Clinical Decision Support for Ordering CTA-PE Studies in the Emergency Department—A Pilot on Feasibility and Clinical Impact in a Tertiary Medical Center

Goehler, Alexander; Moore, Christopher L.; Manne‐Goehler, Jennifer; Arango, Jennifer; D'Amato, L.; Forman, Howard P.; Weinreb, Jeffrey C.

doi:10.1016/j.acra.2018.09.009

Cited by 12 publications

(14 citation statements)

References 16 publications

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“…Providers also believed that their gestalt was superior to risk stratification tools, including a negative D‐dimer in a low‐ or intermediate‐risk patient. This is consistent with studies demonstrating that providers often override these tools, even when presented through a CDS alert . While prior literature shows gestalt can adequately risk stratify patients, the use of risk stratification tools appears to improve CTPA yield, suggesting that the added value of risk stratification tools lies in reducing unnecessary testing .…”

Section: Discussionsupporting

confidence: 81%

“…Multiple validated risk stratification tools exist to promote appropriate workup for PE and are recommended by professional society guidelines, including the Pulmonary Embolism Rule Out Criteria (PERC), Wells score, and D‐dimer laboratory test (Figure ) . Provider uptake of the tools has been slow, with recent ED studies finding 25% of patients who warranted no laboratory or imaging studies still received testing . Prior attempts to mitigate this knowledge translation gap using provider feedback and electronic health record (EHR) clinical decision support (CDS) have had only modest success .…”

Section: Introductionmentioning

confidence: 99%

“…Prior attempts to mitigate this knowledge translation gap using provider feedback and electronic health record (EHR) clinical decision support (CDS) have had only modest success . For example, in a recent study, providers overrode the EHR‐integrated CDS and proceeded to CTPA in 96% of cases . These studies did not use implementation science principles, specifically geared to help promote the uptake of evidence‐based practices, to deliver the interventions, and it is possible that the use of implementation science could improve the uptake of evidence‐based diagnostic approaches …”

Section: Introductionmentioning

confidence: 99%

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Provider Perspectives on the Use of Evidence‐based Risk Stratification Tools in the Evaluation of Pulmonary Embolism: A Qualitative Study

Westafer

Kunz

Bugajska

et al. 2020

Academic Emergency Medicine

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Objectives Providers often pursue imaging in patients at low risk of pulmonary embolism (PE), resulting in imaging yields <10% and false‐positive imaging rates of 10% to 25%. Attempts to curb overtesting have had only modest success and no interventions have used implementation science frameworks. The objective of this study was to identify barriers and facilitators to the adoption of evidence‐based diagnostic testing for PE. Methods We conducted semistructured interviews with a purposeful sample of providers. An interview guide was developed using the implementation science frameworks, consolidated framework for implementation research, and theoretical domains framework. Interviews were recorded, transcribed, and analyzed in an iterative process. Emergent themes were identified, discussed, and organized. Results We interviewed 23 providers from four hospital systems, and participants were diverse with regard to years in practice and practice setting. Barriers were predominately at the provider level and included lack of knowledge of the tools, particularly misunderstanding of the validated scoring systems in Wells, as well as risk avoidance and need for certainty. Barriers to prior implementation strategies included the perception of a clinical decision support (CDS) tool for PE as adding steps with little value; most participants reported that they overrode CDS interventions because they had already made the decision. All providers identified institution‐level strategies as facilitators to use, including endorsed guidelines, audit feedback with peer comparison about imaging yield, and peer pressure. Conclusions This exploration of the use of risk stratification tools in the evaluation of PE found that barriers to use primarily exist at the provider level, whereas facilitators to the use of these tools are largely perceived at the level of the institution. Future efforts to promote the evidence‐based diagnosis of PE should be informed by these determinants.

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Section: Discussionsupporting

confidence: 81%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Provider Perspectives on the Use of Evidence‐based Risk Stratification Tools in the Evaluation of Pulmonary Embolism: A Qualitative Study

Westafer

Kunz

Bugajska

et al. 2020

Academic Emergency Medicine

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“…1,[13][14][15][16][17] Providers tend to resist CDS, often ignore it, and sometimes game the system. 18 "Co-designing" CDS tools with referring providers-incorporating their insights during the development phase-may improve compliance with evidence-based ordering over standard CDS creation while mitigating unintended consequences and/or barriers to implementation. 16,17,[19][20][21][22][23] A recent systematic review with gap analysis recommended that models reflect the complex adaptive sociotechnical system of health informatics to mitigate implementation barriers.…”

Section: Background and Significancementioning

confidence: 99%

Joint Design with Providers of Clinical Decision Support for Value-Based Advanced Shoulder Imaging

et al. 2020

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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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“…The papers [25,26] describe decision support in antibiotic therapy. Publications [27][28][29][30] are devoted to decision-making in sorting patients and providing assistance in emergency situations. The work [31] describes DSS for interpretation of ECG in 12 leads.…”

Section: State Of Artmentioning

confidence: 99%

The Concept of Decision Support in Evaluating the Functional State of Complex System of the Biological type

Nasyrov¹,

Yusupova²,

Zulkarneev³

et al. 2019

Proceedings of the 21st International Workshop on Computer Science and Information Technologies (CSIT 2019)

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The aim of the work is to develop a conceptual approach to decision support in assessing the functional state of a complex system of biological type. The definition of the functional state and the basic principles of its evaluation for complex systems of biological type on the basis of system representations are formulated. A situational model of the problem environment as a set-theoretic composition of the main components and evaluation functions was developed, which allowed to formulate the definition of the problem situation. The structure of the application of data mining to assess the functional state of a complex system using as feedback models of three levels-strategic, tactical and operational. A system of coordinated models for decisionmaking in assessing the functional state of a complex system based on causal representations in the form of Markov chains and Petri nets is proposed.

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Clinical Decision Support for Ordering CTA-PE Studies in the Emergency Department—A Pilot on Feasibility and Clinical Impact in a Tertiary Medical Center

Cited by 12 publications

References 16 publications

Provider Perspectives on the Use of Evidence‐based Risk Stratification Tools in the Evaluation of Pulmonary Embolism: A Qualitative Study

Provider Perspectives on the Use of Evidence‐based Risk Stratification Tools in the Evaluation of Pulmonary Embolism: A Qualitative Study

Joint Design with Providers of Clinical Decision Support for Value-Based Advanced Shoulder Imaging

The Concept of Decision Support in Evaluating the Functional State of Complex System of the Biological type

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