Reducing neuroimaging in first-episode psychosis by facilitating uptake of choosing wisely recommendations: a quality improvement initiative

Srivastava, Raman; Holmes, R Davis; Noel, Christopher W.; Lam, Tong V; Shewchuk, Jason R.

doi:10.1136/bmjoq-2020-001307

Cited by 4 publications

(5 citation statements)

References 14 publications

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“…Education,73–77 audit and feedback,78–82 stakeholder engagement,24 83–86 clinical decision support,87–91 nudge,92–96 clinical champions,97–101 training102–106 and incentives79 107 were the component facets of interventions. Interventions were multifaceted in 79% (113/143) of studies and single faceted in 21% (30/143) of studies.…”

Section: Resultsmentioning

confidence: 99%

“…Feedback worked best when it was immediate,178 specific,73 detailed,179 case-based,180 181 individualised with peer group comparison159 182 and accompanied by deep engagement with clinicians 136. Engagement of multidisciplinary stakeholders in development of priorities, identification of barriers and design of interventions led to effective deimplementation 81 183 184. Clinical champions—frontline clinicians who advocate for change—can be potent and versatile mediators of deimplementation by embracing and disseminating the deimplementation message137 while simultaneously providing nudge, education and feedback 77 124.…”

Section: Discussionmentioning

confidence: 99%

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What works for and what hinders deimplementation of low-value care in emergency medicine practice? A scoping review

Gangathimmaiah,

Drever,

Evans

et al. 2023

BMJ Open

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ObjectivesLow-value care can harm patients and healthcare systems. Despite a decade of global endeavours, low value care has persisted. Identification of barriers and enablers is essential for effective deimplementation of low-value care. This scoping review is an evidence summary of barriers, enablers and features of effective interventions for deimplementation of low-value care in emergency medicine practice worldwide.DesignA mixed-methods scoping review was conducted using the Arksey and O’Malley framework.Data sourcesMedline, CINAHL, Embase, EMCare, Scopus and grey literature were searched from inception to 5 December 2022.Eligibility criteriaPrimary studies which employed qualitative, quantitative or mixed-methods approaches to explore deimplementation of low-value care in an EM setting and reported barriers, enablers or interventions were included. Reviews, protocols, perspectives, comments, opinions, editorials, letters to editors, news articles, books, chapters, policies, guidelines and animal studies were excluded. No language limits were applied.Data extraction and synthesisStudy selection, data collection and quality assessment were performed by two independent reviewers. Barriers, enablers and interventions were mapped to the domains of the Theoretical Domains Framework. The Mixed Methods Appraisal Tool was used for quality assessment.ResultsThe search yielded 167 studies. A majority were quantitative studies (90%, 150/167) that evaluated interventions (86%, 143/167). Limited provider abilities, diagnostic uncertainty, lack of provider insight, time constraints, fear of litigation, and patient expectations were the key barriers. Enablers included leadership commitment, provider engagement, provider training, performance feedback to providers and shared decision-making with patients. Interventions included one or more of the following facets: education, stakeholder engagement, audit and feedback, clinical decision support, nudge, clinical champions and training. Multifaceted interventions were more likely to be effective than single-faceted interventions. Effectiveness of multifaceted interventions was influenced by fidelity of the intervention facets. Use of behavioural change theories such as the Theoretical Domains Framework in the published studies appeared to enhance the effectiveness of interventions to deimplement low-value care.ConclusionHigh-fidelity, multifaceted interventions that incorporated education, stakeholder engagement, audit/feedback and clinical decision support, were administered daily and lasted longer than 1 year were most effective in achieving deimplementation of low-value care in emergency departments. This review contributes the best available evidence to date, but further rigorous, theory-informed, qualitative and mixed-methods studies are needed to supplement the growing body of evidence to effectively deimplement low-value care in emergency medicine practice.

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Section: Resultsmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

What works for and what hinders deimplementation of low-value care in emergency medicine practice? A scoping review

Gangathimmaiah,

Drever,

Evans

et al. 2023

BMJ Open

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“…This study is notable for being the only one in our meta-analysis that reported the prevalence of clinically relevant abnormalities to be lower in patients with psychosis than in controls and was identified as an outlier in the leave-1-out sensitivity analysis. Studies exploring radiological abnormalities in patients with psychosis using computed tomography (CT) have yielded substantially lower estimates than MRI . This likely reflects the relative insensitivity of CT to detect intracranial abnormalities in patients with psychosis.…”

Section: Discussionmentioning

confidence: 99%

“…Studies exploring radiological abnormalities in patients with psychosis using computed tomography (CT) have yielded substantially lower estimates than MRI. 4 , 39 This likely reflects the relative insensitivity of CT to detect intracranial abnormalities in patients with psychosis.…”

Section: Discussionmentioning

confidence: 99%

Prevalence of Neuroradiological Abnormalities in First-Episode Psychosis

Blackman,

Neri,

Al-Doori

et al. 2023

JAMA Psychiatry

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ImportanceIndividuals presenting with first-episode psychosis (FEP) may have a secondary (“organic”) etiology to their symptoms that can be identified using neuroimaging. Because failure to detect such cases at an early stage can have serious clinical consequences, it has been suggested that brain magnetic resonance imaging (MRI) should be mandatory for all patients presenting with FEP. However, this remains a controversial issue, partly because the prevalence of clinically relevant MRI abnormalities in this group is unclear.ObjectiveTo derive a meta-analytic estimate of the prevalence of clinically relevant neuroradiological abnormalities in FEP.Data SourcesElectronic databases Ovid, MEDLINE, PubMed, Embase, PsychINFO, and Global Health were searched up to July 2021. References and citations of included articles and review articles were also searched.Study SelectionMagnetic resonance imaging studies of patients with FEP were included if they reported the frequency of intracranial radiological abnormalities.Data Extraction and SynthesisIndependent extraction was undertaken by 3 researchers and a random-effects meta-analysis of pooled proportions was calculated. Moderators were tested using subgroup and meta-regression analyses. Heterogeneity was evaluated using the I2 index. The robustness of results was evaluated using sensitivity analyses. Publication bias was assessed using funnel plots and Egger tests.Main Outcomes and MeasuresProportion of patients with a clinically relevant radiological abnormality (defined as a change in clinical management or diagnosis); number of patients needed to scan to detect 1 such abnormality (number needed to assess [NNA]).ResultsTwelve independent studies (13 samples) comprising 1613 patients with FEP were included. Of these patients, 26.4% (95% CI, 16.3%-37.9%; NNA of 4) had an intracranial radiological abnormality, and 5.9% (95% CI, 3.2%-9.0%) had a clinically relevant abnormality, yielding an NNA of 18. There were high degrees of heterogeneity among the studies for these outcomes, 95% to 73%, respectively. The most common type of clinically relevant finding was white matter abnormalities, with a prevalence of 0.9% (95% CI, 0%-2.8%), followed by cysts, with a prevalence of 0.5% (95% CI, 0%-1.4%).Conclusions and RelevanceThis systematic review and meta-analysis found that 5.9% of patients presenting with a first episode of psychosis had a clinically relevant finding on MRI. Because the consequences of not detecting these abnormalities can be serious, these findings support the use of MRI as part of the initial clinical assessment of all patients with FEP.

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“…Few publications and, to our knowledge, no professional society guidelines have provided recommendations for the specific presentations included in our study . Our results provide further support for refining guidelines and implementing quality improvement initiatives such as Choosing Wisely …”

Section: Discussionmentioning

confidence: 99%

Yield of Head Computed Tomography Examinations for Common Psychiatric Presentations and Implications for Medical Clearance From a 6-Year Analysis of Acute Hospital Visits

Malhotra

Sheth

et al. 2022

JAMA Intern Med

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Reducing neuroimaging in first-episode psychosis by facilitating uptake of choosing wisely recommendations: a quality improvement initiative

Cited by 4 publications

References 14 publications

What works for and what hinders deimplementation of low-value care in emergency medicine practice? A scoping review

What works for and what hinders deimplementation of low-value care in emergency medicine practice? A scoping review

Prevalence of Neuroradiological Abnormalities in First-Episode Psychosis

Yield of Head Computed Tomography Examinations for Common Psychiatric Presentations and Implications for Medical Clearance From a 6-Year Analysis of Acute Hospital Visits

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