Michael C Brunner1,2, Scott E Sheehan1,2, Eric M Yanke3, Dean F Sittig4, Nasia Safdar3,5, Barbara Hill6, Kenneth S Lee2, John F Orwin7, David J Vanness8, Christopher J Hildebrand3,5, Michael A Bruno9, Timothy J Erickson10, Ryan Zea11, D Paul Moberg6. 1. Department of Radiology, William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin, United States. 2. Department of Radiology, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, United States. 3. Department of Medicine, William S. Middleton Memorial Veteran Hospital, Madison, Wisconsin, United States. 4. Department of Biomedical Informatics, University of Texas Health Science Center, Houston, Texas, United States. 5. Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, United States. 6. Population Health Sciences, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, United States. 7. Department of Orthopedics and Rehabilitation, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, United States. 8. Department of Health Policy and Administration, Pennsylvania State University, University Park, Pennsylvania, United States. 9. Department of Radiology, The Penn State Milton S. Hershey Medical Center and Penn State College of Medicine, Hershey, Pennsylvania, United States. 10. Department of Physical Medicine and Rehabilitation, William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin, United States. 11. Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, Wisconsin, United States.
Abstract
BACKGROUND: Provider orders for inappropriate advanced imaging, while rarely altering patient management, contribute enough to the strain on available health care resources, and therefore the United States Congress established the Appropriate Use Criteria Program. OBJECTIVES: To examine whether co-designing clinical decision support (CDS) with referring providers will reduce barriers to adoption and facilitate more appropriate shoulder ultrasound (US) over magnetic resonance imaging (MRI) in diagnosing Veteran shoulder pain, given similar efficacies and only 5% MRI follow-up rate after shoulder US. METHODS: We used a theory-driven, convergent parallel mixed-methods approach to prospectively (1) determine medical providers' reasons for selecting MRI over US in diagnosing shoulder pain and identify barriers to ordering US, (2) co-design CDS, informed by provider interviews, to prompt appropriate US use, and (3) assess CDS impact on shoulder imaging use. CDS effectiveness in guiding appropriate shoulder imaging was evaluated through monthly monitoring of ordering data at our quaternary care Veterans Hospital. Key outcome measures were appropriate MRI/US use rates and transition to ordering US by both musculoskeletal specialist and generalist providers. We assessed differences in ordering using a generalized estimating equations logistic regression model. We compared continuous measures using mixed effects analysis of variance with log-transformed data. RESULTS: During December 2016 to March 2018, 569 (395 MRI, 174 US) shoulder advanced imaging examinations were ordered by 111 providers. CDS "co-designed" in collaboration with providers increased US from 17% (58/335) to 50% (116/234) of all orders (p < 0.001), with concomitant decrease in MRI. Ordering appropriateness more than doubled from 31% (105/335) to 67% (157/234) following CDS (p < 0.001). Interviews confirmed that generalist providers want help in appropriately ordering advanced imaging. CONCLUSION: Partnering with medical providers to co-design CDS reduced barriers and prompted appropriate transition to US from MRI for shoulder pain diagnosis, promoting evidence-based practice. This approach can inform the development and implementation of other forms of CDS. Georg Thieme Verlag KG Stuttgart · New York.
BACKGROUND: Provider orders for inappropriate advanced imaging, while rarely altering patient management, contribute enough to the strain on available health care resources, and therefore the United States Congress established the Appropriate Use Criteria Program. OBJECTIVES: To examine whether co-designing clinical decision support (CDS) with referring providers will reduce barriers to adoption and facilitate more appropriate shoulder ultrasound (US) over magnetic resonance imaging (MRI) in diagnosing Veteran shoulder pain, given similar efficacies and only 5% MRI follow-up rate after shoulder US. METHODS: We used a theory-driven, convergent parallel mixed-methods approach to prospectively (1) determine medical providers' reasons for selecting MRI over US in diagnosing shoulder pain and identify barriers to ordering US, (2) co-design CDS, informed by provider interviews, to prompt appropriate US use, and (3) assess CDS impact on shoulder imaging use. CDS effectiveness in guiding appropriate shoulder imaging was evaluated through monthly monitoring of ordering data at our quaternary care Veterans Hospital. Key outcome measures were appropriate MRI/US use rates and transition to ordering US by both musculoskeletal specialist and generalist providers. We assessed differences in ordering using a generalized estimating equations logistic regression model. We compared continuous measures using mixed effects analysis of variance with log-transformed data. RESULTS: During December 2016 to March 2018, 569 (395 MRI, 174 US) shoulder advanced imaging examinations were ordered by 111 providers. CDS "co-designed" in collaboration with providers increased US from 17% (58/335) to 50% (116/234) of all orders (p < 0.001), with concomitant decrease in MRI. Ordering appropriateness more than doubled from 31% (105/335) to 67% (157/234) following CDS (p < 0.001). Interviews confirmed that generalist providers want help in appropriately ordering advanced imaging. CONCLUSION: Partnering with medical providers to co-design CDS reduced barriers and prompted appropriate transition to US from MRI for shoulder pain diagnosis, promoting evidence-based practice. This approach can inform the development and implementation of other forms of CDS. Georg Thieme Verlag KG Stuttgart · New York.
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