Imaging utilization rules based on national guidelines may not cover all clinical circumstances. Appropriate use criteria (AUC) based on local best practices can fill this gap, however, and help avoid inappropriate imaging, according to research published online November 7 in the American Journal of Roentgenology.
Researchers at Brigham and Women's Hospital in Boston developed and implemented their own appropriate use criteria covering CT in patients presenting to the emergency department (ED) with renal colic -- an imaging scenario for which evidence-based guidelines are currently lacking. CT utilization dropped by more than one-third in these patients after the AUC was adopted as part of a clinical decision-support (CDS) system.
"Our findings suggest that implementing site-specific multidisciplinary AUCs -- or even disseminating single-center AUCs to other sites for incorporation into their CDS systems -- may be an effective method of curbing potential overuse of imaging of ED patients for disease processes for which high-quality evidence has not been developed," wrote the group led by Dr. Ali Raja. "Once developed, these AUCs can be stored and disseminated online, allowing guidance in situations in which the literature is devoid of high-quality evidence."
While embedding evidence-based imaging guidelines in CDS as part of quality improvement initiatives has been shown to reduce inappropriate imaging utilization, there hasn't been much research on how locally developed AUCs may affect high-cost imaging in the ED, according to the researchers. With the goal of reducing avoidable ED imaging and radiation exposure, an interdisciplinary team collaborated to develop AUC based on local best practice for providers ordering imaging in patients younger than 50 with a history of uncomplicated nephrolithiasis.
Next, the researchers embedded the appropriate use criteria into the CDS module of their hospital's computerized physician order-entry system. Ordering physicians were given alerts if their CT request was not consistent with the criteria, but they were not required to adhere to the recommendations.
To assess the effect of the AUC on CT utilization, the researchers retrospectively reviewed ED records for 18 months prior to the adoption of AUC at their level I trauma center, and again for an additional 18-month period that began one year after implementation. For another comparison, they also reviewed the records at a comparable academic medical center in the same urban healthcare delivery system that had not adopted the AUC.
| Effect of home-grown AUC on CT utilization in ED patients | ||
| Before implementation of AUC | After implementation of AUC | |
| Patients with renal colic and history of uncomplicated renal stone receiving CT | 46/194 (23.7%) | 13/88 (14.8%) |
The 37.5% reduction in utilization was statistically significant (p = 0.03). Meanwhile, utilization at the control site that did not receive the AUC intervention remained statistically unchanged over the study periods, according to the researchers.
"Implementing CDS with a site-specific AUC based on local best practice may be an effective method of curbing potential overuse of imaging in a subset of ED patients with renal colic who are unlikely to have a complicated course or an alternative dangerous diagnosis," the authors wrote.
