hospital, Center for Evidence-Based Imaging, Boston, Massachusetts.,Brigham and Women's Hospital, Department of Radiology, Boston, Massachusetts.,Brigham and Women's Hospital, Department of Emergency Medicine, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Patricia Silveira
- Brigham and Women's Hospital, Center for Evidence-Based Imaging, Boston, Massachusetts.,Brigham and Women's Hospital, Department of Radiology, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Stacy Smith
- Brigham and Women's Hospital, Department of Radiology, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Ramin Khorasani
- Brigham and Women's Hospital, Center for Evidence-Based Imaging, Boston, Massachusetts.,Brigham and Women's Hospital, Department of Radiology, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
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JOURNAL CLUB: Predictors of Provider Response to Clinical Decision Support: Lessons Learned From the Medicare Imaging Demonstration. AJR Am J Roentgenol 2016; 208:351-357. [PMID: 27897445 DOI: 10.2214/ajr.16.16373] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE The efficacy of imaging clinical decision support (CDS) varies. Our objective was to identify CDS factors contributing to imaging order cancellation or modification. SUBJECTS AND METHODS This pre-post study was performed across four institutions participating in the Medicare Imaging Demonstration. The intervention was CDS at order entry for selected outpatient imaging procedures. On the basis of the information entered, computerized alerts indicated to providers whether orders were not covered by guidelines, appropriate, of uncertain appropriateness, or inappropriate according to professional society guidelines. Ordering providers could override or accept CDS. We considered actionable alerts to be those that could generate an immediate order behavior change in the ordering physician (i.e., cancellation of inappropriate orders or modification of orders of uncertain appropriateness that had a recommended alternative). Chi-square and logistic regression identified predictors of order cancellation or modification after an alert. RESULTS A total of 98,894 radiology orders were entered (83,114 after the intervention). Providers ignored 98.9%, modified 1.1%, and cancelled 0.03% of orders in response to alerts. Actionable alerts had a 10 fold higher rate of modification (8.1% vs 0.7%; p < 0.0001) or cancellation (0.2% vs 0.02%; p < 0.0001) orders compared with nonactionable alerts. Orders from institutions with preexisting imaging CDS had a sevenfold lower rate of cancellation or modification than was seen at sites with newly implemented CDS (1.4% vs 0.2%; p < 0.0001). In multivariate analysis, actionable alerts were 12 times more likely to result in order cancellation or modification. Orders at sites with preexisting CDS were 7.7 times less likely to be cancelled or modified (p < 0.0001). CONCLUSION Using results from the Medicare Imaging Demonstration project, we identified potential factors that were associated with CDS effect on provider imaging ordering; these findings may have implications for future design of such computerized systems.
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Ip IK, Silveira PC, Alper EC, Benson CB, Khorasani R. External validation of risk stratification strategy in the use of renal ultrasonography in the evaluation of acute kidney injury. J Hosp Med 2016; 11:763-767. [PMID: 27186959 DOI: 10.1002/jhm.2598] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 03/24/2016] [Accepted: 03/31/2016] [Indexed: 11/06/2022]
Abstract
BACKGROUND Per the American College of Radiology Appropriateness Criteria, renal ultrasound is the most appropriate imaging examination to evaluate patients with acute kidney injury. However, recent studies suggest that renal ultrasound may be more selectively performed, which could lead to reductions in the use of medical imaging. OBJECTIVE Evaluate a published risk stratification prediction model (the Licurse model) for using renal ultrasound in hospitalized patients with acute kidney injury. DESIGN Prospective, observational cohort study. SETTING A 793-bed, quaternary care, academic hospital. PATIENTS All adult hospitalized patients who underwent renal ultrasound for the indication of acute kidney injury. INTERVENTION/EXPOSURE None. MEASUREMENTS Primary outcome was rate of hydronephrosis diagnosed on ultrasound. Secondary outcome was rate of hydronephrosis resulting in urologic intervention. RESULTS Of 778 patients who underwent renal ultrasonography to evaluate acute kidney injury, hydronephrosis was present in 106 (13.6%); urologic intervention was performed in 23 patients (3.0%). The Licurse model had sensitivity of 91.3% (95% confidence interval [CI]: 73.2%-97.6%) for urologic intervention and 93.4% (95% CI: 87.2%-96.8%) for hydronephrosis, respectively. Specificity was low for urologic intervention (23.0% [95% CI: 20.2-26.2]) and hydronephrosis (25.1% [95% CI: 22.0-28.6]). We estimated that for 22.6% of patients, hydronephrosis could be ruled out based on clinical predictors. CONCLUSIONS We found that the Licurse renal ultrasonography risk stratification model was sufficiently accurate in classifying patients at risk for ureteral obstruction among hospitalized patients with acute kidney injury. Journal of Hospital Medicine 2016;11:763-767. © 2016 Society of Hospital Medicine.
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Affiliation(s)
- Ivan K Ip
- Center for Evidence-Based Imaging, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Patricia C Silveira
- Center for Evidence-Based Imaging, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Emily C Alper
- Center for Evidence-Based Imaging, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Carol B Benson
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ramin Khorasani
- Center for Evidence-Based Imaging, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Ngoya PS, Muhogora WE, Pitcher RD. Defining the diagnostic divide: an analysis of registered radiological equipment resources in a low-income African country. Pan Afr Med J 2016; 25:99. [PMID: 28292062 PMCID: PMC5325496 DOI: 10.11604/pamj.2016.25.99.9736] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 07/21/2016] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Diagnostic radiology is recognised as a key component of modern healthcare. However there is marked inequality in global access to imaging. Rural populations of low- and middle-income countries (LMICs) have the greatest need. Carefully coordinated healthcare planning is required to meet the ever increasing global demand for imaging and to ensure equitable access to services. However, meaningful planning requires robust data. Currently, there are no comprehensive published data on radiological equipment resources in low-income countries. The aim of this study was to conduct the first detailed analysis of registered diagnostic radiology equipment resources in a low-income African country and compare findings with recently published South African data. METHODS The study was conducted in Tanzania in September 2014, in collaboration with the Tanzanian Atomic Energy Commission (TAEC), which maintains a comprehensive database of the country's registered diagnostic imaging equipment. All TAEC equipment data were quantified as units per million people by imaging modality, geographical zone and healthcare sector. RESULTS There are 5.7 general radiography units per million people in the public sector with a relatively homogeneous geographical distribution. When compared with the South African public sector, Tanzanian resources are 3-, 21- and 6-times lower in general radiography, computed tomography and magnetic resonance imaging, respectively. CONCLUSION The homogeneous Tanzanian distribution of basic public-sector radiological services reflects central government's commitment to equitable distribution of essential resources. However, the 5.7 general radiography units per million people is lower than the 20 units per million people recommended by the World Health Organization.
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Affiliation(s)
- Patrick Sitati Ngoya
- Division of Radiodiagnosis, Department of Medical Imaging and Clinical Oncology, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa
| | | | - Richard Denys Pitcher
- Division of Radiodiagnosis, Department of Medical Imaging and Clinical Oncology, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa
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Jensen JD, Durand DJ. Partnering With Your Health System to Select and Implement Clinical Decision Support for Imaging. J Am Coll Radiol 2016; 14:262-268. [PMID: 27687751 DOI: 10.1016/j.jacr.2016.07.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Revised: 07/25/2016] [Accepted: 07/27/2016] [Indexed: 11/25/2022]
Abstract
Recent legislation mandates the documentation of appropriateness criteria consultation when ordering advanced imaging for Medicare patients to remain eligible for reimbursement. Implementation of imaging clinical decision support (CDS) is a solution adopted by many systems to automate compliance with the new requirements. This article is intended to help radiologists who are employed by, contracted with, or otherwise affiliated with systems planning to implement CDS in the near future and ensure that they are able to understand and contribute to the process wherever possible. It includes an in-depth discussion of the legislation, evidence for and against the efficacy of imaging CDS, considerations for selecting a CDS vendor, tips for configuring CDS in a fashion consistent with departmental goals, and pointers for implementation and change management.
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Affiliation(s)
- Jeff D Jensen
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University, Baltimore, Maryland.
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Yan Z, Ip IK, Raja AS, Gupta A, Kosowsky JM, Khorasani R. Yield of CT Pulmonary Angiography in the Emergency Department When Providers Override Evidence-based Clinical Decision Support. Radiology 2016; 282:717-725. [PMID: 27689922 DOI: 10.1148/radiol.2016151985] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Purpose To determine the frequency of, and yield after, provider overrides of evidence-based clinical decision support (CDS) for ordering computed tomographic (CT) pulmonary angiography in the emergency department (ED). Materials and Methods This HIPAA-compliant, institutional review board-approved study was performed at a tertiary care, academic medical center ED with approximately 60 000 annual visits and included all patients who were suspected of having pulmonary embolism (PE) and who underwent CT pulmonary angiography between January 1, 2011, and August 31, 2013. The requirement to obtain informed consent was waived. Each CT order for pulmonary angiography was exposed to CDS on the basis of the Wells criteria. For patients with a Wells score of 4 or less, CDS alerts suggested d-dimer testing because acute PE is highly unlikely in these patients if d-dimer levels are normal. The yield of CT pulmonary angiography (number of positive PE diagnoses/total number of CT pulmonary angiographic examinations) was compared in patients in whom providers overrode CDS alerts (by performing CT pulmonary angiography in patients with a Wells score ≤4 and a normal d-dimer level or no d-dimer testing) (override group) and those in whom providers followed Wells criteria (CT pulmonary angiography only in patients with Wells score >4 or ≤4 with elevated d-dimer level) (adherent group). A validated natural language processing tool identified positive PE diagnoses, with subsegmental and/or indeterminate diagnoses removed by means of chart review. Statistical analysis was performed with the χ2 test, the Student t test, and logistic regression. Results Among 2993 CT pulmonary angiography studies in 2655 patients, 563 examinations had a Wells score of 4 or less but did not undergo d-dimer testing and 26 had a Wells score of 4 or less and had normal d-dimer levels. The yield of CT pulmonary angiography was 4.2% in the override group (25 of 589 studies, none with a normal d-dimer level) and 11.2% in the adherent group (270 of 2404 studies) (P < .001). After adjustment for the risk factor differences between the two groups, the odds of an acute PE finding were 51.3% lower when providers overrode alerts than when they followed CDS guidelines. Comparison of the two groups including only patients unlikely to have PE led to similar results. Conclusion The odds of an acute PE finding in the ED when providers adhered to evidence presented in CDS were nearly double those seen when providers overrode CDS alerts. Most overrides were due to the lack of d-dimer testing in patients unlikely to have PE. © RSNA, 2016.
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Affiliation(s)
- Zihao Yan
- From the Center for Evidence-Based Imaging (Z.Y., I.K.I., A.S.R., A.G., R.K.), Department of Radiology (A.S.R., A.G., R.K.), Department of Medicine (I.K.I.), and Department of Emergency Medicine (A.G., J.M.K.), Brigham and Women's Hospital, Harvard Medical School, 20 Kent St, 2nd Floor, Boston, MA 02120; and Department of Emergency Medicine, Massachusetts General Hospital, Boston, Mass (A.S.R.)
| | - Ivan K Ip
- From the Center for Evidence-Based Imaging (Z.Y., I.K.I., A.S.R., A.G., R.K.), Department of Radiology (A.S.R., A.G., R.K.), Department of Medicine (I.K.I.), and Department of Emergency Medicine (A.G., J.M.K.), Brigham and Women's Hospital, Harvard Medical School, 20 Kent St, 2nd Floor, Boston, MA 02120; and Department of Emergency Medicine, Massachusetts General Hospital, Boston, Mass (A.S.R.)
| | - Ali S Raja
- From the Center for Evidence-Based Imaging (Z.Y., I.K.I., A.S.R., A.G., R.K.), Department of Radiology (A.S.R., A.G., R.K.), Department of Medicine (I.K.I.), and Department of Emergency Medicine (A.G., J.M.K.), Brigham and Women's Hospital, Harvard Medical School, 20 Kent St, 2nd Floor, Boston, MA 02120; and Department of Emergency Medicine, Massachusetts General Hospital, Boston, Mass (A.S.R.)
| | - Anurag Gupta
- From the Center for Evidence-Based Imaging (Z.Y., I.K.I., A.S.R., A.G., R.K.), Department of Radiology (A.S.R., A.G., R.K.), Department of Medicine (I.K.I.), and Department of Emergency Medicine (A.G., J.M.K.), Brigham and Women's Hospital, Harvard Medical School, 20 Kent St, 2nd Floor, Boston, MA 02120; and Department of Emergency Medicine, Massachusetts General Hospital, Boston, Mass (A.S.R.)
| | - Joshua M Kosowsky
- From the Center for Evidence-Based Imaging (Z.Y., I.K.I., A.S.R., A.G., R.K.), Department of Radiology (A.S.R., A.G., R.K.), Department of Medicine (I.K.I.), and Department of Emergency Medicine (A.G., J.M.K.), Brigham and Women's Hospital, Harvard Medical School, 20 Kent St, 2nd Floor, Boston, MA 02120; and Department of Emergency Medicine, Massachusetts General Hospital, Boston, Mass (A.S.R.)
| | - Ramin Khorasani
- From the Center for Evidence-Based Imaging (Z.Y., I.K.I., A.S.R., A.G., R.K.), Department of Radiology (A.S.R., A.G., R.K.), Department of Medicine (I.K.I.), and Department of Emergency Medicine (A.G., J.M.K.), Brigham and Women's Hospital, Harvard Medical School, 20 Kent St, 2nd Floor, Boston, MA 02120; and Department of Emergency Medicine, Massachusetts General Hospital, Boston, Mass (A.S.R.)
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Lavelle LP, Dunne RM, Carroll AG, Malone DE. Evidence-based Practice of Radiology. Radiographics 2016; 35:1802-13. [PMID: 26466187 DOI: 10.1148/rg.2015150027] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Current health care reform in the United States is producing a shift in radiology practice from the traditional volume-based role of performing and interpreting a large number of examinations to providing a more affordable and higher-quality service centered on patient outcomes, which is described as a value-based approach to the provision of health care services. In the 1990 s, evidence-based medicine was defined as the integration of current best evidence with clinical expertise and patient values. When these methods are applied outside internal medicine, the process is called evidence-based practice (EBP). EBP facilitates understanding, interpretation, and application of the best current evidence into radiology practice, which optimizes patient care. It has been incorporated into "Practice-based Learning and Improvement" and "Systems-based Practice," which are two of the six core resident competencies of the Accreditation Council for Graduate Medical Education and two of the 12 American Board of Radiology milestones for diagnostic radiology. Noninterpretive skills, such as systems-based practice, are also formally assessed in the "Quality and Safety" section of the American Board of Radiology Core and Certifying examinations. This article describes (a) the EBP framework, with particular focus on its relevance to the American Board of Radiology certification and maintenance of certification curricula; (b) how EBP can be integrated into a residency program; and (c) the current value and likely place of EBP in the radiology information technology infrastructure. Online supplemental material is available for this article.
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Affiliation(s)
- Lisa P Lavelle
- From the Department of Radiology, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland (L.P.L., A.G.C., D.E.M.); and Department of Radiology, Brigham and Women's Hospital, Boston, Mass (R.M.D.)
| | - Ruth M Dunne
- From the Department of Radiology, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland (L.P.L., A.G.C., D.E.M.); and Department of Radiology, Brigham and Women's Hospital, Boston, Mass (R.M.D.)
| | - Anne G Carroll
- From the Department of Radiology, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland (L.P.L., A.G.C., D.E.M.); and Department of Radiology, Brigham and Women's Hospital, Boston, Mass (R.M.D.)
| | - Dermot E Malone
- From the Department of Radiology, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland (L.P.L., A.G.C., D.E.M.); and Department of Radiology, Brigham and Women's Hospital, Boston, Mass (R.M.D.)
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Abstract
Diagnostic imaging is the most rapidly growing physician service in the Medicare and privately insured population. The growing share of medical costs devoted to imaging procedures has led to increasing concerns among the key federal agencies and private payers. In an attempt to educate health care providers, patients, and families on the importance of making optimal clinical decisions, the American Board of Internal Medicine Foundation organized the Choosing Wisely initiative with strong collaboration from specialty societies representing nearly all medical disciplines. Among 45 tests and treatments listed on the Choosing Wisely Web site, 24 are directly related to imaging. Eleven of the 24 are associated with neuroimaging. The listing of imaging tests in the Choosing Wisely program by multiple medical societies other than the radiology societies acknowledges that appropriate use of medical imaging is a shared responsibility between radiologists and referring physicians. In this article, we highlight why radiologists are uniquely positioned to support the appropriate use of imaging. We review some of the strategies that radiologists can use to help their referring physicians with appropriate ordering of neuroimaging in real-world practice and address some the challenges and pitfalls in implementing patient-centered imaging decision-making and shifting to a value-based focus in radiology.
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Affiliation(s)
- J Buethe
- From the Department of Radiology (J.B.), Johns Hopkins Hospital, Baltimore, Maryland
| | - J Nazarian
- Department of Neuroradiology (J.N.), Mallinckrodt Institute of Radiology, St. Louis, Missouri
| | - K Kalisz
- Department of Radiology (K.K.), University Hospitals Case Medical Center Case Western Reserve University, Cleveland, Ohio
| | - M Wintermark
- Department of Radiology (M.W.), Neuroradiology Section, Stanford University School of Medicine, Stanford, California.
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Lacson R, Raja AS, Osterbur D, Ip I, Schneider L, Bain P, Mita C, Whelan J, Silveira P, Dement D, Khorasani R. Assessing Strength of Evidence of Appropriate Use Criteria for Diagnostic Imaging Examinations. J Am Med Inform Assoc 2016; 23:649-53. [PMID: 26911819 DOI: 10.1093/jamia/ocv194] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 11/09/2015] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE For health information technology tools to fully inform evidence-based decisions, recommendations must be reliably assessed for quality and strength of evidence. We aimed to create an annotation framework for grading recommendations regarding appropriate use of diagnostic imaging examinations. METHODS The annotation framework was created by an expert panel (clinicians in three medical specialties, medical librarians, and biomedical scientists) who developed a process for achieving consensus in assessing recommendations, and evaluated by measuring agreement in grading the strength of evidence for 120 empirically selected recommendations using the Oxford Levels of Evidence. RESULTS Eighty-two percent of recommendations were assigned to Level 5 (expert opinion). Inter-annotator agreement was 0.70 on initial grading (κ = 0.35, 95% CI, 0.23-0.48). After systematic discussion utilizing the annotation framework, agreement increased significantly to 0.97 (κ = 0.88, 95% CI, 0.77-0.99). CONCLUSIONS A novel annotation framework was effective for grading the strength of evidence supporting appropriate use criteria for diagnostic imaging exams.
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Affiliation(s)
- Ronilda Lacson
- Center for Evidence Based Imaging, Department of Radiology, Brigham and Women's Hospital, Boston, MA 02115, USA Harvard Medical School, Boston, MA 02115, USA
| | - Ali S Raja
- Harvard Medical School, Boston, MA 02115, USA Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
| | - David Osterbur
- Harvard Medical School, Boston, MA 02115, USA Countway Library of Medicine, Boston, MA 02115, USA
| | - Ivan Ip
- Center for Evidence Based Imaging, Department of Radiology, Brigham and Women's Hospital, Boston, MA 02115, USA Harvard Medical School, Boston, MA 02115, USA Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Louise Schneider
- Harvard Medical School, Boston, MA 02115, USA Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Paul Bain
- Harvard Medical School, Boston, MA 02115, USA Countway Library of Medicine, Boston, MA 02115, USA
| | - Carol Mita
- Harvard Medical School, Boston, MA 02115, USA Countway Library of Medicine, Boston, MA 02115, USA
| | - Julia Whelan
- Harvard Medical School, Boston, MA 02115, USA Countway Library of Medicine, Boston, MA 02115, USA
| | - Patricia Silveira
- Center for Evidence Based Imaging, Department of Radiology, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - David Dement
- Center for Evidence Based Imaging, Department of Radiology, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Ramin Khorasani
- Center for Evidence Based Imaging, Department of Radiology, Brigham and Women's Hospital, Boston, MA 02115, USA Harvard Medical School, Boston, MA 02115, USA
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Schneider E, Zelenka S, Grooff P, Alexa D, Bullen J, Obuchowski NA. Radiology order decision support: examination-indication appropriateness assessed using 2 electronic systems. J Am Coll Radiol 2015; 12:349-57. [PMID: 25842015 DOI: 10.1016/j.jacr.2014.12.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Accepted: 12/15/2014] [Indexed: 10/23/2022]
Abstract
PURPOSE The goal of the study was to determine the effects of guideline implementation strategy using 2 commercial radiology clinical decision support (CDS) systems. METHODS The appropriateness and insurance dispositions of MRI and CT orders were evaluated using the Medicalis SmartReq and Nuance RadPort CDS systems during 2 different 3-month periods. Logistic regression was used to compare these outcomes between the 2 systems, after adjusting for patient-mix differences. RESULTS Approximately 2,000 consecutive outpatient MRI and CT orders were evaluated over 2 periods of 3 months each. Medicalis scored 60% of exams as "indeterminate" (insufficient information) or "not validated" (no guidelines). Excluding these cases, Nuance scored significantly more exams as appropriate than did Medicalis (80% versus 51%, P < .001) and predicted insurance outcome significantly more often (76% versus 58%, P < .001). Only when the Medicalis "indeterminate" and "not validated" categories were combined with the high- or moderate-utility categories did the 2 CDS systems have similar performance. Overall, 19% of examinations with low-utility ratings were reimbursed. Conversely, 0.8% of examinations with high- or moderate-utility ratings were denied reimbursement. CONCLUSIONS The chief difference between the 2 CDS systems, and the strongest influence on outcomes, was how exams without relevant guidelines or with insufficient information were handled. Nuance augmented published guidelines with clinical best practice; Medicalis requested additional information utilizing pop-up windows. Thus, guideline implementation choices contributed to decision making and outcomes. User interface, specifically, the number of screens and completeness of indication choices, controlled CDS interactions and, coupled with guidance implementation, influenced willingness to use the CDS system.
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Affiliation(s)
- Erika Schneider
- Imaging Institute, Cleveland Clinic Foundation, Cleveland, Ohio.
| | - Stacy Zelenka
- Imaging Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Paul Grooff
- Imaging Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Dan Alexa
- Imaging Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Jennifer Bullen
- Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Nancy A Obuchowski
- Imaging Institute, Cleveland Clinic Foundation, Cleveland, Ohio; Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, Ohio
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Levin DC. The 2014 RSNA Annual Oration in Diagnostic Radiology: Transitioning from Volume-based to Value-based Practice-A Meaningful Goal for All Radiologists or a Meaningless Platitude? Radiology 2015; 275:314-20. [PMID: 25906298 DOI: 10.1148/radiol.15142861] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/18/2024]
Affiliation(s)
- David C Levin
- From the Department of Radiology, Thomas Jefferson University Hospital, 132 S 10th St, Philadelphia, PA 19107; and HealthHelp, Houston, Tex
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Goldzweig CL, Orshansky G, Paige NM, Miake-Lye IM, Beroes JM, Ewing BA, Shekelle PG. Electronic health record-based interventions for improving appropriate diagnostic imaging: a systematic review and meta-analysis. Ann Intern Med 2015; 162:557-65. [PMID: 25894025 DOI: 10.7326/m14-2600] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND One driver of increasing health care costs is the use of radiologic imaging procedures. More appropriate use could improve quality and reduce costs. PURPOSE To review interventions that use the computerized clinical decision-support (CCDS) capabilities of electronic health records to improve appropriate use of diagnostic radiologic test ordering. DATA SOURCES English-language articles in PubMed from 1995 to September 2014 and searches in Web of Science and PubMed of citations related to key articles. STUDY SELECTION 23 studies, including 3 randomized trials, 7 time-series studies, and 13 pre-post studies that assessed the effect of CCDS on diagnostic radiologic test ordering in adults. DATA EXTRACTION 2 independent reviewers extracted data on functionality, study outcomes, and context and assessed the quality of included studies. DATA SYNTHESIS Thirteen studies provided moderate-level evidence that CCDS improves appropriateness (effect size, -0.49 [95% CI, -0.71 to -0.26]) and reduces use (effect size, -0.13 [CI, -0.23 to -0.04]). Interventions with a "hard stop" that prevents a clinician from overriding the CCDS without outside consultation, as well as interventions in integrated care delivery systems, may be more effective. Harms have rarely been assessed but include decreased ordering of appropriate tests and physician dissatisfaction. LIMITATION Potential for publication bias, insufficient reporting of harms, and poor description of context and implementation. CONCLUSION Computerized clinical decision support integrated with the electronic health record can improve appropriate use of diagnostic radiology by a moderate amount and decrease use by a small amount. Before widespread adoption can be recommended, more data are needed on potential harms. PRIMARY FUNDING SOURCE U.S. Department of Veterans Affairs. (PROSPERO registration number: CRD42014007469).
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Affiliation(s)
- Caroline Lubick Goldzweig
- From West Los Angeles Veterans Affairs Medical Center and University of California, Los Angeles, Fielding School of Public Health, Los Angeles, and RAND Corporation, Southern California Evidence-based Practice Center, Santa Monica, California
| | - Greg Orshansky
- From West Los Angeles Veterans Affairs Medical Center and University of California, Los Angeles, Fielding School of Public Health, Los Angeles, and RAND Corporation, Southern California Evidence-based Practice Center, Santa Monica, California
| | - Neil M. Paige
- From West Los Angeles Veterans Affairs Medical Center and University of California, Los Angeles, Fielding School of Public Health, Los Angeles, and RAND Corporation, Southern California Evidence-based Practice Center, Santa Monica, California
| | - Isomi M. Miake-Lye
- From West Los Angeles Veterans Affairs Medical Center and University of California, Los Angeles, Fielding School of Public Health, Los Angeles, and RAND Corporation, Southern California Evidence-based Practice Center, Santa Monica, California
| | - Jessica M. Beroes
- From West Los Angeles Veterans Affairs Medical Center and University of California, Los Angeles, Fielding School of Public Health, Los Angeles, and RAND Corporation, Southern California Evidence-based Practice Center, Santa Monica, California
| | - Brett A. Ewing
- From West Los Angeles Veterans Affairs Medical Center and University of California, Los Angeles, Fielding School of Public Health, Los Angeles, and RAND Corporation, Southern California Evidence-based Practice Center, Santa Monica, California
| | - Paul G. Shekelle
- From West Los Angeles Veterans Affairs Medical Center and University of California, Los Angeles, Fielding School of Public Health, Los Angeles, and RAND Corporation, Southern California Evidence-based Practice Center, Santa Monica, California
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Journal club: Requiring clinical justification to override repeat imaging decision support: impact on CT use. AJR Am J Roentgenol 2015; 203:W482-90. [PMID: 25341162 DOI: 10.2214/ajr.14.13017] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE The purpose of this study was to determine the impact of requiring clinical justification to override decision support alerts on repeat use of CT. SUBJECTS AND METHODS This before and after intervention study was conducted at a 793-bed tertiary hospital with computerized physician order entry and clinical decision support systems. When a CT order is placed, decision support alerts the orderer if the patient's same body part has undergone CT within the past 90 days. The study cohort included all 28,420 CT orders triggering a repeat alert in 2010. The intervention required clinical justification, selected from a predetermined menu, to override repeat CT decision support alerts to place a CT order; otherwise the order could not be placed and was dropped. The primary outcome, dropped repeat CT orders, was analyzed using three methods: chi-square tests to compare proportions dropped before and after intervention; multiple logistic regression tests to control for orderer, care setting, and patient factors; and statistical process control for temporal trends. RESULTS The repeat CT order drop rate had an absolute increase of 1.4%; 6.1% (682/11,230) before to 7.5% (1290/17,190) after intervention, which was a 23% relative change (7.5 - 6.1)/6.1 × 100 = 23%; p < 0.0001). Orders were dropped more often after intervention (odds ratio, 1.3; 95% CI, 1.1-1.4; p < 0.0001). Statistical control analysis supported the association between the increase in the drop rate with intervention rather than underlying trends. CONCLUSION Adding a requirement for clinical justification to override alerts modestly but significantly improves the impact of repeat CT decision support (23% relative change), with the overall effect of preventing one in 13 repeat CT orders.
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Dunne RM, Ip IK, Abbett S, Gershanik EF, Raja AS, Hunsaker A, Khorasani R. Effect of Evidence-based Clinical Decision Support on the Use and Yield of CT Pulmonary Angiographic Imaging in Hospitalized Patients. Radiology 2015; 276:167-74. [PMID: 25686367 DOI: 10.1148/radiol.15141208] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To determine the effect of clinical decision support (CDS) on the use and yield of inpatient computed tomographic (CT) pulmonary angiography for acute pulmonary embolism (PE). MATERIALS AND METHODS This HIPAA-compliant, institutional review board-approved study with waiver of informed consent included all adults admitted to a 793-bed teaching hospital from April 1, 2007, to June 30, 2012. The CDS intervention, implemented after a baseline observation period, informed providers who placed an order for CT pulmonary angiographic imaging about the pretest probability of the study based on a validated decision rule. Use of CT pulmonary angiographic and admission data from administrative databases was obtained for this study. By using a validated natural language processing algorithm on radiology reports, each CT pulmonary angiographic examination was classified as positive or negative for acute PE. Primary outcome measure was monthly use of CT pulmonary angiography per 1000 admissions. Secondary outcome was CT pulmonary angiography yield (percentage of CT pulmonary angiographic examinations that were positive for acute PE). Linear trend analysis was used to assess for effect and trend differences in use and yield of CT pulmonary angiographic imaging before and after CDS. RESULTS In 272 374 admissions over the study period, 5287 patients underwent 5892 CT pulmonary angiographic examinations. A 12.3% decrease in monthly use of CT pulmonary angiography (26.0 to 22.8 CT pulmonary angiographic examinations per 1000 admissions before and after CDS, respectively; P = .008) observed 1 month after CDS implementation was sustained over the ensuing 32-month period. There was a nonsignificant 16.3% increase in monthly yield of CT pulmonary angiography or percentage of CT pulmonary angiographic examinations positive for acute PE after CDS (P = .65). CONCLUSION Implementation of evidence-based CDS for inpatients was associated with a 12.3% immediate and sustained decrease in use of CT pulmonary angiographic examinations in the evaluation of inpatients for acute PE. for this article.
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Affiliation(s)
- Ruth M Dunne
- From the Center for Evidence-Based Imaging (R.M.D., I.K.I., E.F.G., A.S.R., R.K.), Department of Radiology (R.M.D., I.K.I., E.F.G., A.S.R., A.H., R.K.), Department of Medicine (I.K.I., E.F.G.), Department of Emergency Medicine (A.S.R.), and Brigham and Women's Physician Organization (S.A.), Brigham and Women's Hospital, Harvard Medical School, 20 Kent St, 2nd Floor, Boston, MA 02120
| | - Ivan K Ip
- From the Center for Evidence-Based Imaging (R.M.D., I.K.I., E.F.G., A.S.R., R.K.), Department of Radiology (R.M.D., I.K.I., E.F.G., A.S.R., A.H., R.K.), Department of Medicine (I.K.I., E.F.G.), Department of Emergency Medicine (A.S.R.), and Brigham and Women's Physician Organization (S.A.), Brigham and Women's Hospital, Harvard Medical School, 20 Kent St, 2nd Floor, Boston, MA 02120
| | - Sarah Abbett
- From the Center for Evidence-Based Imaging (R.M.D., I.K.I., E.F.G., A.S.R., R.K.), Department of Radiology (R.M.D., I.K.I., E.F.G., A.S.R., A.H., R.K.), Department of Medicine (I.K.I., E.F.G.), Department of Emergency Medicine (A.S.R.), and Brigham and Women's Physician Organization (S.A.), Brigham and Women's Hospital, Harvard Medical School, 20 Kent St, 2nd Floor, Boston, MA 02120
| | - Esteban F Gershanik
- From the Center for Evidence-Based Imaging (R.M.D., I.K.I., E.F.G., A.S.R., R.K.), Department of Radiology (R.M.D., I.K.I., E.F.G., A.S.R., A.H., R.K.), Department of Medicine (I.K.I., E.F.G.), Department of Emergency Medicine (A.S.R.), and Brigham and Women's Physician Organization (S.A.), Brigham and Women's Hospital, Harvard Medical School, 20 Kent St, 2nd Floor, Boston, MA 02120
| | - Ali S Raja
- From the Center for Evidence-Based Imaging (R.M.D., I.K.I., E.F.G., A.S.R., R.K.), Department of Radiology (R.M.D., I.K.I., E.F.G., A.S.R., A.H., R.K.), Department of Medicine (I.K.I., E.F.G.), Department of Emergency Medicine (A.S.R.), and Brigham and Women's Physician Organization (S.A.), Brigham and Women's Hospital, Harvard Medical School, 20 Kent St, 2nd Floor, Boston, MA 02120
| | - Andetta Hunsaker
- From the Center for Evidence-Based Imaging (R.M.D., I.K.I., E.F.G., A.S.R., R.K.), Department of Radiology (R.M.D., I.K.I., E.F.G., A.S.R., A.H., R.K.), Department of Medicine (I.K.I., E.F.G.), Department of Emergency Medicine (A.S.R.), and Brigham and Women's Physician Organization (S.A.), Brigham and Women's Hospital, Harvard Medical School, 20 Kent St, 2nd Floor, Boston, MA 02120
| | - Ramin Khorasani
- From the Center for Evidence-Based Imaging (R.M.D., I.K.I., E.F.G., A.S.R., R.K.), Department of Radiology (R.M.D., I.K.I., E.F.G., A.S.R., A.H., R.K.), Department of Medicine (I.K.I., E.F.G.), Department of Emergency Medicine (A.S.R.), and Brigham and Women's Physician Organization (S.A.), Brigham and Women's Hospital, Harvard Medical School, 20 Kent St, 2nd Floor, Boston, MA 02120
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Ip IK, Raja AS, Seltzer SE, Gawande AA, Joynt KE, Khorasani R. Use of Public Data to Target Variation in Providers' Use of CT and MR Imaging among Medicare Beneficiaries. Radiology 2015; 275:718-24. [PMID: 25658040 DOI: 10.1148/radiol.15141964] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To examine geographic variation in providers' use of diagnostic imaging to identify potential targets for quality improvement initiatives after adjusting for imaging referral across hospital referral regions (HRRs). MATERIALS AND METHODS Using two Centers for Medicare and Medicaid Services datasets, the authors included all claims for beneficiaries enrolled in the Medicare fee-for-service program. Diagnostic imaging procedures were selected on the basis of common procedure coding system codes, excluding interventional procedures. The authors assessed providers' use of imaging for each HRR after creating an imaging referral index (IRI) to adjust for imaging referral rates across HRRs. Relative risk statistics were used to assess geographic variation. The authors calculated two imaging measures for computed tomography (CT) and magnetic resonance (MR) imaging: IRI-adjusted utilization intensity (number of examinations per 1000 beneficiaries) and total payments (in dollars, after deducting deductibles and coinsurances) in each HRR. High-impact regions were defined as those in the highest deciles for both imaging intensity and payment. RESULTS For 34 million Medicare beneficiaries, 124 million unique diagnostic imaging services (totaling $5.6 billion) were performed in 2012. The average adjusted CT utilization intensity ranged from 330.4 studies per 1000 beneficiaries in the lowest decile to 684.0 in the highest decile (relative risk, 2.1); adjusted MR imaging utilization intensity varied from 105.7 studies per 1000 beneficiaries to 256.3 (relative risk, 2.4). The most common CT and MR imaging procedures were head CT and lumbar spine MR imaging. CONCLUSION With use of public data, the authors identified a wide variation in imaging use across the United States. Potential targets for future imaging quality improvement initiatives include head CT and lumbar spine MR imaging.
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Affiliation(s)
- Ivan K Ip
- From the Center for Evidence-based Imaging (I.K.I., A.S.R., R.K.), Department of Radiology (I.K.I., A.S.R., S.E.S., R.K.), Department of Medicine (I.K.I., K.E.J.), Department of Surgery (A.A.G.), and Department of Emergency Medicine (A.S.R.), Brigham and Women's Hospital, 20 Kent St, 2nd Floor, Boston, MA 02120; Department of Health Policy and Management, Harvard School of Public Health, Boston, Mass (A.A.G., K.E.J.); and VA Boston Healthcare System, Boston, Mass (K.E.J.)
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Lee J, Geyer B, Naraghi L, Kaafarani HMA, Eikermann M, Yeh DD, Bajwa EK, Cobb JP, Raja AS. Advanced imaging use in intensive care units has decreased, resulting in lower charges without negative effects on patient outcomes. J Crit Care 2014; 30:460-4. [PMID: 25596998 DOI: 10.1016/j.jcrc.2014.12.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Revised: 12/15/2014] [Accepted: 12/18/2014] [Indexed: 12/22/2022]
Abstract
PURPOSE There has been both greater recognition and scrutiny of the increased use of advanced imaging. Our aim was to determine whether there has been a change over time in the use of computed tomography (CT), magnetic resonance imaging (MRI), ultrasound (US) modalities in the intensive care units (ICUs). MATERIALS AND METHODS A retrospective review of 75657 admissions to 20 ICUs was conducted. Results were analyzed with multivariate linear, negative binomial, and Poisson regressions. Primary outcomes were rates of use of CT, MRI, and US per 1000 ICU admissions every 6 months. Secondary outcomes were changes in radiology use associated with impacts on mortality, hospital length of stay (LOS), ICU LOS, and hospital charges. RESULTS The rate of imaging use decreased by 13.5% between 2007 and 2011 (incidence rate ratio [IRR], 0.982; P < .001). Most of this decrease was by CTs (21.0%; IRR, 0.973; P < .001). Use of MRI decreased by 6.0% (IRR, 0.991; P = .04), whereas US increased by 18.9% (IRR, 1.012; P < .001). The charges associated with imaging decreased by $74 per ICU admission, which would save an estimated $1.2 million in charges during 2011. Decreased imaging was not associated with changes in mortality, hospital, and ICU LOS. CONCLUSION Advanced imaging use decreased for 5 years in the ICUs, resulting in decreased charges without negative effects on patient outcomes.
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Affiliation(s)
- Jarone Lee
- Departments of Surgery and Emergency Medicine, Massachusetts General Hospital & Harvard Medical School, Boston, MA.
| | - Brian Geyer
- Department of Emergency Medicine, Brigham and Women's Hospital and Massachusetts General Hospital, Boston, MA.
| | - Leily Naraghi
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital & Harvard Medical School, Boston, MA.
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital & Harvard Medical School, Boston, MA.
| | - Matthias Eikermann
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital & Harvard Medical School, Boston, MA.
| | - D Dante Yeh
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital & Harvard Medical School, Boston, MA.
| | - Ednan K Bajwa
- Department of Pulmonary and Critical Care Medicine, Massachusetts General Hospital & Harvard Medical School, Boston, MA.
| | - J Perren Cobb
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital & Harvard Medical School, Boston, MA.
| | - Ali S Raja
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA.
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