Effect of clinical decision rules, patient cost and malpractice information on clinician brain CT image ordering: a randomized controlled trial

Abstract

BackgroundThe frequency of head computed tomography (CT) imaging for mild head trauma patients has raised safety and cost concerns. Validated clinical decision rules exist in the published literature and on-line sources to guide medical image ordering but are often not used by emergency department (ED) clinicians. Using simulation, we explored whether the presentation of a clinical decision rule (i.e. Canadian CT Head Rule - CCHR), findings from malpractice cases related to clinicians not ordering CT imaging in mild head trauma cases, and estimated patient out-of-pocket cost might influence clinician brain CT ordering. Understanding what type and how information may influence clinical decision making in the ordering advanced medical imaging is important in shaping the optimal design and implementation of related clinical decision support systems.MethodsMulti-center, double-blinded simulation-based randomized controlled trial. Following standardized clinical vignette presentation, clinicians made an initial imaging decision for the patient. This was followed by additional information on decision support rules, malpractice outcome review, and patient cost; each with opportunity to modify their initial order. The malpractice and cost information differed by assigned group to test the any temporal relationship. The simulation closed with a second vignette and an imaging decision.ResultsOne hundred sixteen of the 167 participants (66.9%) initially ordered a brain CT scan. After CCHR presentation, the number of clinicians ordering a CT dropped to 76 (45.8%), representing a 21.1% reduction in CT ordering (P = 0.002). This reduction in CT ordering was maintained, in comparison to initial imaging orders, when presented with malpractice review information (p = 0.002) and patient cost information (p = 0.002). About 57% of clinicians changed their order during study, while 43% never modified their imaging order.ConclusionThis study suggests that ED clinician brain CT imaging decisions may be influenced by clinical decision support rules, patient out-of-pocket cost information and findings from malpractice case review.Trial registrationNCT03449862, February 27, 2018, Retrospectively registered.Electronic supplementary materialThe online version of this article (10.1186/s12911-018-0602-1) contains supplementary material, which is available to authorized users.

Behavioral Economics Interventions in Clinical Decision Support Systems

“…The 12 selected articles reported on 10 distinct studies. Among these studies, three addressed monitoring and individual feedback [32][33][34], two compared framed presentations [35,36], two addressed heuristics [37,38] and [39], one was about social norms [40], one addressed the ordering effect [41], and one used a combination of overconfidence, risk aversion, and herding [42,43]. Figure 1 presents the flowchart of this systematic review.…”

“…While no differences were found in terms of changes in intentions and other outcomes, the authors found that the format of numbers plus a framed presentation was effective for numerate patients. A very recent study [36] found that the ordering of advanced medical imaging procedures was affected by framed information designed to show physicians guideline rules, malpractice cases, and costs.…”

Reducing Unnecessary Head Computed Tomographic Scans in an Adult Emergency Department

“…A multidisciplinary team approach and a reduction in head CT scans with use of the CCHR are consistent with data from previously published studies. [14][15][16] The clinical decision pathway created for this project is in alignment with the American College of Emergency Physicians' current recommendations on the management of patients who present with minor head injury. 3,6 Using the CCHR within the pathway, all patients with brain injuries were properly risk stratified.…”

“…This resulted in a decrease of head CT imaging use by 7.8%. 15 Gimbel et al 16 used vignette case study stimulations in which clinicians made an initial imaging decision followed by education on CCHR application and an opportunity to modify the initial order. This approach led to a 21.1% reduction in head CT use.…”

“…This approach led to a 21.1% reduction in head CT use. 16 Studies focused on attitudes and adherence showed that common reasons physicians ordered a head CT scan were to confirm or exclude a diagnosis, fear of missing a diagnosis, and to expedite a diagnosis. 17 Zakhari and Sterrett 18 indicated that clinicians would adopt the CCHR to a moderate extent if they found it appealing and it was required by a governing authority.…”