Impact of Provider-led, Technology-enabled Radiology Management Program on Imaging

Ip, Ivan K.; Schneider, Louise I.; Seltzer, Steven E.; Smith, Allen E.; Dudley, Jessica C.; Menard, Andrew; Khorasani, Ramin

doi:10.1016/j.amjmed.2012.11.034

Cited by 61 publications

(33 citation statements)

References 21 publications

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“…There was no significant increase or decrease in use of CT pulmonary angiographic imaging in the periods before (April 1, 2007, to October 31, 2009) and after CDS training. Consequences for ignoring evidence may be needed to potentiate the effect of CDS in reducing unwarranted variations in care (9,12,24). The observed 15.7% overall relative reduction in use of CT pulmonary angiographic imaging after CDS was greater than the estimated 12.3% reduction of use of CT pulmonary angiographic imaging within 30 days after CDS.…”

Section: Discussionmentioning

confidence: 42%

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Effect of Evidence-based Clinical Decision Support on the Use and Yield of CT Pulmonary Angiographic Imaging in Hospitalized Patients

Dunne¹,

Ip²,

Abbett³

et al. 2015

Radiology

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MPH 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.q RSNA, 2015

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Section: Discussionmentioning

confidence: 42%

“…Imaging CDS and CDS-enabled interventions have been associated with reductions in use of imaging and improved appropriateness (8)(9)(10)(11)(12)(13). Although condition-specific imaging CDS interventions for outpatients (9) and in the emergency department (ED) (10) have been reported, reports on inpatient interventions are lacking.…”

Section: Discussionmentioning

confidence: 99%

Effect of Evidence-based Clinical Decision Support on the Use and Yield of CT Pulmonary Angiographic Imaging in Hospitalized Patients

Dunne¹,

Ip²,

Abbett³

et al. 2015

Radiology

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“…To improve quality of care and reduce waste, the Affordable Care Act encourages the adoption of electronic health records as well as computerized physician order entry systems with integrated CDS (14,25). Additionally, under the Protecting Access to Medicare Act of 2014, health care providers will be required to consult specified appropriate use criteria by using a qualified decision support mechanism when ordering advanced imaging for Medicare patients beginning in January 2017 (26).…”

Section: Discussionmentioning

confidence: 99%

“…Clinical decision support (CDS) integrated with a computerized physician order entry system can help improve workflow efficiency and increase guideline adherence (14)(15)(16). Specifically, CDS based on high-quality evidencebased guidelines reduces the use of advanced imaging and decreases the rate of inappropriate imaging in certain outpatient and ED settings (17-19).…”

Section: Methodsmentioning

confidence: 99%

Yield of CT Pulmonary Angiography in the Emergency Department When Providers Override Evidence-based Clinical Decision Support

Yan

Raja

et al. 2017

Radiology

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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 andMethods: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 x 2 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.q RSNA, 2016

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“…Since its adoption, various implemented decision-support tools have led to improvement in appropriateness adherence in numerous settings. For example, Ip et al 67 showed a 12% sustained reduction in cross-sectional imaging for the outpatient, while Dunne et al 68 showed a 12% sustained reduction in CT pulmonary angiography use in the emergency department after implementation of clinical decision-support systems. Although early data on imaging use with support tools are promising, their effect on clinical outcomes has yet to be fully evaluated.…”

Section: Importance Of Ordering Wisely and Clinical Decision Supportmentioning

confidence: 99%

Neuroimaging Wisely

Buethe

Nazarian

Kalisz

et al. 2016

AJNR Am J Neuroradiol

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SUMMARY: 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. ABBREVIATIONS: AAFP

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Impact of Provider-led, Technology-enabled Radiology Management Program on Imaging

Cited by 61 publications

References 21 publications

Effect of Evidence-based Clinical Decision Support on the Use and Yield of CT Pulmonary Angiographic Imaging in Hospitalized Patients

Effect of Evidence-based Clinical Decision Support on the Use and Yield of CT Pulmonary Angiographic Imaging in Hospitalized Patients

Yield of CT Pulmonary Angiography in the Emergency Department When Providers Override Evidence-based Clinical Decision Support

Neuroimaging Wisely

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