Photo courtesy of NIH
Tools that help physicians decide whether to use diagnostic imaging can help reduce the use of unnecessary tests.
But new research suggests these tools may not be able to determine which tests are necessary most of the time.
The tools in question are computerized clinical decision support (CDS) systems, which match a patient’s characteristics against appropriateness
criteria to produce algorithmic treatment recommendations.
In a study published in JAMA, CDS systems did increase orders of imaging tests rated as “appropriate.”
However, the systems were not able to assign appropriateness ratings for a majority of tests because no appropriateness criteria were available for a particular test, or because the systems themselves were not able to find matching criteria.
“The increase in orders rated as appropriate is promising, but the number of tests that were not rated indicates there is room for further improvement of these tools,” said study author Peter S. Hussey, PhD, of the RAND Corporation in Boston, Massachusetts.
Study details
Dr Hussey and his colleagues used data from the Medicare Imaging Demonstration to evaluate the relationship of CDS system use with the proportion of imaging orders matched to appropriateness criteria, the appropriateness of ordered images, and the proportion of orders that changed after feedback.
The team compared 2 time periods during which clinicians used computerized radiology order entry systems and CDS systems for MRI, CT, and nuclear medicine procedures.
During a 6-month baseline period, the CDS systems tracked whether orders were linked with appropriateness criteria but did not provide clinicians with feedback on the appropriateness of orders.
During the 18-month intervention period, the CDS systems provided feedback indicating whether the order was linked to appropriateness criteria and, if so, the appropriateness rating, any recommendations for alternative orders, and a link to documentation supporting each rating.
National medical specialty societies developed the appropriateness criteria using expert panels that reviewed evidence and completed a structured rating process. The same appropriateness criteria were loaded into the CDS systems tools for all participating clinicians.
In all, 3340 clinicians placed 117,348 orders for advanced diagnostic imaging procedures.
Results
The CDS systems could not match most orders to appropriateness criteria. The systems did not identify relevant criteria for 63.3% of orders made during the baseline period and 66.5% of orders made during the intervention period.
Of the orders CDS systems could rate, 73.7% ordered during the baseline period and 81% ordered during the intervention period were rated as appropriate, and 11.1% and 6.4%, respectively, were rated inappropriate.
Of the orders that were initially rated as inappropriate, 4.8% were changed, and 1.9% were canceled.
When the CDS systems suggested an alternative for inappropriate orders, 9.9% of the orders were changed, and 0.4% were canceled. When the systems did not provide an alternative, 1.4% of inappropriate orders were changed, and 2.8% were canceled.
“In response to these findings, we recommend that clinical decision support efforts should focus on tools that help clinicians perform their work more efficiently and effectively,” said study author Katherine Kahn, MD, of the University of California, Los Angeles.
“We need a more comprehensive set of evidence-based guidelines that cover a greater proportion of advanced imaging orders for Medicare patients, and provide better methods for communicating feedback to clinicians.”
