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While federal regulations will require the use of clinical decision support (CDS) for imaging beginning in 2018 (https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/appropriate-use-criteria-program/index.html), advice generated by non–evidence-based CDS (typically based on expert opinion in guidelines) has been shown to have little impact on physician ordering (AJR Am J Roentgenol 2017; 208:351).
These researchers focused on the implementation of three evidence-based CDS tools (for imaging of head injury, cervical spine injury, and pulmonary embolism [PE]) into the electronic health record (Epic, Madison, WI) in a five-site system. In a before-and-after study, they compared use of computed tomography (CT) for each of the three indications overall and by physicians categorized as low, average, or high utilizers based on CT use at the start of the study.
Roughly 235,000 patients were included in the study. After implementation of the CDS tools, CT of the head and cervical spine decreased significantly (by10% and 6%, respectively) while use of CT for PE did not change significantly. Use of CT by initially high utilizers decreased for all three indications, while use by average utilizers remained unchanged. Interestingly, low utilizers increased their use of cervical spine and PE CT after implementation.
Bookman K et al. Embedded clinical decision support in electronic health record decreases use of high cost imaging in the emergency department: EmbED study. Acad Emerg Med 2017 Apr 9; [e-pub]. (http://dx.doi.org/10.1111/acem.13195)
Comment
It's no surprise that CT use decreased after implementation of evidence-based CDS tools that were developed based on well-accepted emergency medicine clinical decision rules. We should all have such guidance at our fingertips when ordering imaging. While the increase in CT use among low-utilizer physicians might seem strange at first glance, it's likely due to appropriate ordering of CT for patients who met imaging indications. However, the authors should go back and look at the appropriateness (instead of just the use) of these CT scans to be sure.