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Kharel P, Zadro JR, Wong G, Rojanabenjawong K, Traeger A, Linklater J, Maher CG. Effectiveness of implementation strategies for increasing clinicians' use of five validated imaging decision rules for musculoskeletal injuries: a systematic review. BMC Emerg Med 2024; 24:84. [PMID: 38760697 PMCID: PMC11100091 DOI: 10.1186/s12873-024-00996-x] [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: 07/15/2023] [Accepted: 04/29/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND Strategies to enhance clinicians' adherence to validated imaging decision rules and increase the appropriateness of imaging remain unclear. OBJECTIVE To evaluate the effectiveness of various implementation strategies for increasing clinicians' use of five validated imaging decision rules (Ottawa Ankle Rules, Ottawa Knee Rule, Canadian C-Spine Rule, National Emergency X-Radiography Utilization Study and Canadian Computed Tomography Head Rule). DESIGN Systematic review. METHODS The inclusion criteria were experimental, quasi-experimental study designs comprising randomised controlled trials (RCTs), non-randomised controlled trials, and single-arm trials (i.e. prospective observational studies) of implementation interventions in any care setting. The search encompassed electronic databases up to March 11, 2024, including MEDLINE (via Ovid), CINAHL (via EBSCO), EMBASE (via Ovid), Cochrane CENTRAL, Web of Science, and Scopus. Two reviewers assessed the risk of bias of studies independently using the Cochrane Effective Practice and Organization of Care Group (EPOC) risk of bias tool. The primary outcome was clinicians' use of decision rules. Secondary outcomes included imaging use (indicated, non-indicated and overall) and knowledge of the rules. RESULTS We included 22 studies (5-RCTs, 1-non-RCT and 16-single-arm trials), conducted in emergency care settings in six countries (USA, Canada, UK, Australia, Ireland and France). One RCT suggested that reminders may be effective at increasing clinicians' use of Ottawa Ankle Rules but may also increase the use of ankle radiography. Two RCTs that combined multiple intervention strategies showed mixed results for ankle imaging and head CT use. One combining educational meetings and materials on Ottawa Ankle Rules reduced ankle injury imaging among ED physicians, while another, with similar efforts plus clinical practice guidelines and reminders for the Canadian CT Head Rule, increased CT imaging for head injuries. For knowledge, one RCT suggested that distributing guidelines had a limited short-term impact but improved clinicians' long-term knowledge of the Ottawa Ankle Rules. CONCLUSION Interventions such as pop-up reminders, educational meetings, and posters may improve adherence to the Ottawa Ankle Rules, Ottawa Knee Rule, and Canadian CT Head Rule. Reminders may reduce non-indicated imaging for knee and ankle injuries. The uncertain quality of evidence indicates the need for well-conducted RCTs to establish effectiveness of implementation strategies.
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Affiliation(s)
- Priti Kharel
- The University of Sydney, Sydney Musculoskeletal Health, Sydney, NSW, Australia, PO Box M179, Priti Kharel - Level 10 North, King George V Building, Royal Prince Alfred Hospital, Missenden Road, 2050.
| | - Joshua R Zadro
- The University of Sydney, Sydney Musculoskeletal Health, Sydney, NSW, Australia, PO Box M179, Priti Kharel - Level 10 North, King George V Building, Royal Prince Alfred Hospital, Missenden Road, 2050
| | - Grace Wong
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
| | | | - Adrian Traeger
- The University of Sydney, Sydney Musculoskeletal Health, Sydney, NSW, Australia, PO Box M179, Priti Kharel - Level 10 North, King George V Building, Royal Prince Alfred Hospital, Missenden Road, 2050
| | | | - Christopher G Maher
- The University of Sydney, Sydney Musculoskeletal Health, Sydney, NSW, Australia, PO Box M179, Priti Kharel - Level 10 North, King George V Building, Royal Prince Alfred Hospital, Missenden Road, 2050
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Gangathimmaiah V, Drever N, Evans R, Moodley N, Sen Gupta T, Cardona M, Carlisle K. What works for and what hinders deimplementation of low-value care in emergency medicine practice? A scoping review. BMJ Open 2023; 13:e072762. [PMID: 37945299 PMCID: PMC10649718 DOI: 10.1136/bmjopen-2023-072762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 10/26/2023] [Indexed: 11/12/2023] Open
Abstract
OBJECTIVES Low-value care can harm patients and healthcare systems. Despite a decade of global endeavours, low value care has persisted. Identification of barriers and enablers is essential for effective deimplementation of low-value care. This scoping review is an evidence summary of barriers, enablers and features of effective interventions for deimplementation of low-value care in emergency medicine practice worldwide. DESIGN A mixed-methods scoping review was conducted using the Arksey and O'Malley framework. DATA SOURCES Medline, CINAHL, Embase, EMCare, Scopus and grey literature were searched from inception to 5 December 2022. ELIGIBILITY CRITERIA Primary studies which employed qualitative, quantitative or mixed-methods approaches to explore deimplementation of low-value care in an EM setting and reported barriers, enablers or interventions were included. Reviews, protocols, perspectives, comments, opinions, editorials, letters to editors, news articles, books, chapters, policies, guidelines and animal studies were excluded. No language limits were applied. DATA EXTRACTION AND SYNTHESIS Study selection, data collection and quality assessment were performed by two independent reviewers. Barriers, enablers and interventions were mapped to the domains of the Theoretical Domains Framework. The Mixed Methods Appraisal Tool was used for quality assessment. RESULTS The search yielded 167 studies. A majority were quantitative studies (90%, 150/167) that evaluated interventions (86%, 143/167). Limited provider abilities, diagnostic uncertainty, lack of provider insight, time constraints, fear of litigation, and patient expectations were the key barriers. Enablers included leadership commitment, provider engagement, provider training, performance feedback to providers and shared decision-making with patients. Interventions included one or more of the following facets: education, stakeholder engagement, audit and feedback, clinical decision support, nudge, clinical champions and training. Multifaceted interventions were more likely to be effective than single-faceted interventions. Effectiveness of multifaceted interventions was influenced by fidelity of the intervention facets. Use of behavioural change theories such as the Theoretical Domains Framework in the published studies appeared to enhance the effectiveness of interventions to deimplement low-value care. CONCLUSION High-fidelity, multifaceted interventions that incorporated education, stakeholder engagement, audit/feedback and clinical decision support, were administered daily and lasted longer than 1 year were most effective in achieving deimplementation of low-value care in emergency departments. This review contributes the best available evidence to date, but further rigorous, theory-informed, qualitative and mixed-methods studies are needed to supplement the growing body of evidence to effectively deimplement low-value care in emergency medicine practice.
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Affiliation(s)
- Vinay Gangathimmaiah
- Department of Emergency Medicine, Townsville University Hospital, Townsville, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Natalie Drever
- Department of Obstetrics and Gynaecology, Cairns Hospital, Cairns, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Cairns, Queensland, Australia
| | - Rebecca Evans
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Nishila Moodley
- Department of Emergency Medicine, Townsville University Hospital, Townsville, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Tarun Sen Gupta
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Magnolia Cardona
- A/Prof Implementation Science, Faculty of Health and Behavioural Sciences, School of Psychology, The University of Queensland, Brisbane, Queensland, Australia
- Honorary A/Prof of Research Translation, Institute for Evidence Based Healthcare, Bond University, Gold Coast, Queensland, Australia
| | - Karen Carlisle
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
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Walther F, Eberlein-Gonska M, Hoffmann RT, Schmitt J, Blum SFU. Measuring appropriateness of diagnostic imaging: a scoping review. Insights Imaging 2023; 14:62. [PMID: 37052758 PMCID: PMC10102275 DOI: 10.1186/s13244-023-01409-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 03/18/2023] [Indexed: 04/14/2023] Open
Abstract
In radiology, the justification of diagnostic imaging is a key performance indicator. To date, specific recommendations on the measurement of appropriateness in diagnostic imaging are missing. To map the study literature concerning the definition, measures, methods and data used for analyses of appropriateness in research of diagnostic imaging. We conducted a scoping review in Medline, EMBASE, Scopus and the Cochrane Central Register of Controlled Trials. Two independent reviewers undertook screening and data extraction. After screening 6021 records, we included 50 studies. National guidelines (n = 22/50) or American College of Radiology Appropriateness Criteria (n = 23/50) were used to define and rate appropriateness. 22/50 studies did not provide methodological details about the appropriateness assessment. The included studies varied concerning modality, amount of reviewed examinations (88-13,941) and body regions. Computed tomography (27 studies, 27,168 examinations) was the most frequently analyzed modality, followed by magnetic resonance imaging (17 studies, 6559 examinations) and radiography (10 studies, 7095 examinations). Heterogeneous appropriateness rates throughout single studies (0-100%), modalities, and body regions (17-95%) were found. Research on pediatric and outpatient imaging was sparse. Multicentric, methodologically robust and indication-oriented studies would strengthen appropriateness research in diagnostic imaging and help to develop reliable key performance indicators.
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Affiliation(s)
- Felix Walther
- Center for Evidence-Based Healthcare, University Hospital Carl Gustav Carus and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany.
- Quality and Medical Risk Management, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
| | - Maria Eberlein-Gonska
- Quality and Medical Risk Management, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Ralf-Thorsten Hoffmann
- Institute and Polyclinic for Diagnostic and Interventional Radiology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Jochen Schmitt
- Center for Evidence-Based Healthcare, University Hospital Carl Gustav Carus and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Sophia F U Blum
- Quality and Medical Risk Management, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Institute and Polyclinic for Diagnostic and Interventional Radiology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
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Boonrod A, Boonrod A, Meethawolgul A, Twinprai P. Diagnostic accuracy of deep learning for evaluation of C-spine injury from lateral neck radiographs. Heliyon 2022; 8:e10372. [PMID: 36061007 PMCID: PMC9433686 DOI: 10.1016/j.heliyon.2022.e10372] [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: 03/15/2022] [Revised: 06/01/2022] [Accepted: 08/16/2022] [Indexed: 11/30/2022] Open
Abstract
Background Traumatic spinal cord injury (TSI) is a leading cause of morbidity and mortality worldwide, with the cervical spine being the most affected. Delayed diagnosis carries a risk of morbidity and mortality. However, cervical spine CT scans are time-consuming, costly, and not always available in general care. In this study, deep learning was used to assess and improve the detection of cervical spine injuries on lateral radiographs, the most widely used screening method to help physicians triage patients quickly and avoid unnecessary CT scans. Materials and methods Lateral neck or lateral cervical spine radiographs were obtained for patients who underwent CT scan of cervical spine. Ground truth was determined based on CT reports. CiRA CORE, a codeless deep learning program, was used as a training and testing platform. YOLO network models, including V2, V3, and V4, were trained to detect cervical spine injury. The diagnostic accuracy, sensitivity, and specificity of the model were calculated. Results A total of 229 radiographs (129 negative and 100 positive) were selected for inclusion in our study from a list of 625 patients with cervical spine CT scans, 181 (28.9%) of whom had cervical spine injury. The YOLO V4 model performed better than the V2 or V3 (AUC = 0.743), with sensitivity, specificity, and accuracy of 80%, 72% and 75% respectively. Conclusion Deep learning can improve the accuracy of lateral c-spine or neck radiographs. We anticipate that this will assist clinicians in quickly triaging patients and help to minimize the number of unnecessary CT scans.
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Affiliation(s)
- Arunnit Boonrod
- Department of Radiology, Khon Kaen University, Khon Kaen, 40002, Thailand
- AI and Informatics in Medical Imaging (AIIMI) Research Group, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand
| | - Artit Boonrod
- Department of Orthopedics, Khon Kaen University, Khon Kaen, 40002, Thailand
- AI and Informatics in Medical Imaging (AIIMI) Research Group, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand
| | | | - Prin Twinprai
- Department of Radiology, Khon Kaen University, Khon Kaen, 40002, Thailand
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Al-Dasuqi K, Johnson MH, Cavallo JJ. Use of artificial intelligence in emergency radiology: An overview of current applications, challenges, and opportunities. Clin Imaging 2022; 89:61-67. [PMID: 35716432 DOI: 10.1016/j.clinimag.2022.05.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 05/04/2022] [Accepted: 05/23/2022] [Indexed: 11/16/2022]
Abstract
The value of artificial intelligence (AI) in healthcare has become evident, especially in the field of medical imaging. The accelerated pace and acuity of care in the Emergency Department (ED) has made it a popular target for artificial intelligence-driven solutions. Software that helps better detect, report, and appropriately guide management can ensure high quality patient care while enabling emergency radiologists to better meet the demands of quick turnaround times. Beyond diagnostic applications, AI-based algorithms also have the potential to optimize other important steps within the ED imaging workflow. This review will highlight the different types of AI-based applications currently available for use in the ED, as well as the challenges and opportunities associated with their implementation.
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Affiliation(s)
- Khalid Al-Dasuqi
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, Box 208042, Tompkins East 2, 333 Cedar St, New Haven, CT 06520-8042, United States of America.
| | - Michele H Johnson
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, Box 208042, Tompkins East 2, 333 Cedar St, New Haven, CT 06520-8042, United States of America.
| | - Joseph J Cavallo
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, Box 208042, Tompkins East 2, 333 Cedar St, New Haven, CT 06520-8042, United States of America.
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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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