CDS makes ‘modest, but significant’ impact on imaging order appropriateness

Clinical decision support (CDS) tools can improve the appropriateness of advanced imaging orders, according to new findings published in the American Journal of Roentgenology. The difference, however, wasn’t necessarily drastic; the authors described it as “modest, but significant.”

“Despite the impending requirement for CDS use during clinician order entry for advanced imaging, few randomized trials have rigorously assessed methods to curb unnecessary or inappropriate imaging studies,” wrote Ted E. Palen, MD, Colorado Permanente Medical Group in Denver, and colleagues. “The aim of this study was to use a stepped-wedge, cluster randomized clinical trial to evaluate whether a point-of-care CDS tool improved the appropriateness scores of advanced imaging orders in primary and specialty care ambulatory clinics.”

The authors implemented CDS software that was incorporated into their institution’s electronic medical record. The software would score each ordered examination on a scale of one to nine based on American College of Radiology (ACR) criteria. A seven, eight or nine represented an “appropriate” order. When an inappropriate order was detected, the software launched a best practice alert (BPA) that recommended an alternative plan of action. BPAs included radiation dose information as well, further helping physicians make decisions that have the best possible outcome for the patient.

For the study, the CDS software was slowly introduced. BPAs were not displayed at first and then slowly “activated” for different users. (The authors also noted that there had been prior attempts to improve the appropriateness of imaging orders, describing continued education and quality improvement as “an established part of the care delivery processes” at their institution).

Overall, the authors explored data from more than 31,000 CT or MRI examination orders from Oct. 5, 2015 to Feb. 22, 2016. There was an increase in the percentage of appropriate examinations ordered by physicians (80.7% vs. 78%) and nonphysicians (76.9% vs. 73.8%) after BPAs were activated.

“In this stepped-wedge, cluster randomized clinical trial, we found that the use of ACR Select criteria through a CDS tool and BPA resulted in a modest but statistically significant improvement in appropriateness scores for advanced imaging orders in outpatient ambulatory practices,” the authors wrote. “The improvement was smaller in magnitude than the few prior evaluations of CDS tools, in part because baseline appropriateness scores were higher.”

Looking at the long-term impact of CDS, Palen et al. also observed ordering habits through August 31, 2017, noting that “the rate of imaging orders did not change significantly after CDS BPA activation.”