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Alami Idrissi Y, Virador GM, Singh RB, Rao D, Stone JA, Sandhu SJS. Imaging 3.0: A scoping review. Curr Probl Diagn Radiol 2024; 53:399-404. [PMID: 38242771 DOI: 10.1067/j.cpradiol.2024.01.012] [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: 11/11/2023] [Accepted: 01/16/2024] [Indexed: 01/21/2024]
Abstract
We aim to provide a comprehensive summary of the current body of literature concerning the Imaging 3.0 initiative and its implications for patient care within the field of radiology. We offer a thorough analysis of the literature pertaining to the Imaging 3.0 initiative, emphasizing the practical application of the five pillars of the program, their cost-effectiveness, and their benefits in patient management. By doing so, we hope to illustrate the impact the Imaging 3.0 Initiative can have on the future of radiology and patient care.
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Affiliation(s)
- Yassine Alami Idrissi
- Hillman Cancer Center, University of Pittsburgh Medical Center, 5030 Centre avenue, Pittsburgh, PA 15213, United States.
| | - Gabriel M Virador
- Department of Internal Medicine, Medstar Union Memorial Hospital, Baltimore, MD, United States
| | - Rahul B Singh
- Department of Internal Medicine, New York City Health and Hospitals/South Brooklyn Health, Brooklyn, NY, United States
| | - Dinesh Rao
- Department of Radiology, Mayo Clinic, Jacksonville, FL, United States
| | - Jeffrey A Stone
- Department of Radiology, Mayo Clinic, Jacksonville, FL, United States
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2
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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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Dijk SW, Kroencke T, Wollny C, Barkhausen J, Jansen O, Halfmann MC, Rizopoulos D, Hunink MGM. Medical Imaging Decision And Support (MIDAS): Study protocol for a multi-centre cluster randomized trial evaluating the ESR iGuide. Contemp Clin Trials 2023; 135:107384. [PMID: 37949165 DOI: 10.1016/j.cct.2023.107384] [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: 07/03/2023] [Revised: 10/20/2023] [Accepted: 11/03/2023] [Indexed: 11/12/2023]
Abstract
OBJECTIVES Medical imaging plays an essential role in healthcare. As a diagnostic test, imaging is prone to substantial overuse and potential overdiagnosis, with dire consequences to patient outcomes and health care costs. Clinical decision support systems (CDSSs) were developed to guide referring physicians in making appropriate imaging decisions. This study will evaluate the effect of implementing a CDSS (ESR iGuide) with versus without active decision support in a physician order entry on the appropriate use of imaging tests and ordering behaviour. METHODS A protocol for a multi-center cluster-randomized trial with departments acting as clusters, combined with a before-after-revert design. Four university hospitals with eight participating departments each for a total of thirty-two clusters will be included in the study. All departments start in control condition with structured data entry of the clinical indication and tracking of the imaging exams requested. Initially, the CDSS is implemented and all physicians remain blinded to appropriateness scores based on the ESR imaging referral guidelines. After randomization, half of the clusters switch to the active intervention of decision support. Physicians in the active condition are made aware of the categorization of their requests as appropriate, under certain conditions appropriate, or inappropriate, and appropriate exams are suggested. Physicians may change their requests in response to feedback. In the revert condition, active decision support is removed to study the educational effect. RESULTS/CONCLUSIONS The main outcome is the proportion of inappropriate diagnostic imaging exams requested per cluster. Secondary outcomes are the absolute number of imaging exams, radiation from diagnostic imaging, and medical costs. TRIAL REGISTRATION NUMBER Approval from the Medical Ethics Review Committee was obtained under protocol numbers 20-069 (Augsburg), B 238/21 (Kiel), 20-318 (Lübeck) and 2020-15,125 (Mainz). The trial is registered in the ClinicalTrials.gov register under registration number NCT05490290.
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Affiliation(s)
- Stijntje W Dijk
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Epidemiology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Thomas Kroencke
- Department of Diagnostic and Interventional Radiology, University Hospital Augsburg, Augsburg, Germany
| | - Claudia Wollny
- Department of Diagnostic and Interventional Radiology, University Hospital Augsburg, Augsburg, Germany
| | - Joerg Barkhausen
- Department of Radiology and Nuclear Medicine, University of Lübeck, Lübeck, Germany
| | - Olav Jansen
- Department of Radiology and Neuroradiology, University Medical Center Schleswig-Holstein (UKSH), Kiel, Germany
| | - Moritz C Halfmann
- Department of Diagnostic and Interventional Radiology, University Medical Center Mainz, Mainz, Germany
| | - Dimitris Rizopoulos
- Department of Biostatistics, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - M G Myriam Hunink
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Epidemiology, Erasmus MC University Medical Center, Rotterdam, the Netherlands; Centre for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, United States of America.
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Yang A, Kuang W, Guan A, Woo BKP. Letter re: Implementation of Electronic Clinical Decision Support Tools. Am Surg 2023; 89:6432. [PMID: 34463539 DOI: 10.1177/00031348211041561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Alvin Yang
- College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, CA, USA
| | - Wayne Kuang
- College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, CA, USA
| | - Angel Guan
- College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, CA, USA
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Shashar S, Ellen M, Codish S, Davidson E, Novack V. Unravelling the determinants of medical practice variation in referrals among primary care physicians: insights from a retrospective cohort study in Southern Israel. BMJ Open 2023; 13:e072837. [PMID: 37586857 PMCID: PMC10432653 DOI: 10.1136/bmjopen-2023-072837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 07/04/2023] [Indexed: 08/18/2023] Open
Abstract
OBJECTIVES Reducing medical practice variation (MPV) is a central theme of system improvement because it is associated with poor health outcomes, increased costs and disparities in care. This study aimed to estimate the extent to which each determinant (patient, physician, clinic) explains MPV among primary care physicians and to identify the characteristics of health services with a greater explained variance. METHODS A retrospective cohort study of primary care physicians practising in non-private clinics of Clalit Health Services in Southern Israel, for longer than a year between 2011 and 2017 and with more than 100 adult patients per practice. We assessed the variation in referral rates among 17 health services and the proportion explained by each domain (patient, physician and clinic). We used generalised linear negative binomial mixed models and the Nakagawa's R2, computing the marginal r2. RESULTS The study included 243 physicians working in 295 practices and 139 clinics. The mean-explained variance was 28.5%±10.0%, where physician characteristics explained 4.5% of the variation. The intrapractice variation (within a single physician between the years) was explained better than the interphysician (between physicians). Health services with high explained variation were blood tests characterised by both low intrapractice variation (Rs=-0.65, p value=0.005) and high referral rates (Rs=0.46, p value=0.06). CONCLUSION Over 70% of MPV is not explained by the patient, clinic and physician demographic and professional characteristics. Future research should focus on the fraction of MPV that is explained by the physicians' psychological characteristics, and thus potentially identify psychological targets for behavioural modifications aimed at reducing MPV.
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Affiliation(s)
- Sagi Shashar
- Soroka University Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Moriah Ellen
- Department of Health Policy and Management, Guilford Glazer Faculty of Business and Management, Faculty of Health Sciences, Ben Gurion University, Beer Sheva, Israel
- Institute of Health Policy Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Shlomi Codish
- Soroka University Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Ehud Davidson
- General Management, Clalit Health Services, Tel Aviv, Israel
| | - Victor Novack
- Soroka University Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel
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Zygmont ME, Ikuta I, Nguyen XV, Frigini LAR, Segovis C, Naeger DM. Clinical Decision Support: Impact on Appropriate Imaging Utilization. Acad Radiol 2023; 30:1433-1440. [PMID: 36336523 DOI: 10.1016/j.acra.2022.10.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 10/01/2022] [Accepted: 10/03/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Matthew E Zygmont
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia.
| | - Ichiro Ikuta
- Department of Radiology & Biomedical Imaging, Neuroradiology, Yale University School of Medicine, New Haven, Connecticut
| | - Xuan V Nguyen
- Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | | | - Colin Segovis
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - David M Naeger
- Denver Health and Hospital Authority, Department of Radiology, Denver CO, and the University of Colorado School of Medicine, Aurora, Colorado
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Sharpe RE, Huffman RI, McLaughlin CG, Blubaugh P, Strobel MJ, Palen T. Applying Implementation Science Principles to Systematize High-Quality Care for Potentially Significant Imaging Findings. J Am Coll Radiol 2023; 20:324-334. [PMID: 36922106 DOI: 10.1016/j.jacr.2022.11.019] [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: 06/30/2022] [Revised: 10/29/2022] [Accepted: 11/16/2022] [Indexed: 03/14/2023]
Abstract
OBJECTIVE Use principles of implementation science to improve the diagnosis and management of potentially significant imaging findings. METHODS Multidisciplinary stakeholders codified the diagnosis and management of potentially significant imaging findings in eight organs and created a finding tracking management system that was embedded in radiologist workflows and IT systems. Radiologists were trained to use this system. An automated finding tracking management system was created to support consistent high-quality care through care pathway visualizations, increased awareness of specific findings in the electronic medical record, templated notifications, and creation of an electronic safety net. Primary outcome was the rate of quality reviews related to eight targeted imaging findings. Secondary outcome was radiologist use of the finding tracking management tool. RESULTS In the 4 years after implementation, the tool was used to track findings in 7,843 patients who received 10,015 ultrasound, CT, MRI, x-ray, and nuclear medicine examinations that were interpreted by all 34 radiologists. Use of the tool lead to a decrease in related quality reviews (from 8.0% to 0.0%, P < .007). Use of the system increased from 1.7% of examinations in the early implementation phase to 3.1% (+82%, P < .00001) in the postimplementation phase. Each radiologist used the tool on an average of 294.6 unique examinations (SD 404.8). Overall, radiologists currently use the tool approximately 4,000 times per year. DISCUSSION Radiologists frequently used a finding tracking management system to ensure effective communication and raise awareness of the importance of recommended future follow-up studies. Use of this system was associated with a decrease in the rate of quality review requests in this domain.
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Affiliation(s)
- Richard E Sharpe
- Division Chair of Breast Imaging and Radiologist, Mayo Clinic, Phoenix, Arizona; Member, ACR Peer Learning Committee; Member, ACR Appropriateness Panel for Breast Imaging; and Member, ACR Commission on Screening & Emerging Technology Committee.
| | - Ryan I Huffman
- Radiologist, Scripps Clinic Medical Group, La Jolla, California
| | - Christopher G McLaughlin
- Radiologist, Department Technical Lead, Radiology, Colorado Permanente Medical Group, Denver, Colorado
| | | | - Mary Jo Strobel
- Director, Clinical Quality Oversight, Quality, Risk, and Patient Safety, Kaiser Permanente Colorado, Denver, Colorado
| | - Ted Palen
- Internal Medicine Physician and Scientific Investigator, Colorado Permanente Medical Group, Denver, Colorado
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8
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Ramsey SD, Bansal A, Sullivan SD, Lyman GH, Barlow WE, Arnold KB, Watabayashi K, Bell-Brown A, Kreizenbeck K, Le-Lindqwister NA, Dul CL, Brown-Glaberman UA, Behrens RJ, Vogel V, Alluri N, Hershman DL. Effects of a Guideline-Informed Clinical Decision Support System Intervention to Improve Colony-Stimulating Factor Prescribing: A Cluster Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2238191. [PMID: 36279134 PMCID: PMC9593234 DOI: 10.1001/jamanetworkopen.2022.38191] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
IMPORTANCE Colony-stimulating factors are prescribed to patients undergoing chemotherapy to reduce the risk of febrile neutropenia. Research suggests that 55% to 95% of colony-stimulating factor prescribing is inconsistent with national guidelines. OBJECTIVE To examine whether a guideline-based standing order for primary prophylactic colony-stimulating factors improves use and reduces the incidence of febrile neutropenia. DESIGN, SETTING, AND PARTICIPANTS This cluster randomized clinical trial, the Trial Assessing CSF Prescribing Effectiveness and Risk (TrACER), involved 32 community oncology clinics in the US. Participants were adult patients with breast, colorectal, or non-small cell lung cancer initiating cancer therapy and enrolled between January 2016 and April 2020. Data analysis was performed from July to October 2021. INTERVENTIONS Sites were randomized 3:1 to implementation of a guideline-based primary prophylactic colony-stimulating factor standing order system or usual care. Automated orders were added for high-risk regimens, and an alert not to prescribe was included for low-risk regimens. Risk was based on National Comprehensive Cancer Network guidelines. MAIN OUTCOMES AND MEASURES The primary outcome was to find an increase in colony-stimulating factor use among high-risk patients from 40% to 75%, a reduction in use among low-risk patients from 17% to 7%, and a 50% reduction in febrile neutropenia rates in the intervention group. Mixed model logistic regression adjusted for correlation of outcomes within a clinic. RESULTS A total of 2946 patients (median [IQR] age, 59.0 [50.0-67.0] years; 2233 women [77.0%]; 2292 White [79.1%]) were enrolled; 2287 were randomized to the intervention, and 659 were randomized to usual care. Colony-stimulating factor use for patients receiving high-risk regimens was high and not significantly different between groups (847 of 950 patients [89.2%] in the intervention group vs 296 of 309 patients [95.8%] in the usual care group). Among high-risk patients, febrile neutropenia rates for the intervention (58 of 947 patients [6.1%]) and usual care (13 of 308 patients [4.2%]) groups were not significantly different. The febrile neutropenia rate for patients receiving high-risk regimens not receiving colony-stimulating factors was 14.9% (17 of 114 patients). Among the 585 patients receiving low-risk regimens, colony-stimulating factor use was low and did not differ between groups (29 of 457 patients [6.3%] in the intervention group vs 7 of 128 patients [5.5%] in the usual care group). Febrile neutropenia rates did not differ between usual care (1 of 127 patients [0.8%]) and the intervention (7 of 452 patients [1.5%]) groups. CONCLUSIONS AND RELEVANCE In this cluster randomized clinical trial, implementation of a guideline-informed standing order did not affect colony-stimulating factor use or febrile neutropenia rates in high-risk and low-risk patients. Overall, use was generally appropriate for the level of risk. Standing order interventions do not appear to be necessary or effective in the setting of prophylactic colony-stimulating factor prescribing. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02728596.
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Affiliation(s)
- Scott D. Ramsey
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Aasthaa Bansal
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, Washington
- The Comparative Health Outcomes, Policy, and Economics Institute, School of Pharmacy, University of Washington, Seattle
| | - Sean D. Sullivan
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, Washington
- The Comparative Health Outcomes, Policy, and Economics Institute, School of Pharmacy, University of Washington, Seattle
| | - Gary H. Lyman
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, Washington
- School of Medicine, University of Washington, Seattle
| | - William E. Barlow
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, Washington
- SWOG Statistics and Data Management Center, Seattle, Washington
| | - Kathryn B. Arnold
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, Washington
- SWOG Statistics and Data Management Center, Seattle, Washington
| | - Kate Watabayashi
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Ari Bell-Brown
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Karma Kreizenbeck
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Nguyet A. Le-Lindqwister
- Illinois CancerCare–Peoria (Heartland Cancer Research National Cancer Institute Community Oncology Research Program), Peoria
| | - Carrie L. Dul
- Ascension St John Hospital (Michigan Cancer Research Consortium National Cancer Institute Community Oncology Research Program), Detroit
| | - Ursa A. Brown-Glaberman
- University of New Mexico Cancer Center (New Mexico Minority Underserved National Cancer Institute Community Oncology Research Program, Albuquerque
| | - Robert J. Behrens
- Medical Oncology and Hematology Associates–Des Moines (Iowa-Wide Oncology Research Coalition National Cancer Institute Community Oncology Research Program), Des Moines
| | - Victor Vogel
- Geisinger Medical Center (Geisinger Cancer Institute National Cancer Institute Community Oncology Research Program), Danville, Pennsylvania
| | - Nitya Alluri
- St Luke’s Cancer Institute–Boise (Pacific Cancer Research Consortium National Cancer Institute Community Oncology Research Program), Boise, Idaho
| | - Dawn L. Hershman
- Department of Medicine and Epidemiology, Columbia University, New York, New York
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Woelfel IA, Smith BQ, Salani R, Harzman AE, Cochran AL, Chen X(P. The long game: Evolution of clinical decision making throughout residency and fellowship. Am J Surg 2022; 223:266-272. [PMID: 33752873 PMCID: PMC9045150 DOI: 10.1016/j.amjsurg.2021.03.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 02/10/2021] [Accepted: 03/10/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND The purpose of this study was to explore the trajectory of autonomy in clinical decision making. METHODS We conducted a qualitative secondary analysis of interviews with 45 residents and fellows from the General Surgery and Obstetrics & Gynecology departments across all clinical postgraduate years (PGY) using convenience sampling. Each interview was recorded, transcribed and iteratively analyzed using a framework method. RESULTS A total of 16 junior residents, 22 senior residents and 7 fellows participated in 12 original interviews. Early in training residents take their abstract ideas about disease processes and make them concrete in their applications to patient care. A transitional stage follows in which residents apply concepts to concrete patient care. Chief residents re-abstract their concrete technical and clinical knowledge to prepare for future surgical practice. CONCLUSIONS Understanding where each learner is on this pathway will assist development of curriculum that fosters resident readiness for practice at each PGY level.
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Affiliation(s)
- Ingrid A. Woelfel
- Department of Surgery, The Ohio State University, 395 W 12th Ave Suite 670, Columbus, OH, 43201, USA,Corresponding author. Department of Surgery, 395 W 12th Ave Suite 670, Columbus, OH, 43201, USA. (I.A. Woelfel)
| | - Brentley Q. Smith
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, The Ohio State University, Starling-Loving Hall, 320 West 10th Ave, Columbus, OH, 43210, USA
| | - Ritu Salani
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, The Ohio State University, Starling-Loving Hall, 320 West 10th Ave, Columbus, OH, 43210, USA
| | - Alan E. Harzman
- Department of Surgery, The Ohio State University, 395 W 12th Ave Suite 670, Columbus, OH, 43201, USA
| | - Amalia L. Cochran
- Department of Surgery, The Ohio State University, 395 W 12th Ave Suite 670, Columbus, OH, 43201, USA
| | - Xiaodong (Phoenix) Chen
- Department of Surgery, The Ohio State University, 395 W 12th Ave Suite 670, Columbus, OH, 43201, USA
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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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11
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Frija G, Damilakis J, Paulo G, Loose R, Vano E. Cumulative effective dose from recurrent CT examinations in Europe: proposal for clinical guidance based on an ESR EuroSafe Imaging survey. Eur Radiol 2021; 31:5514-5523. [PMID: 33710370 PMCID: PMC8270793 DOI: 10.1007/s00330-021-07696-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 11/24/2020] [Accepted: 12/17/2020] [Indexed: 01/31/2023]
Abstract
In recent years, the issue of cumulative effective dose received from recurrent computed tomography examinations has become a subject of increasing concern internationally. Evidence, predominantly from the USA, has shown that a significant number of patients receive a cumulative effective dose of 100 mSv or greater. To obtain a European perspective, EuroSafe Imaging carried out a survey to collect European data on cumulative radiation exposure of patients from recurrent computed tomography examinations. The survey found that a relatively low percentage of patients (0.5%) received a cumulative effective dose equal to or higher than 100 mSv from computed tomography, most of them having an oncological disease. However, there is considerable variation between institutions as these values ranged from 0 to 2.72%, highlighting that local practice or, depending on the institution and its medical focus, local patient conditions are likely to be a significant factor in the levels of cumulative effective dose received, rather than this simply being a global phenomenon. This paper also provides some practical actions to support the management of cumulative effective dose and to refine or improve practice where recurrent examinations are required. These actions are focused around increasing awareness of referring physicians through encouraging local dialogue, actions focused on optimisation where a team approach is critical, better use of modern equipment and the use of Dose Management and Clinical Decision Support Systems together with focused clinical audits. The proper use of cumulative effective dose should be part of training programmes for referrers and practitioners, including what information to give to patients. Radiation is used to the benefit of patients in diagnostic procedures such as CT examinations, and in therapeutic procedures like the external radiation treatment for cancer. However, radiation is also known to increase the risk of cancer. To oversee this risk, the cumulative effective dose (CED) received by a patient from imaging procedures over his or her life is important. In this paper, the authors, on behalf of EuroSafe Imaging, report on a survey carried out in Europe that aims to estimate the proportion of patients that undergo CT examinations and are exposed to a CED of more than 100 mSv. At the same time, the survey enquires about and underlines radiologists' measures and radiology departments' strategies to limit such exposure. Over the period of 2015-2018, respondents reported that 0.5% (0-2.72%) of patients were exposed to a CED of ≥ 100 mSv from imaging procedures. The background radiation dose in Europe depends on the location, but it is around 2.5 mSv per year. It is obvious that patients with cancer, chronic diseases and trauma run the highest risk of having a high CED. However, even if the number of patients exposed to ≥ 100 mSv is relatively low, it is important to lower this number even further. Measures could consist in using procedures that do not necessitate radiation, using very low dose procedures, being very critical in requiring imaging procedures and increasing awareness about the issue. KEY POINTS: • A relatively low percentage of patients (0.5%) received a cumulative effective dose from CT computed tomography equal to or greater than 100 mSv, in Europe, most of them having an oncological disease. • There is a wide range in the number of patients who receive cumulative effective dose equal to or greater than 100 mSv (0-2.72%) and optimisation should be improved. • Increasing the awareness of referring physicians through encouraging local dialogue, concrete actions focused on optimisation and development of dose management systems is suggested.
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Affiliation(s)
- Guy Frija
- Université de Paris, 12 Rue de l'École de Médecine, 75006, Paris, France.
| | - John Damilakis
- School of Medicine, University of Crete, 71003, Iraklion, Greece
| | - Graciano Paulo
- ESTESC-Coimbra Health School, Medical Imaging and Radiotherapy Department, Instituto Politécnico de Coimbra, Rua 5 de Outubro, S. Martinho do Bispo, 3046-854, Coimbra, Portugal
| | - Reinhard Loose
- Institute of Medical Physics, Hospital Nuremberg, Prof.-Ernst-Nathan-Str. 1, 90419, Nuremberg, Germany
| | - Eliseo Vano
- Radiology Department, Complutense University, 28040, Madrid, Spain
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12
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Fried JG, Pakpoor J, Kahn CE, Zafar HM. Lessons From the Free-Text Epidemic: Opportunities to Optimize Deployment of Imaging Clinical Decision Support. J Am Coll Radiol 2021; 18:467-474. [PMID: 33663756 DOI: 10.1016/j.jacr.2021.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 01/05/2021] [Accepted: 01/10/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The Protecting Access to Medicare Act of 2014 requires clinicians to consult Appropriate Use Criteria (AUC) when ordering advanced imaging procedures. Free-text order indications are available when there is no applicable structured indication but are unscored by the AUC. We determined the proportion of free-text indications among all advanced imaging orders and the proportion of free-text indications that could be mapped to a single structured indication. METHODS All outpatient advanced diagnostic imaging orders placed in a large multisite health system were recorded after initial AUC deployment (November 20, 2017, to December 19, 2017). Clinicians were prompted upon order entry to select a structured indication or enter a free-text indication. We manually reviewed the two imaging examinations with the highest rate of free-text indications: enhanced CT abdomen/pelvis and unenhanced CT head. Regression analysis examined differences in patient-, imaging-, context-, and provider-level characteristics between scored and unscored examinations. RESULTS Among all 39,533 orders for advanced imaging procedures, 59% (23,267 of 39,533) were unscored by the system. The regression model c-statistic (0.50-0.55) demonstrated poor model fit to evaluate for differences between scored and unscored examinations. Free-text indications were found in 71% (16,440 of 23,267) of unscored examinations and 42% (16,440 of 39,533) of all examinations. Manual review of all 1,693 CT abdomen/pelvis and 1,527 CT head examinations with free-text indications revealed that 3,132 free-text indications (97%) could be mapped to a single existing structured indication. DISCUSSION Of all initially placed outpatient advanced imaging procedure orders, 42% included free-text indications and 97% of manually reviewed free-text indications could be mapped to a single structured indication.
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Affiliation(s)
- Jessica G Fried
- Department of Radiology, University of Michigan, Ann Arbor, Michigan.
| | - Jina Pakpoor
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Charles E Kahn
- Vice Chair, Department of Radiology and Vice Chair of Informatics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Hanna M Zafar
- Co-director, Automated Radiology Recommendation Tracking Engine; Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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13
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Golding LP, Nicola GN. Clinical Decision Support: The Law, the Future, and the Role for Radiologists. Curr Probl Diagn Radiol 2020; 49:337-339. [PMID: 32222263 DOI: 10.1067/j.cpradiol.2020.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 01/10/2020] [Accepted: 02/25/2020] [Indexed: 11/22/2022]
Abstract
Clinical Decision Support (CDS) was designed as an interactive, electronic tool for use by clinicians that communicates Appropriate Use Criteria (AUC) information to the user and assists them in making the most appropriate treatment decision for a patient's specific clinical condition. Policymakers recognized AUC as a potential solution to control inappropriate utilization of imaging and made CDS mandatory in the Protecting Access to Medicare Act of 2014. In the years since Protecting Access to Medicare Act, data on the potential impact of CDS has been mixed and much of the physician community has expressed concern about the logistics of the program. This article aims to review the legislation behind the AUC program, the events that have transpired since, and some of the challenges and opportunities facing radiologists in the current environment.
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14
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Brunner MC, Sheehan SE, Yanke EM, Sittig DF, Safdar N, Hill B, Lee KS, Orwin JF, Vanness DJ, Hildebrand CJ, Bruno MA, Erickson TJ, Zea R, Moberg DP. Joint Design with Providers of Clinical Decision Support for Value-Based Advanced Shoulder Imaging. Appl Clin Inform 2020; 11:142-152. [PMID: 32074651 DOI: 10.1055/s-0040-1701256] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Provider orders for inappropriate advanced imaging, while rarely altering patient management, contribute enough to the strain on available health care resources, and therefore the United States Congress established the Appropriate Use Criteria Program. OBJECTIVES To examine whether co-designing clinical decision support (CDS) with referring providers will reduce barriers to adoption and facilitate more appropriate shoulder ultrasound (US) over magnetic resonance imaging (MRI) in diagnosing Veteran shoulder pain, given similar efficacies and only 5% MRI follow-up rate after shoulder US. METHODS We used a theory-driven, convergent parallel mixed-methods approach to prospectively (1) determine medical providers' reasons for selecting MRI over US in diagnosing shoulder pain and identify barriers to ordering US, (2) co-design CDS, informed by provider interviews, to prompt appropriate US use, and (3) assess CDS impact on shoulder imaging use. CDS effectiveness in guiding appropriate shoulder imaging was evaluated through monthly monitoring of ordering data at our quaternary care Veterans Hospital. Key outcome measures were appropriate MRI/US use rates and transition to ordering US by both musculoskeletal specialist and generalist providers. We assessed differences in ordering using a generalized estimating equations logistic regression model. We compared continuous measures using mixed effects analysis of variance with log-transformed data. RESULTS During December 2016 to March 2018, 569 (395 MRI, 174 US) shoulder advanced imaging examinations were ordered by 111 providers. CDS "co-designed" in collaboration with providers increased US from 17% (58/335) to 50% (116/234) of all orders (p < 0.001), with concomitant decrease in MRI. Ordering appropriateness more than doubled from 31% (105/335) to 67% (157/234) following CDS (p < 0.001). Interviews confirmed that generalist providers want help in appropriately ordering advanced imaging. CONCLUSION Partnering with medical providers to co-design CDS reduced barriers and prompted appropriate transition to US from MRI for shoulder pain diagnosis, promoting evidence-based practice. This approach can inform the development and implementation of other forms of CDS.
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Affiliation(s)
- Michael C Brunner
- Department of Radiology, William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin, United States.,Department of Radiology, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, United States
| | - Scott E Sheehan
- Department of Radiology, William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin, United States.,Department of Radiology, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, United States
| | - Eric M Yanke
- Department of Medicine, William S. Middleton Memorial Veteran Hospital, Madison, Wisconsin, United States
| | - Dean F Sittig
- Department of Biomedical Informatics, University of Texas Health Science Center, Houston, Texas, United States
| | - Nasia Safdar
- Department of Medicine, William S. Middleton Memorial Veteran Hospital, Madison, Wisconsin, United States.,Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, United States
| | - Barbara Hill
- Population Health Sciences, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, United States
| | - Kenneth S Lee
- Department of Radiology, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, United States
| | - John F Orwin
- Department of Orthopedics and Rehabilitation, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, United States
| | - David J Vanness
- Department of Health Policy and Administration, Pennsylvania State University, University Park, Pennsylvania, United States
| | - Christopher J Hildebrand
- Department of Medicine, William S. Middleton Memorial Veteran Hospital, Madison, Wisconsin, United States.,Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, United States
| | - Michael A Bruno
- Department of Radiology, The Penn State Milton S. Hershey Medical Center and Penn State College of Medicine, Hershey, Pennsylvania, United States
| | - Timothy J Erickson
- Department of Physical Medicine and Rehabilitation, William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin, United States
| | - Ryan Zea
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, Wisconsin, United States
| | - D Paul Moberg
- Population Health Sciences, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, United States
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15
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Mendelson RM. Diagnostic imaging: Doing the right thing. J Med Imaging Radiat Oncol 2020; 64:353-360. [PMID: 32052577 DOI: 10.1111/1754-9485.13004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 01/01/2020] [Accepted: 01/09/2020] [Indexed: 12/17/2022]
Abstract
Inappropriate diagnostic imaging (DI) is a burgeoning issue and embraces its overuse and its misapplication. The obverse problem is one of underuse - that is when patients who should undergo imaging fail to do so. This article attempts to define these problems, examines the causes and effects and suggests some potential solutions.
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Affiliation(s)
- Richard M Mendelson
- Department of Diagnostic and Interventional Radiology, Royal Perth Hospital, Perth, Western Australia, Australia.,School of Surgery, University of Western Australia, Perth, Western Australia, Australia
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16
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Chen D, Bhambhvani HP, Hom J, Mahoney M, Wintermark M, Sharp C, Ratliff J, Chen YR. Effect of Electronic Clinical Decision Support on Imaging for the Evaluation of Acute Low Back Pain in the Ambulatory Care Setting. World Neurosurg 2020; 134:e874-e877. [DOI: 10.1016/j.wneu.2019.11.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 11/04/2019] [Accepted: 11/05/2019] [Indexed: 10/25/2022]
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17
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Pourjabbar S, Cavallo JJ, Arango J, Tocino I, Staib LH, Imanzadeh A, Forman HP, Pahade JK. Impact of Radiologist-Driven Change-Order Requests on Outpatient CT and MRI Examinations. J Am Coll Radiol 2020; 17:1014-1024. [PMID: 31954708 DOI: 10.1016/j.jacr.2019.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 12/13/2019] [Accepted: 12/18/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE To assess impact of electronic medical record-embedded radiologist-driven change-order request on outpatient CT and MRI examinations. METHODS Outpatient CT and MRI requests where an order change was requested by the protocoling radiologist in our tertiary care center, from April 11, 2017, to January 3, 2018, were analyzed. Percentage and categorization of requested order change, provider acceptance of requested change, patient and provider demographics, estimated radiation exposure reduction, and cost were analyzed. P < .05 was used for statistical significance. RESULTS In 79,310 outpatient studies in which radiologists determined protocol, change-order requests were higher for MRI (5.2%, 1,283 of 24,553) compared with CT (2.9%, 1,585 of 54,757; P < .001). Provider approval of requested change was equivalent for CT (82%, 1,299 of 1,585) and MRI (82%, 1,052 of 1,283). Change requests driven by improper contrast media utilization were most common and different between CT (76%, 992 of 1,299) and MRI (65%, 688 of 1,052; P < .001). Changing without and with intravenous contrast orders to with contrast only was most common for CT (39%, 505 of 1,299) and with and without intravenous contrast to without contrast only was most common for MRI (26%, 274 of 1,052; P < .001). Of approved changes in CT, 51% (661 of 1,299) resulted in lower radiation exposure. Approved changes frequently resulted in less costly examinations (CT 67% [799 of 1,198], MRI 48% [411 of 863]). CONCLUSION Outpatient CT and MRI orders are deemed incorrect in 2.9% to 5% of cases. Radiologist-driven change-order request for CT and MRI are well accepted by ordering providers and decrease radiation exposure associated with imaging.
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Affiliation(s)
- Sarvenaz Pourjabbar
- Department of Radiology and Biomedical Imaging, Yale-New Haven Hospital, Yale School of Medicine, New Haven, Connecticut
| | - Joseph J Cavallo
- Department of Radiology and Biomedical Imaging, Yale-New Haven Hospital, Yale School of Medicine, New Haven, Connecticut
| | - Jennifer Arango
- Department of Radiology and Biomedical Imaging, Yale-New Haven Hospital, Yale School of Medicine, New Haven, Connecticut
| | - Irena Tocino
- Vice Chair of IT, Department of Radiology and Biomedical Imaging, Yale-New Haven Hospital, Yale School of Medicine, New Haven, Connecticut
| | - Lawrence H Staib
- Department of Radiology and Biomedical Imaging, Yale-New Haven Hospital, Yale School of Medicine, New Haven, Connecticut
| | - Amir Imanzadeh
- Department of Radiology and Biomedical Imaging, Yale-New Haven Hospital, Yale School of Medicine, New Haven, Connecticut
| | - Howard P Forman
- Faculty director for Finance, Department of Radiology. Professor, Radiology and Public Health (Health Policy), Professor in the Practice of Management; Professor of Economics; Director, MD/MBA Program @ Yale; Director, Executive MBA Program (Healthcare focus area); Health Care Management Program (HCM) at Yale School of Public Health, New Haven, Connecticut
| | - Jay K Pahade
- Vice Chair of Quality and Safety, Yale Department of Radiology and Biomedical Imaging; Radiology Medical Director for Quality and Safety, Yale New Haven Health; Associate Professor, Abdominal Imaging and Ultrasound, Department of Radiology and Biomedical Imaging, Yale-New Haven Hospital, Yale School of Medicine, New Haven, Connecticut.
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18
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Rehani MM, Melick ER, Alvi RM, Doda Khera R, Batool-Anwar S, Neilan TG, Bettmann M. Patients undergoing recurrent CT exams: assessment of patients with non-malignant diseases, reasons for imaging and imaging appropriateness. Eur Radiol 2019; 30:1839-1846. [PMID: 31792584 DOI: 10.1007/s00330-019-06551-8] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 10/15/2019] [Accepted: 10/25/2019] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To determine percent of patients without malignancy and ≤ 40 years of age with high cumulative radiation doses through recurrent CT exams and assess imaging appropriateness. METHODS From the cohort of patients who received cumulative effective dose (CED) of ≥ 100 mSv over a 5-year period, a sub-set was identified with non-malignant disease. The top 50 clinical indications leading to multiple CTs were determined. Clinical decision support (CDS) system scores were analyzed using a widely adopted standard of 1-3 (red) as "not usually appropriate," 4-6 (yellow) "may or may not be appropriate," and 7-9 (green) "usually appropriate." Clinicians reviewed patient records to assess compliance with appropriate use criteria (AUC). RESULTS 9.6% of patients in our series were with non-malignant conditions and 1.4% with age ≤ 40 years. CDS scores (rounded) were 2% red, 38% yellow, 27% green, and 33% unscored CTs. Clinical society guidelines for CT exams, wherever available, were followed in 87.5 to 100% of cases. AUCs were not available for several clinical indications as also referral guidelines for serial CT imaging. More than half of CT exams were unrelated to follow-up of a primary chronic disease. CONCLUSIONS We are faced with a situation wherein patients in age ≤ 40 years require or are thought to require many CT exams over the course of a few years but the radiation risk creates concern. There is a fair number of conditions for which AUC are not available. Suggested solutions include development of CT scanners with lesser radiation dose and further development of appropriateness criteria. KEY POINTS We are faced with a situation wherein patients in age group 0-40 years and with non-malignant diagnosis require or are thought to require many CT exams over the course of a few years. More than half of CT exams were unrelated to follow-up of a primary chronic disease. Imaging guidelines and appropriateness use criteria are not available for many conditions. Wherever available, they are for initial work-up and diagnosis and there is a lack of guidance on serial CT imaging.
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Affiliation(s)
- Madan M Rehani
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.
| | - Emily R Melick
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Raza M Alvi
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Ruhani Doda Khera
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | | | - Tomas G Neilan
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Michael Bettmann
- Wake Forest University School of Medicine, Winston-Salem, NC, 27101, USA
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19
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Abstract
OBJECTIVE. The objective of this article is to discuss clinical decision support (CDS) and the article by Palen and colleagues in this issue of AJR. CONCLUSION. The Palen et al. study provides strong evidence to date that CDS can lead to improvement in imaging appropriateness scores. However, the relevance of appropriateness scores in clinical practice is unknown and CDS is potentially highly disruptive to workflow, and therefore research into its true impact on clinical care is essential.
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