Purpose:To determine the effect of evidence-based clinical decision support (CDS) on the use and yield of computed tomographic (CT) pulmonary angiography for acute pulmonary embolism (PE) in the emergency department (ED).

While ICU health care workers consistently identify a number of patient factors as important in decisions to withdraw care, there is extreme variability, which may be explained in part by the values of individual health care providers.

Objective To assess radiology utilization trends for emergency department (ED) patients from 1993 through 2012. Methods In this institutional review board-approved, retrospective study at a 793-bed tertiary care academic medical center, we reviewed radiology utilization from January 1, 1993 through December 31, 2012, during which time the number of ED patient visits increased from 48,000 to 61,000, and determined the number of imaging studies by modality (x-ray, sonography, CT, MRI, other) and associated relative value units (RVUs). We used linear regression to assess for trends in the number of imaging RVUs and imaging accession numbers, our primary and secondary outcomes, respectively. Results The total RVUs attributable to ED imaging per thousand ED visits increased 208% from 1993–2007 (p<0.0001) and then decreased 24.7% by 2012 (p<0.0019). The total number of imaging accession numbers per thousand ED visits increased 47.8%from 1993 until 2005(p=0.0003), then decreased 26.9% by 2012 (p<0.0001). CT RVUs per thousand ED visits increased 493% until 2007 (p<0.0001) and then decreased 33% (p<0.0001), MRI RVUs increased 2,475% until 2008 (p<0.0001) and then decreased 20.7% (p<0.032). Ultrasound RVUs increased 75.7% over the study period (p<0.0001) while x-ray RVUs decreased 28.1% (p=0.0009). Conclusions Following a period of substantial increase from 1993–2007, volume-adjusted ED imaging RVUs declined from 2007–2012, largely due to decreasing use of CT and MRI. Further studies are needed to determine the causes of this decline, which may include quality improvement activities, advocacy for appropriateness by leadership, concerns regarding radiation exposure and cost, and health IT interventions.

Background Examine the impact of a multi-faceted, clinical decision support (CDS)-enabled intervention on magnetic resonance imaging (MRI) use in adult primary care patients with low back pain. Methods After a baseline observation period, we implemented a CDS targeting lumbar-spine MRI use in primary care patients with low back pain through our computerized physician order entry (CPOE) as well as two accountability tools: 1) mandatory peer-to-peer consultation when test utility was uncertain and 2) quarterly practice pattern variation reports to providers. Our primary outcome measure was rate of lumbar-spine MRI use. Secondary measures included utilization of MRI of any body part, comparing to that of a concurrent national comparison, as well as proportion of lumbar-spine MRI performed in the study cohort that was adherent to evidence-based guideline. Chi-square, t-tests, and logistic regression were used to assess pre- and post-intervention differences. Results In the study cohort, pre-intervention, 5.3% of low back pain-related primary care visits resulted in lumbar-spine MRI compared to 3.7% of visits post-intervention (p<0.0001, Adjusted Odds Ratio 0.68). There was a 30.8% relative decrease (6.5% vs. 4.5%, p<0.0001, Adjusted Odds Ratio 0.67) in the use of MRI of any body part by the primary care providers in the study cohort. This difference was not detected in the control cohort (5.6% vs. 5.3%, p=0.712). In the study cohort, adherence to evidence-based guideline in the use of lumbar-spine MRI increased from 78% to 96% (p=0.0002). Conclusions CDS and associated accountability tools may reduce potentially inappropriate imaging in patients with low back pain.

OBJECTIVE The study objective was to determine whether previously documented effects of clinical decision support on computed tomography for pulmonary embolism in the emergency department (ie, decreased use and increased yield) are due to a decrease in unwarranted variation. We evaluated clinical decision support effect on intra- and inter-physician variability in the yield of pulmonary embolism computed tomography (PE-CT) in this setting. METHODS The study was performed in an academic adult medical center emergency department with 60,000 annual visits. We enrolled all patients who had PE-CT performed 18 months pre- and post-clinical decision support implementation. Intra- and inter-physician variability in yield (% PE-CT positive for acute pulmonary embolism) were assessed. Yield variability was measured using logistic regression accounting for patient characteristics. RESULTS A total of 1542 PE-CT scans were performed before clinical decision support, and 1349 PE-CT scans were performed after clinical decision support. Use of PE-CT decreased from 26.5 to 24.3 computed tomography scans/1000 patient visits after clinical decision support (P < .02); yield increased from 9.2% to 12.6% (P < .01). Crude inter-physician variability in yield ranged from 2.6% to 20.5% before clinical decision support and from 0% to 38.1% after clinical decision support. After controlling for patient characteristics, the post-clinical decision support period showed significant inter-physician variability (P < .04). Intra-physician variability was significant in 3 of the 25 physicians (P < .04), all with increased yield post-clinical decision support. CONCLUSIONS Overall PE-CT yield increased after clinical decision support implementation despite significant heterogeneity among physicians. Increased inter-physician variability in yield after clinical decision support was not explained by patient characteristics alone and may be due to variable physician acceptance of clinical decision support. Clinical decision support alone is unlikely to eliminate unwarranted variability, and additional strategies and interventions may be needed to help optimize acceptance of clinical decision support to maximize returns on national investments in health information technology.

IMPORTANCE The Wells score to determine the pretest probability of deep vein thrombosis (DVT) was validated in outpatient settings, but it is unclear whether it applies to inpatients. OBJECTIVE To evaluate the utility of the Wells score for risk stratification of inpatients with suspected DVT. DESIGN, SETTING, AND PARTICIPANTS A prospective study was conducted in a 793-bed quaternary care, academic hospital using Wells score clinical predictor findings entered by health care professionals in a computerized physician order entry system at the time lower-extremity venous duplex ultrasound studies were ordered. All adult inpatients suspected of having lower-extremity DVT who underwent lower-extremity venous duplex ultrasound studies between November 1, 2012, and December 31, 2013, were included. Patients with DVT diagnosed within the prior 3 months were excluded. For patients undergoing multiple lower-extremity venous duplex ultrasound studies, only the first was included. MAIN OUTCOMES AND MEASURES Our primary outcome was the Wells score's utility for risk stratification among inpatients with suspected DVT as measured by the difference in incidence of proximal DVT among the 3 Wells score categories (low, moderate, and high pretest probability), the discrimination accuracy of the Wells score categories as the area under the receiver operating characteristics curve, the failure rate of Wells score prediction, and the efficiency of the Wells score to exclude DVT. RESULTS In a study cohort of 1135 inpatients, 137 (12.1%) had proximal DVT. Proximal DVT incidence in low, moderate, and high pretest probability groups was 5.9% (8 of 135), 9.5% (48 of 506), and 16.4% (81 of 494), respectively (P < .001). The area under the receiver operating characteristics curve for the discriminatory accuracy of the Wells score for risk of proximal DVT identified on lower-extremity venous duplex ultrasound studies was 0.60. The failure rate of the Wells score to classify patients with a low pretest probability was 5.9% (95% CI, 3.0%-11.3%); the efficiency was 11.9% (95% CI, 10.1%-13.9%). CONCLUSIONS AND RELEVANCE The Wells score performed only slightly better than chance for discrimination of risk for DVT in hospitalized patients. It had a higher failure rate and a lower efficiency in the inpatient setting compared with that reported in the outpatient literature. Therefore, the Wells score risk stratification is not sufficient to rule out DVT or influence management decisions in the inpatient setting.

FCPLs are common, and nearly one-quarter of radiology reports recommend at least one follow-up imaging study. Significant variation exists in the rate of recommendation for further imaging studies by radiologists, even after controlling for key explanatory variables.

Imaging utilization in emergency departments (EDs) has increased significantly. More than half of the 1.2 million patients with mild traumatic brain injury (MTBI) presenting to US EDs receive head CT. While evidence-based guidelines can help emergency clinicians decide whether to obtain head CT in these patients, adoption of these guidelines has been highly variable. Promulgation of imaging efficiency guidelines by the National Quality Forum has intensified the need for performance reporting, but measuring adherence to these imaging guidelines currently requires labor-intensive and potentially inaccurate manual chart review. We implemented clinical decision support (CDS) based on published evidence to guide emergency clinicians towards appropriate head CT use in patients with MTBI and automated data capture needed for unambiguous guideline adherence metrics. Implementation of the CDS was associated with a 56% relative increase in documented adherence to evidence-based guidelines for imaging in ED patients with MTBI.