Study Results
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Basic Information
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COMPLETED
NA
3511 participants
INTERVENTIONAL
2016-12-15
2018-12-31
Brief Summary
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Detailed Description
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In particular, there is widespread concern in both the medical profession and the public sector of the cost and health risks of "over-scanning". Estimates suggest that as many as 30% of imaging in the U.S. are unnecessary. Medicare direct spending on "high-cost" scans (e.g. MRs and CTs) was about $10 billion in 2012, or about 2% of total Medicare costs ; the indirect costs are likely considerably greater, since imaging often triggers additional follow up care. It is also estimated that about 2 percent of cancers in the U.S. are due to CT use.
Reflecting this concern, starting in 2018 Medicare will no longer reimburse for high-cost scans unless ordered using an "acceptable" Clinical Decision Support (CDS) system. Despite this upcoming policy change, the investigators know of no large-scale randomized trials on the impact of CDS for imaging.
The intervention in this study provides Clinical Decision Support (CDS) for targeted high-cost radiology orders, (MR, CT, NM, and PET scans), to healthcare providers treating patients in settings affiliated with the Aurora Health Care system headquartered in Wisconsin. CDS is a tool embedded in an order entry system that provides information and guidance to providers on whether their intended order is "appropriate" and whether there are more highly recommended alternatives. The randomization is at the provider level: half will receive the CDS, while the remaining half of providers in the study will serve as the control group.
The CDS will be delivered through the order-entry software, Epic, through ACR Select software, which is a leading decision support tool based on the American College of Radiology (ACR) Appropriateness Criteria.
Recommendations that appear in the CDS tool are a digitized version of guidelines created by the American College of Radiology (ACR). The guidelines score the appropriateness of a scan order for a given health indication, where indications include common symptoms and diagnosis keywords, such as "acute headache." In particular, indication-scan pairs are assigned an "appropriateness rating" from 1-9. Scores 1-3 are 'usually not appropriate,' 4-6 are 'may be appropriate,' and 7-9 are 'usually appropriate.'
To learn more about how CDS impacts ordering behavior, the investigators will investigate whether those exposed to CDS orders in ways that avoids CDS, such as placing them via clerical workers or choosing different indications. The investigators plan to analyze outcomes across different settings (Inpatient vs Outpatient and in the ED). Last, if the investigators find effects of CDS on ordering they will examine effects on utilization, including length of inpatient stays.
The primary outcome is the number of imaging orders that would produce a best-practice alert suggesting a change. The investigators conducted power calculations using a 7-month intervention window and 6 months of pre-period data to calculate the lag of the dependent variable as a control. With this control, the minimum detectible effect is a 13% reduction compared to a mean of 11 scans over that time period.
In addition, the investigators will investigate the number of scans (all high-cost, high-cost scoring 1-3, high-cost scoring 4-6, and substitution to low-cost scans. The investigators will also investigate whether treatment group orders in ways that avoids the CDS, such as placing them via clerical workers or choosing different indications. The investigators plan to analyze outcomes across different settings (Inpatient vs Outpatient and in the ED). Last, if the investigators find effects of CDS on ordering they will examine effects on utilization, including length of inpatient stays.
Conditions
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Study Design
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RANDOMIZED
PARALLEL
HEALTH_SERVICES_RESEARCH
Study Groups
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Treatment
Clinical Decision Support (CDS)
Clinical Decision Support (CDS)
A best practices alert (BPA) pop-up screen providing CDS will appear at physician sign-off for all scans scored 1-6, and scans scored 7-8 for which an alternative scan scored 8-9 exists.
This screen will show the appropriateness score of the original scan order, and will display up to 7 alternative scans that are scored \>4 and greater than or equal to the original score for the same indications and patient characteristics. It will also display a link to relevant ACR documentation relevant to the selected scan and indication.
Control
Will not receive Clinical Decision Support (CDS)
No interventions assigned to this group
Interventions
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Clinical Decision Support (CDS)
A best practices alert (BPA) pop-up screen providing CDS will appear at physician sign-off for all scans scored 1-6, and scans scored 7-8 for which an alternative scan scored 8-9 exists.
This screen will show the appropriateness score of the original scan order, and will display up to 7 alternative scans that are scored \>4 and greater than or equal to the original score for the same indications and patient characteristics. It will also display a link to relevant ACR documentation relevant to the selected scan and indication.
Eligibility Criteria
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Inclusion Criteria
* Is a Medical Doctor (MD), Doctors of Osteopathic Medicine (DO), podiatrist (DPM), nurse practitioner (NP), physician assistant (PA), or certified nurse midwife (CNM)
* Has imaging order permissions at Aurora Health Care.
* Has at least one high- or low-cost imaging order in the year from November 1, 2015 to November 1, 2016 or is medical resident who joined Aurora since that time.
Exclusion Criteria
ALL
No
Sponsors
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Wake Forest University Health Sciences
OTHER
Laura and John Arnold Foundation
OTHER
Massachusetts Institute of Technology
OTHER
Abdul Latif Jameel Poverty Action Lab
OTHER
Responsible Party
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Principal Investigators
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Joseph Doyle, PhD
Role: PRINCIPAL_INVESTIGATOR
Massachusetts Institute of Technology
Amy Finkelstein, PhD
Role: PRINCIPAL_INVESTIGATOR
Massachusetts Institute of Technology
Sarah Reimer, MD
Role: PRINCIPAL_INVESTIGATOR
Wake Forest University Health Sciences
Laura Feeney, MA
Role: PRINCIPAL_INVESTIGATOR
Massachusetts Institute of Technology
Sarah Abraham
Role: PRINCIPAL_INVESTIGATOR
Massachusetts Institute of Technology
Locations
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Aurora Health Care
Milwaukee, Wisconsin, United States
Countries
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References
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Callaghan BC, Kerber KA, Pace RJ, Skolarus LE, Burke JF. Headaches and neuroimaging: high utilization and costs despite guidelines. JAMA Intern Med. 2014 May;174(5):819-21. doi: 10.1001/jamainternmed.2014.173. No abstract available.
Georgiou A, Prgomet M, Markewycz A, Adams E, Westbrook JI. The impact of computerized provider order entry systems on medical-imaging services: a systematic review. J Am Med Inform Assoc. 2011 May 1;18(3):335-40. doi: 10.1136/amiajnl-2010-000043. Epub 2011 Mar 8.
Shreibati JB, Baker LC. The relationship between low back magnetic resonance imaging, surgery, and spending: impact of physician self-referral status. Health Serv Res. 2011 Oct;46(5):1362-81. doi: 10.1111/j.1475-6773.2011.01265.x. Epub 2011 Apr 21.
Brenner DJ, Hall EJ. Computed tomography--an increasing source of radiation exposure. N Engl J Med. 2007 Nov 29;357(22):2277-84. doi: 10.1056/NEJMra072149. No abstract available.
Centers for Medicare & Medicaid Services, 2013. National Health Expenditures 2013 Highlights. Centers for Medicare & Medicaid Services.
Sherman, D., 2012. Stemming the tide of overtreatment in U.S. healthcare. Reuters. Feb 16, 2012.
U.S. Government Accountability Office, 2008. Medicare Part B Imaging Services: Rapid Spending Growth and Shift to Physician Offices Indicate Need for CMS to Consider Additional Management Practices [WWW Document]. URL http://www.gao.gov/products/GAO-08-452 (accessed 2.23.15).
Consumer Reports, 2015. Surprising Dangers of CT Scans and X-rays - Consumer Reports [WWW Document]. URL http://www.consumerreports.org/cro/magazine/2015/01/the-surprising-dangers-of-ct-sans-and-x-rays/index.htm (accessed 2.25.15).
Dehn, T.G., O'Connell, B., Hall, R.N., Moulton, T., 2000. Appropriateness of imaging examinations: current state and future approaches. Imaging Econ 13, 18-26.
Medicare Payment Advisory Commission, 2014. Health Care Spending and the Medicare Program. MedPAC.
Pitts, J., 2014. The Protecting Access to Medicare Act of 2014.
Other Identifiers
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JPAL-5002
Identifier Type: -
Identifier Source: org_study_id
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