Emergency docs want decision support to tackle CT overuse

By Erik L. Ridley, AuntMinnie staff writer

October 21, 2013 -- Generating roughly one-third of all CT scans, the emergency department (ED) would seem a key target for imaging decision-support software. And emergency physicians would welcome the technology, if research from Washington University School of Medicine is any indication.

In a survey of emergency physicians (EPs) in the St. Louis area, respondents reported that overutilization of CT is a problem in the ED, and they showed interest in imaging decision support to help address the issue, according to lead author Dr. Richard Griffey, associate chief of emergency medicine at Washington University School of Medicine/Barnes-Jewish Hospital.

The researchers shared their results in a poster presentation last week at the American College of Emergency Physicians (ACEP) Research Forum in Seattle.

The poster is part of a series of three projects being funded by the Washington University Institute of Clinical and Translational Sciences, the Emergency Medicine Foundation, and the Emergency Medicine Patient Safety Foundation, Griffey said. The first project was a survey of EPs to evaluate their attitudes, preferences, and knowledge regarding CT utilization, radiation, and imaging decision support, while the second was an exploratory retrospective project to identify "highly imaged conditions," he said.

The third project, which has just concluded data collection, evaluated the impact of providing CT study counts and other information to emergency physicians, he said. The initial survey was the subject of the poster.

Imaging decision support

A number of studies have evaluated the efficacy of different computer-based interventions to help optimize imaging, producing mixed results. However, the success of these systems often hinges upon the attitudes and preferences of the end users and how the systems meet their workflow needs, Griffey told AuntMinnie.com.

As a result, the researchers sought to assess the knowledge, attitudes, and preferences of emergency physicians related to CT utilization, radiation risks, and decision support. In particular, they wanted to determine whether emergency physicians view overutilization as a problem, whether they want imaging decision support, and, if they do want decision support, what kinds they prefer, according to the researchers.

A secondary goal of the survey was to determine what factors or demographic characteristics, if any, were associated with interest in decision support.

The team asked 235 EPs in the St. Louis area to fill out a 42-item Web-based survey. Of these, 155 (66%) responded.

Opinions were gathered on topics including the following:

  • Whether overutilization is a problem with significant opportunity for improvement in the ED
  • Whether cumulative study counts affect decisions to order CT or the type of study ordered
  • Whether multiple prior evaluations with CT influence the decision of whether or not to order a CT exam
  • The impact of malpractice and patient satisfaction on CT ordering
  • The information EPs want for decision support before ordering a CT

A problem

On a scale of 1 (strongly agree) to 5 (strongly disagree), respondents had a mean score of 1.79 for the three questions related to whether there is significant opportunity for improvement regarding overutilization in the ED.

"CT overutilization is perceived as a problem," the authors wrote.

Four questions related to cumulative study counts and their effect on ordering decisions had a mean response score of 3.37 on a scale of 1 (never) to 5 (always). Three questions related to whether multiple prior CT evaluations affect CT ordering had a mean response score of 1.79 on a scale of 1 (strongly agree) to 5 (strongly disagree).

"CT count impacts ordering only some of the time, but knowledge of repeat/multiple imaging impacts ordering behavior," the authors wrote.

The survey also asked about other factors that influence the decision to order a CT.

"EPs felt unavailability of other imaging modalities, especially at night or on weekends, impacted this decision," Griffey said. "They also felt pressure from patients and other physicians, such as consultants and referring MDs; concern about patient satisfaction scores; and concern about malpractice."

Decision-support capabilities

The researchers also surveyed the EPs for their interest in the following imaging decision-support capabilities:

  • Effective dose of the imaging study being ordered
  • A patient's cumulative CT study count
  • A patient's cumulative radiation exposure in mSv
  • A patient's lifetime attributable risk (LAR) of cancer based on this exposure
  • The appropriateness ranking of a particular study for a given indication
  • Other imaging options
  • Reminders or alerts about patients at increased risk due to multiple imaging, etc.

On a scale of 1 (strongly agree) to 5 (strongly disagree), respondents had a mean score of 2.00 for the first four capabilities and 2.05 for the remaining three.

"EPs are interested in all types of imaging decision support proposed to help optimize imaging ordering in the ED and to reduce radiation to their patients," the authors wrote.

Poor knowledge

Emergency physicians performed poorly on three questions assessing knowledge of radiation dose information and effects.

"EPs want effective dose information but are not familiar enough with this information to make use of it," the authors wrote. "Knowledge of common dosages is poor, consistent with other studies across specialties."

If provided with information about the risks of imaging, 87% of respondents said they would use the information to discuss risks with patients.

Copyright © 2013 AuntMinnie.com

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