Appropriateness Criteria Research Articles

Appropriate Use of Inpatient Erythropoiesis Stimulating Agents

Background: Anemia is a significant global public health issue, and it is associated with lethargy, weakness, tiredness, and shortness of breath. Erythropoietin stimulating agents (ESAs) are recombinant / synthetic erythropoietin and can increase hemoglobin (Hb) levels. There are increased risks of cardiovascular events and death associated with the use of ESAs when raising Hb levels above 12 g/dL. Methods: This was a baseline safety assessment via a retrospective chart review, including patients who recently received an inpatient dose of an ESA within The Mount Sinai Hospital (MSH) from November 1, 2015 (after MSH ESA guideline revision) to August 1, 2023. All adult patients who received an ESA (originator or biosimilar products) during hospitalization were included. Data collection was in reverse chronology, and only the most recent dose administered to each unique patient was collected. Results: If an ESA dose was dispensed when the Hb was less than the upper limit of the target Hb for the specific indication, this was considered appropriate use. Based on data from June 15 to August 1, 2023 (~47 days of inpatient utilization), for the primary outcome, 169 out of 171 doses (98.8%) met the predefined criteria for appropriateness. One dose was dispensed when the Hb was 11.1 g/dL to a patient on renal replacement therapy, and one dose was dispensed when the Hb was 13.8 g/dL to a surgical patient who refused blood transfusions. Among secondary outcomes of interest, there was a difference in blood transfusions administered in critical versus non-critical care settings. Conclusion: Inpatient use of ESA at MSH was appropriate when looking at Hb targets. There are currently no formal order sets, service-line restrictions, or additional chairperson approvals needed at MSH. Despite this, there remained significant adherence to prevailing Hb targets, reflecting provider and pharmacy teams' knowledge and awareness of contemporary best practices.

A decision support system to increase the compliance of diagnostic imaging examinations with imaging guidelines: focused on cerebrovascular diseases.

Diagnostic imaging decision support (DI-DS) system has emerged as an innovative evidence-based solution to decrease inappropriate diagnostic imaging. The aim of the present study was to design and evaluate a DI-DS system for cerebrovascular diseases. The present study was an applied piece of research. First, the conceptual model of the DI-DS system was designed based on its functional and non-functional requirements. Afterwards, to create the system's knowledge base, cerebrovascular diseases diagnostic imaging algorithms were extracted from the American College of Radiology Appropriateness Criteria (ACR-AC). Subsequently, the system was developed based on the obtained conceptual model and the extracted algorithms. The software was programmed by means of the C#. After debugging the system, it was evaluated regarding its performance and also the users' satisfaction with it. Assessing the users' satisfaction with the system demonstrated that all the evaluation criteria met the acceptable threshold (85 %). The retrospective evaluation of the system's performance indicated that from among 76 imaging examinations, which had previously been performed for 30 patients, 12 (15.78 %) were deemed inappropriate. And, the system accurately identified all the inappropriate physicians' decisions. The concurrent evaluation of the system's performance indicated that the system's recommendations helped the physicians remove 100 % (4 out of 4) of the inappropriate and 40 % (2 out of 5) of the inconclusive imaging examinations from their initial choices. A DI-DS system could increase the compliance of the physicians' decisions with diagnostic imaging guidelines, and also improve treatment outcomes through correct diagnosis and providing timely care.

A Comparative Evaluation of Large Language Model Utility in Neuroimaging Clinical Decision Support.

Imaging utilization has increased dramatically in recent years, and at least some of these studies are not appropriate for the clinical scenario. The development of large language models (LLMs) may address this issue by providing a more accessible reference resource for ordering providers, but their relative performance is currently understudied. Evaluate and compare the relative appropriateness and usefulness of imaging recommendations generated by eight publicly available models in response to neuroradiology clinical scenarios. Twenty-four common neuroradiology clinical scenarios were selected which often yield suboptimal imaging utilization. Questions were crafted to assess the ability of LLMs to provide accurate and actionable advice. The LLMs were assessed in August 2023 using natural-language 1-2 sentence queries requesting advice about optimal image ordering given certain clinical parameters. Eight of the most well-known LLMs were chosen for evaluation: ChatGPT, GPT4, Bard (Versions 1 and 2), Bing Chat, Llama 2, Perplexity, and Claude. The models were graded by three fellowship-trained neuroradiologists on whether their advice was "optimal" or "not optimal" according to the ACR Appropriateness Criteria or the New Orleans Head CT Criteria. The raters also ranked the models based on the appropriateness, helpfulness, concision, and source-citations in their response. The models varied in their ability to deliver an "optimal" recommendation based on these scenarios as follows: ChatGPT (20/24), GPT4 (23/24), Bard 1 (13/24), Bard 2 (14/24), Bing Chat (14/24), Llama (5/24), Perplexity (19/24), and Claude (19/24). The median ranks of the LLMs were as follows: ChatGPT (3), GPT4 (1.5), Bard 1 (4.5), Bard 2 (5), Bing Chat (6), Llama (7.5), Perplexity (4), and Claude (3). Characteristic errors are described and discussed. GPT-4, ChatGPT, and Claude generally outperformed Bard, Bing Chat, and Llama 2. This study evaluates the performance of a greater variety of publicly available LLMs in settings that more closely mimic real-world use cases as well as discussing the practical challenges of doing so. This is the first study to evaluate and compare a wide range of publicly available LLMs to determine appropriateness of their neuroradiology imaging recommendations.

An Analysis of the English Textbook “Bright” Used for the Ninth Grade of MTSN 6 Agam

This research analyzed the English textbook "Bright" used for ninth grade students at MTsN 6 Agam. This study aims to assess how well the textbook is in accordance with the appropriateness of content based on the 2013 curriculum from the National Education Standardization Agency (BSNP). The method used in this research is qualitative content analysis to assess the appropriateness of the English textbook "Bright" used for ninth-grade students at MTsN 6 Agam. Especially focused on comprehensively analyzing the content of the textbook based on standards set by the Education National Standardization Board (BSNP). Data were gathered from the entirety of the "Bright" textbook, supplemented by documentation notes with an English teacher. The researcher served as the primary instrument, ensuring methodological rigor and transparency throughout the study. The analysis involved coding and reduction techniques to identify patterns and themes related to content appropriateness. Findings from the research aimed to provide insights for English teachers, students, textbook writers, and future researchers. The study contributed to the understanding of how well the "Bright" textbook aligned with educational standards and offered recommendations for improving English teaching materials. The research findings indicated that the English textbook "Bright" used at MTsN 6 Agam aligned well with the objectives and curriculum set by BSNP. Data analysis from documentation notes with teachers showed that the textbook generally met the criteria for content appropriateness. While there were minor shortcomings in its ability to supplement other subjects, the "Bright" textbook was deemed relevant, accurate, and inspiring for students. Overall, the textbook portrayed national themes that strengthened pride and appreciation for the nation's culture. This conclusion provides valuable insights for curriculum developers, affirming the suitability of the "Bright" textbook for teaching English at MTsN 6 Agam and advocating for continuous improvement in English education in Indonesia.

Patient-Physician Racial Concordance Increases Likelihood of Total Knee Arthroplasty Recommendation

BackgroundMinority patients have been shown to underutilize total knee arthroplasty (TKA) compared to non-Hispanic White (NHW) patients. Specific drivers of this underutilization have not been identified. We sought to determine if racial concordance between patient and physician is associated with the surgeon’s likelihood to recommend TKA. MethodsThere were 402 patients who presented for management of knee osteoarthritis to the clinics of four fellowship-trained arthroplasty surgeons at a single academic center. We recorded the patient and surgeon’s race/ethnicity as well as the physician-recommended treatment. Patient clinical data was input to the American Academy of Orthopaedic Surgeons (AAOS) Appropriate Use Criteria (AUC) website to generate a guideline-based procedure recommendation for TKA. Patients who were not appropriate for TKA based on AAOS guidelines were excluded from analyses to minimize selection bias. Chi-square and multivariable regression analyses evaluated the relationship between TKA recommendation by surgeon and physician-patient racial concordance. ResultsPatients in this cohort who experienced racial concordance with their surgeon were more likely to receive a recommendation for TKA than patients who experienced racial discordance. Black patients who received racially concordant care were more likely to be offered surgery compared to those who received racially discordant care (55.1 versus 23.0%, P = 0.0001). The same effect was not observed in NHW patients, where there was no significant difference in surgery offers between patients who received concordant versus discordant care (P = 0.18). Multivariable analyses were also conducted to test factors associated with TKA recommendations. Racial concordance was found to be an independent predictor of TKA recommendation while controlling for patient factors and individual differences by the surgeon. ConclusionPatients receiving racially concordant care in this cohort were more likely to be offered TKA, and the effect of racial concordance on TKA recommendation was greater among Black patients. These findings provide insight into possible drivers of TKA underutilization among minority groups.

Appropriateness Criteria for Radiation Therapy in the Setting of Presumed Early-Stage Lung Cancer

Low-dose chest computed tomography imaging for lung cancer screening is revealing increasing numbers of radiographic early-stage lung cancers. This topic discussion describes when a clinical scenario merits radiation therapy without a histologic diagnosis, with an emphasis on pragmatic algorithms in settings without readily available advanced biopsy techniques.

Clinical imaging guidelines: current status and challenges

Background: Advances in medical technology and health insurance coverage policies have significantly promoted radiological examinations in Korea. In 2019, the number of computed tomography examinations performed in Korea was approximately 1.5-times higher than the Organisation for Economic Co-operation and Development average. This surge in radiological examinations has raised concerns regarding inappropriate imaging practices that may lead to unnecessary radiation exposure and increased healthcare cost.Current Concepts: Two fundamental principles guide the radiation safety practices in medicine: Optimization and justification. Optimization, represented by the “As Low As Reasonably Achievable” principle, minimizes the radiation dose while maintaining the diagnostic quality. Justification ensures that the benefits of radiological procedures outweigh their potential risks. Evidence-based clinical imaging guidelines, such as the UK iRefer guidelines and USA American College of Radiology Appropriateness Criteria, have been internationally proposed to implement these principles. In Korea, collaborative efforts between the National Evidence-based Healthcare Collaborating Agency and Korean Society of Radiology have led to the development of Korean evidence-based clinical imaging guidelines.Discussion and Conclusion: Implementation of evidence-based imaging guidelines is crucial to reduce unnecessary radiation exposure and optimize resource utilization. However, various challenges, including the adaptation of the guidelines to individual patient needs and successful integration of rapidly advancing medical technologies, remain. Continuous updates, professional education, and system-wide support are essential to ensure the effective implementation of these guidelines. Future studies should focus on enhancing the precision and applicability of these guidelines in clinical practice to improve the patient safety and healthcare efficiency.

ESR Essentials: staging and restaging with FDG-PET/CT in oncology-practice recommendations by the European Society for Hybrid, Molecular and Translational Imaging.

Positron emission tomography (PET) stands as the paramount clinical molecular imaging modality, especially in oncology. Unlike conventional anatomical-morphological imaging methods such as computed tomography (CT) and magnetic resonance imaging (MRI), PET provides detailed visualizations of internal activity at the molecular and cellular levels. 18-fluorine-fluorodeoxyglucose ([18F]FDG)-PET combined with contrast-enhanced CT (ceCT) significantly improves the detection of various cancers. Appropriate patient selection is crucial, and physicians should carefully assess the appropriateness of [18F]FDG-PET/CT based on specific clinical criteria and evidence. Due to its high diagnostic accuracy, [18F]FDG-PET/CT is indispensable for evaluating the extent of disease, staging, and restaging known malignancies, and assessing the response to therapy. PET/CT imaging offers significant advantages in patient management, particularly by identifying occult metastases that might otherwise go undetected. This can help prevent unnecessary surgeries, allowing many patients to be redirected to systemic chemotherapy instead. However, it is important to note that the gold standard for surgical planning remains CT and/or MRI, depending on the body region. These imaging modalities, with or without associated angiography, provide superior contrast and spatial resolution, essential for detailed surgical preparation and planning. [18F]FDG-PET/CT has a central role in the precise and early diagnosis of cancer, contributing significantly to personalized treatment plans. However, it has limitations, including non-tumor-specific uptake and the potential to inaccurately capture the metabolic activity of certain tumor types due to low uptake in some well-differentiated tumor cell lines. Therefore, it should be utilized in clinical scenarios where it offers crucial diagnostic insights not readily available with other imaging modalities. KEY POINTS: Use [18F]FDG-PET/CT selectively based on clinical appropriateness criteria and existing evidence to optimize resource utilization and minimize patient exposure. Employ [18F]FDG-PET/CT in treatment planning and monitoring, particularly for assessing chemotherapy or radiotherapy response in FDG-avid lymphoma and solid tumors. When available, [18F]FDG-PET/CT can be integrated with other diagnostic tools, such as MRI, to enhance overall diagnostic accuracy.

Routine Use of [64Cu]Cu-DOTATATE PET/CT in a Neuroendocrine Tumor Center: Referral Patterns and Image Results of 2,249 Consecutive Scans.

The role of somatostatin receptor (SSTR) PET/CT, using 68Ga-based tracers or [64Cu]Cu-DOTATATE (64Cu-DOTATATE), in the management of patients with neuroendocrine neoplasm (NEN) is guided by appropriate use criteria (AUC). In this study, we performed systematic analyses of referral patterns and image findings of routine 64Cu-DOTATATE PET/CT scans to support AUC development. Methods: We included all clinical routine 64Cu-DOTATATE PET/CT scans performed between April 10, 2018 (start of clinical use), and May 2, 2022, at Copenhagen University Hospital-Rigshospitalet. We reviewed the referral text and image report of each scan and classified the indication according to clinical scenarios as listed in the AUC. Results: In total, 1,290 patients underwent 2,249 64Cu-DOTATATE PET/CT scans. Monitoring of patients with NEN seen both on conventional imaging and on SSTR PET without clinical evidence of progression was the most common indication (defined as "may be appropriate" in the AUC) and accounted for 703 (31.3%) scans. Initial staging after NEN diagnosis ("appropriate" in the AUC) and restaging after curative-intent surgery ("may be appropriate" in the AUC) accounted for 221 (9.8%) and 241 (10.7%) scans, respectively. Selection of patients eligible for peptide receptor radionuclide therapy ("appropriate" in the AUC) and restaging after peptide receptor radionuclide therapy completion ("appropriate" in the AUC) accounted for 95 (4.2%) and 115 (5.1%) scans, respectively. The number of scans performed for indications not defined in the AUC was 371 (16.5%). Image result analysis revealed no disease in 669 scans (29.7%), stable disease in 582 (25.9%), and progression in 461 (20.5%). In 99 of the 461 (21.5%) scans, progression was detected on PET but not on CT. Conclusion: Our study provided real-life data that may contribute to support development of 64Cu-DOTATATE/SSTR PET/CT guidelines including AUC. Some scenarios listed as "may be appropriate" in the current AUC were frequent in our data. Monitoring of patients with NEN without clinical evidence of progression was the most frequent indication for 64Cu-DOTATATE PET/CT, in which disease progression was detected in more than one third, and a large proportion was visible by PET only. We therefore conclude that this scenario could potentially be classified as appropriate.

Projected Annual Lecanemab Treatment Eligibility in an Irish Regional Specialist Memory Clinic.

The advent of Disease Modifying Therapies (DMTs) for the treatment of Alzheimer's Disease (AD) has the potential to transform the lives of those with early AD. Timely identification of eligible patients is needed to ensure treatments are delivered during a narrow window of therapeutic opportunity. Appropriate clinical service design will hinge on improved understanding of future demands, thus there is a pressing need to investigate patient eligibility in real world clinical cohorts. The primary aim of this study is to assess the eligibility by appropriate use criteria (AUC) for lecanemab therapy in a real-world, undifferentiated clinical patient cohort attending a Regional Specialist Memory Clinic (RSMC), with the secondary aims of determining the proportion of patients with biomarker positive Alzheimer's Disease (AD) who would be eligible for lecanemab therapy by AUC. Clinical trial eligibility criteria were also applied to both groups and discrepancies that exist between eligibility rates explored. A retrospective cohort study of all new patients attending a RSMC from 1st January 2022 to 31st December 2022 was conducted. Data collected included demographic details, outcomes of diagnostic assessments and comorbidities. MRI images, where indicated, were reviewed. Amyloid positivity was defined as either Amyloid and Tau positive (A+T+) or Amyloid positive with a positive P-Tau/Ab42 ratio on cerebrospinal fluid (CSF) testing. Appropriate use criteria (AUC) and clinical trial criteria for lecanemab were applied. Proportion of eligible patients was calculated. Eleven (5.9%) of 188 new patient attenders were eligible (average age 66.7years [SD 8.9], 63.6% female) by AUC, with 26.2% of patients with biomarker positive Alzheimer's Disease eligible for lecanemab therapy. The most common reason for exclusion was a lack of biomarker confirmation of AD pathology followed by cognitive ineligibility (based on defined cognitive testing cut-offs) at the time of referral and/or initial assessment. Only 40.4% of patients had CSF testing for AD biomarkers while almost 20% of the patients with biomarker positive AD were excluded due to lack of a screening MRI in the previous 12months. In this study, the potential eligibility rate by AUC of the entire patient cohort (5.9%) was limited by the small proportion of patients who had CSF testing for AD biomarkers. So while disease-modification with Lecanemab is a welcome therapeutic advance, although only a small proportion of people currently attending specialist services will be eligible. Successful delivery of DMTs will require significant resource allocation and optimisation of referral pathways to facilitate early identification of potentially eligible patients.

Summary: Appropriate Use Criteria for the Use of Nuclear Medicine in Fever of Unknown Origin.

The diagnostic work-up of patients with fever of unknown origin (FUO) begins with a thorough history and physical examination, complete blood count with differential, chest x-ray, urinalysis and culture, electrolyte panel, liver enzymes, erythrocyte sedimentation rate, and C-reactive protein level. Additional imaging procedures, including nuclear medicine tests, are generally used as second-line procedures, with 18F-FDG PET and PET/CT assuming increasingly important roles in the diagnostic work-up. The Society of Nuclear Medicine and Molecular Imaging, the Infectious Diseases Society of America, and the American College of Nuclear Medicine convened an autonomous expert work group to comprehensively review the published literature for nuclear imaging in adults and children with FUO and establish appropriate use criteria (AUC). This process was performed in accordance with the Protecting Access to Medicare Act of 2014, which requires that all referring physicians consult AUC by using a clinical decision support mechanism before ordering advanced diagnostic imaging services. The complete findings and discussions of the work group were published on January 8, 2023, and are available at https://www.snmmi.org/ClinicalPractice/content.aspx?ItemNumber=15666 The AUC in the final document are intended to assist referring health care providers in appropriate use of nuclear medicine imaging procedures in patients with FUO. The work group noted limitations in the current literature on nuclear medicine imaging for FUO, with the need for well-designed prospective multicenter investigations. Consensus findings from published data and expert opinions were used to create recommendations in common clinical scenarios for adults and children. Included in the complete document is a discussion of inflammation of unknown origin (IUO), a recently described entity. In view of the fact that the criteria for FUO and IUO are similar (except for fever > 38.3°C [100.9°F]) and that the most common etiologies of these 2 entities are similar, it is the expert opinion of the work group that the recommendations for nuclear medicine imaging of FUO are also applicable to IUO. These recommendations are included in the full guidance document. This summary reviews rationale, methodology, and main findings and refers the reader to the complete AUC document.

Enhancing chatbot performance for imaging recommendations: Leveraging GPT-4 and context-awareness for trustworthy clinical guidance

PurposeTo investigate if GPT-4 improves the accuracy, consistency, and trustworthiness of a context-aware chatbot to provide personalized imaging recommendations from American College of Radiology (ACR) appropriateness criteria documents using semantic similarity processing: In addition, we sought to enable auditability of the output by revealing the information source the decision relies on. Material and MethodsWe refined an existing chatbot that incorporated specialized knowledge of the ACR guidelines by upgrading GPT-3.5-Turbo to its successor GPT-4 by OpenAI, using the latest version of LlamaIndex, and improving the prompting strategy. This chatbot was compared to the previous version, generic GPT-3.5-Turbo and GPT-4, and general radiologists regarding the performance in applying the ACR appropriateness guidelines. ResultsThe refined context-aware chatbot performed superior to the previous version using GPT-3.5-Turbo, generic chatbots GPT-3.5-Turbo and GPT-4, and general radiologists in providing “usually or may be appropriate” recommendations according to the ACR guidelines (all p < 0.001). It also outperformed GPT-3.5-Turbo and general radiologists in respect to “usually appropriate” recommendations (both p < 0.001). Moreover, the consistency in correct answers was higher with 78 % consistent correct “usually appropriate” answers and 94 % for “usually or may be appropriate” recommendations. In all cases, the same source documents were chosen, ensuring transparency. ConclusionOur study demonstrates the significance of context awareness in ensuring the use of appropriate knowledge and proposes a strategy to enhance trust in chatbot-based outputs to provide transparency. The improvements in accuracy, consistency, and source transparency address trust issues and enhance the clinical decision support process.Abbreviations: ACR, American College of Radiology; accGPT, appropriateness criteria context aware GPT; accGPT-4, appropriateness criteria context aware GPT using GPT-4; GPT, generative pre-trained transformer; LLM, Large Language Model.

The results of 3 years registry on myocardial perfusion imaging, do we use the appropriateness criteria as expected?

The results of 3 years registry on myocardial perfusion imaging, do we use the appropriateness criteria as expected?

Framework for Successful Integration of Health Services Research Into a Breast Imaging Career.

Health services research (HSR)is a multidisciplinary field of inquiry that examines how health care is structured, providing valuable data on health care outcomes and delivery. Over the past few decades, a shift in the U.S. health care system toward value-based care has placed a priority on health services topics. Health services research has been central to the evolution of breast imaging over this period, with increased emphasis placed on the following: (1) design of appropriate-use criteria for imaging services; (2) determination of cost-effectiveness of imaging protocols and screening regimens guiding policy; and (3) evaluation of policy related to reimbursement for diagnostic imaging and image-guided procedures. Examples of HSR topics that can be applied directly to breast imaging include evaluation of health care availability and accessibility, analysis of health care use patterns, exploration of patient preferences, assessment of technological innovation, development and implementation of clinical practice guidelines and screening strategies, and examination of health care organization and delivery models. Breast imaging radiologists who perform HSR are uniquely positioned to advocate for patients, to promote transformative health care interventions, and to influence policy changes and public health initiatives in breast imaging through analysis of health care data and translation of their research findings. In this Training and Professional Development article, we aim to provide practical approaches to explore interest in HSR and to describe a framework for successful integration of HSR into a breast imaging career.

Appropriate Use Criteria (AUC) for the Management of Non-Small Cell Lung Cancer in a Central/Ultra-Central Location: Guidelines from the American Radium Society

IntroductionDefinitive radiation therapy is considered standard therapy for medically inoperable early-stage NSCLC. Nevertheless, for patients with tumors located near structures such as the proximal tracheobronchial tree, esophagus, heart, spinal cord, and brachial plexus, the optimal management regimen is controversial. The objective was to develop expert multidisciplinary consensus guidelines on managing medically inoperable NSCLC located in a central or ultracentral location relative to critical organs at risk. MethodsCase variants regarding centrally and ultracentrally located lung tumors were developed by the 15-member multidisciplinary American Radium Society (ARS) Thoracic Appropriate Use Criteria (AUC) expert panel. A comprehensive review of the English medical literature was performed from January 1 1946 to December 31 2023 to inform consensus guidelines. Modified Delphi methods were used by the panel to evaluate the variants and procedures, with at least three rating points from median defining agreement/consensus. The guideline was then approved by the ARS Executive Committee and released for public comment per established ARS procedures. ResultsThe Thoracic ARS AUC Panel identified 90 relevant references and obtained consensus in all variants. Radiotherapy alone was considered appropriate, with additional immunotherapy to be considered primarily in the clinical trial setting. Hypofractionated radiotherapy in eight to 18 fractions was considered appropriate for ultracentral lesions near the proximal tracheobronchial tree, upper trachea, and esophagus. For other ultracentral lesions near the heart, great vessels, brachial plexus, and spine, or for non-ultracentral but still central lesions, five-fraction stereotactic body radiation therapy was also considered an appropriate option. Intensity-modulated radiotherapy was considered appropriate and three-dimensional–conformal radiotherapy inappropriate for all variants. Other treatment planning techniques to decrease the risk of overdosing critical organs at risk were also considered. ConclusionsThe ARS Thoracic AUC panel has developed multidisciplinary consensus guidelines for various presentations of stage I NSCLC in a central or ultracentral location.

Clinical decision-making process and distributive justice: The mediating role of economic analysis. Empirical evidence from Italy.

The COVID-19 pandemic has not only tested the resilience of public health systems but also underscored the criticality of allocative choices on health resources. These choices, however, are not confined to health emergencies but are integral to public health decisions, which inherently grapple with limited resources. In this context, physicians play a pivotal role as the architects of clinical actions in various scenarios. Therefore, doctors are called upon to make their decisions by considering not only the criteria of clinical appropriateness but also the ethical aspects linked, in particular, to the principle of justice. Indeed, the assessment of the effectiveness of a treatment for a particular patient must be balanced against criteria of equity and justice for the whole. To be fully applied, the principle of justice presupposes the use of economic evaluation techniques designed to drive the organisation decisions by effectiveness and efficiency. The present paper aims to empirically analyse whether and to what extent economic evaluation is known and used by doctors in healthcare decision-making and, therefore, what the most widespread approaches are used in such processes. In particular, this paper intends to present the results of an empirical study on a sample of doctors registered with the Order of Physicians in Lombardy (Italy), one of the areas most affected by the COVID-19 pandemic. The research reveals a particular awareness of the criticality of allocation issues accompanied by a lack of knowledge of the economic evaluation techniques or, more broadly, by an almost total disuse of financial criteria. The main reasons are doctors' need for more knowledge of these tools and insufficient availability of economic information at the country system level. In the conclusion, we propose some suggestions to facilitate the transition to more current decision-making models consistent with the characteristics of more advanced national healthcare contexts.

Value-Based Radiology in Canada: Reducing Low-Value Care and Improving System Efficiency.

Radiology departments are increasingly tasked with managing growing demands on services including long waitlists for scanning and interventional procedures, human health resource shortages, equipment needs, and challenges incorporating advanced imaging solutions. The burden of system inefficiencies and the overuse of "low-value" imaging causes downstream impact on patients at the individual level, the economy and healthcare system at the societal level, and planetary health at an overarching level. Low value imaging includes those performed for an inappropriate clinical indication, with little to no value to the management of the patient, and resulting in healthcare resource waste; it is estimated that up to a quarter of advanced imaging studies in Canada meet this criterion. Strategies to reduce low-value imaging include the development and use of referral guidelines, use of appropriateness criteria, optimization of existing protocols, and integration of clinical decision support tools into the ordering provider's workflow. Additional means of optimizing system efficiency such as centralized intake models, improved access to electronic medical records and outside imaging, enhanced communication with patients and referrers, and the utilization of artificial intelligence will further increase the value of radiology provided to patients and care providers.

Determining Appropriateness of Total Joint Arthroplasty for Hip and Knee Osteoarthritis: A Patient-Centred Conceptual Model.

Total joint arthroplasty (TJA) for osteoarthritis is one of several treatment options with benefits and harms that patients value differently. However, the process for determining TJA appropriateness does not sufficiently acknowledge patient perspectives. The aim of this paper is to propose an evidence-informed patient-centred conceptual model for elective TJA appropriateness for hip and knee osteoarthritis. Our interprofessional team developed a conceptual model for determining the appropriateness of adults considering elective TJA. The model was informed by a review of the evidence, a qualitative study we conducted with adults who underwent TJA for osteoarthritis to determine barriers and facilitators to the use of appropriateness criteria, and the research and clinical experience of team members. Appropriateness is providing health services (e.g., TJA) with net benefits to the right patient at the right time. The proposed Patient-centred Elective TJA Appropriateness Conceptual Model involves three key steps. First, assess adults with osteoarthritis to determine eligibility for TJA. Second, acknowledge the patient's informed preferences including their expectations and goals. Third, explore and support their mental and physical readiness for TJA. Given that osteoarthritis is a chronic condition, these steps can be revisited over time with patients. Our proposed conceptual model reconceptualises the appropriateness of TJA to be more patient-centred. Hence, this approach has the potential to be a more inclusive approach and ensure patients undergoing TJA are eligible, ready to proceed, and achieve what matters most to them. Future research is needed to test and validate the model.

Generative Artificial Intelligence Platform for Automating Social Media Posts From Urology Journal Articles: A Cross-Sectional Study and Randomized Assessment.

This cross-sectional study assessed a generative artificial intelligence platform to automate the creation of accurate, appropriate, and compelling social media (SoMe) posts from urological journal articles. One hundred SoMe posts from the top 3 journals in urology X (formerly Twitter) profiles were collected from August 2022 to October 2023. A freeware generative pre-trained transformer (GPT) tool was developed to autogenerate SoMe posts, which included title summarization, key findings, pertinent emojis, hashtags, and digital object identifier links to the article. Three physicians independently evaluated GPT-generated posts for achieving tetrafecta of accuracy and appropriateness criteria. Fifteen scenarios were created from 5 randomly selected posts from each journal. Each scenario contained both the original and the GPT-generated post for the same article. Five questions were formulated to investigate the posts' likability, shareability, engagement, understandability, and comprehensiveness. The paired posts were then randomized and presented to blinded academic authors and general public through Amazon Mechanical Turk (AMT) responders for preference evaluation. Median time for post autogeneration was 10.2 seconds (interquartile range 8.5-12.5). Of the 150 rated GPT-generated posts, 115 (76.6%) met the correctness tetrafecta: 144 (96%) accurately summarized the title, 147 (98%) accurately presented the articles' main findings, 131 (87.3%) appropriately used emojis, and 138 (92%) appropriately used hashtags. A total of 258 academic urologists and 493 AMT responders answered the surveys, wherein the GPT-generated posts consistently outperformed the original journals' posts for both academicians and AMT responders (P < .05). Generative artificial intelligence can automate the creation of SoMe posts from urology journal abstracts that are both accurate and preferable by the academic community and general public.

Return to Play to Pre-Injury Level Following Anterior Cruciate Ligament Injury.

The American Academy of Orthopaedic Surgeons has developed Appropriate Use Criteria (AUC) for the Return to Play to Pre-Injury Level Following Anterior Cruciate Ligament (ACL) Injury. Evidence-based information, in conjunction with the clinical expertise of physicians, was used to develop the criteria to determine the appropriateness of return to play to pre-injury level after an ACL injury. The AUC for the Return to Play to Pre-Injury Level Following ACL Injury were derived by identifying clinical indications typical of patients wishing to return to play after an ACL injury. These indications were most often clinically significant parameters, including symptoms and diagnostic findings. In addition, "patient-level variables" (eg, activity level or demographics) can be considered. A total of 576 patient scenarios and 3 procedure recommendations were developed by the writing panel, a group of clinicians who are specialists in this AUC topic. Next, a separate multidisciplinary rating panel (made up of specialists and nonspecialists) rated the appropriateness of treatment of each patient scenario using a 9-point scale to designate a treatment as "appropriate" (median rating, 7 to 9), "may be appropriate" (median rating, 4 to 6), or "rarely appropriate" (median rating, 1 to 3).