Inappropriate Imaging Research Articles

S0060 Characterization of Diagnostic Patterns of Chronic Pancreatitis Within a Large Health Management Organization

INTRODUCTION: Chronic pancreatitis (CP) is an irreversible and progressive fibro-inflammatory disease of the pancreas causing pain and/or loss of exocrine/endocrine function. It is typically diagnosed with a combination of clinical and imaging criteria including atrophy, ductal dilatation, multiple parenchymal and intraductal calcifications. One of the main challenges in making a diagnosis of CP is the lack of universally agreed gold standard diagnostic criteria. To better understand the diagnostic patterns of this chronic, often disabling illness, we performed a retrospective analysis of 215 patients with CP treated at 9 hospitals of MedStar Health. METHODS: Using ICD 10 codes, we retrieved charts of patients presenting to acute care sites within the MedStar Health system between March 2015 and June 2019. These included emergency room visits and inpatient admissions. The following 7 variables pertaining to diagnosis of CP were manually extracted: 1. How was CP diagnosed? 2. Who made the diagnosis? 3. Demographics including sex, age 4. Length of stay 5. Was a GI consult obtained? 6. Location of care (Tertiary care vs. Non-tertiary care hospital) 7. Presumed etiology. Statistical analysis was performed by ANOVA analysis using GraphPad PRISM for Mac OS (Version 8). RESULTS: We found 215 encounters eligible for retrospective chart review. Average length of stay (in days) was longest when a gastroenterologist made the diagnosis (7.48), followed by the internist (2.02), or when a prior diagnosis was known (1.35). When a gastroenterologist was consulted, the chance of making an accurate diagnosis of CP was highest (53%) vs. when they weren’t consulted (20%). Most patients received a diagnosis of CP at a non-tertiary care center. The specialist making the diagnosis significantly changed the probability of accurate diagnosis (P < 0.0001) by clinical and imaging criteria. CONCLUSION: Most patients with CP are diagnosed at non-tertiary centers within the MedStar Health System. Most of these patients are given a diagnosis based on a prior diagnosis of CP. Accuracy of diagnosis significantly improved when a gastroenterologist was consulted. Non-tertiary centers most commonly made a diagnosis of CP based on inappropriate clinical and imaging criteria. These represent avenues for targeted interventions to standardize the diagnosis of CP across a large health management organization.Table 1.: TablesFigure 1.: Retrospective study design.Figure 2.: Graphs.

A Clinical Reminder Order Check Intervention to Improve Guideline-concordant Imaging Practices for Men With Prostate Cancer: A Pilot Study

ObjectiveTo understand how to potentially improve inappropriate prostate cancer imaging rates we used National Comprehensive Cancer Network's guidelines to design and implement a Clinical Reminder Order Check (CROC) that alerts ordering providers of potentially inappropriate imaging orders in real-time based on patient features of men diagnosed with low-risk prostate cancer. MethodsWe implemented the CROC at VA New York Harbor Healthcare System from April 2, 2015 to November 15, 2017. We then used VA administrative claims from the VA's Corporate Data Warehouse to analyze imaging rates among men with low-risk prostate cancer at VA New York Harbor Healthcare System before and after CROC implementation. We also collected and cataloged provider responses in response to overriding the CROC in qualitative analysis. Results Fifty seven percent(117/205) of Veterans before CROC installation and 73% (61/83) of Veterans post-intervention with low-risk prostate cancer received guideline-concordant care. ConclusionWhile the decrease in inappropriate imaging during our study window was almost certainly due to many factors, a Computerized Patient Record System-based CROC intervention is likely associated with at least moderate improvement in guideline-concordant imaging practices for Veterans with low-risk prostate cancer.

Inappropriate imaging for management of cryptorchidism: Has the choosing Wisely® recommendation reduced occurrence?

Cryptorchidism is one of the most common referral diagnoses to pediatric urologists. It is well recognized in the urologic community that diagnostic imaging is unnecessary in the work-up of these patients, and the Choosing Wisely® recommendation (CWR) on this subject re-emphasized this in 2013. Many boys, however, still are sent for testing prior to referral. The purpose of our study was dual in nature. We pursued, first, to identify any factors that make patients more likely to be sent for imaging prior to referral, and second, to determine if rates of diagnostic imaging for cryptorchidism decreased after the release of the CWR. We included all boys who had surgery for cryptorchidism by Urology at our institution between January 2007 and August 2018. Demographics and clinical data were collected including height, weight, race, insurance type, pre-referral imaging status, testis location at time of surgery, and distance from our medical center. Chi-squared analysis was utilized to compare imaging use before and after CWR. Influence of other clinical and socioeconomic factors on imaging utilization was also evaluated using chi-squared and two-sample t tests. Those found to be significant at the 0.2 level were analyzed in multivariate logistic regression. Significance was set at 0.05. 1010 boys were available for analysis. Of the 256 patients (25.3%) with pre-referral studies, 7 had axial exams (CT or MRI), and the remainder underwent ultrasounds. Children living closer to the medical center were more likely to undergo imaging (p<0.01) as were boys with testes not found in the inguinal canal at the time of surgery (p=0.007). Race, insurance status, age at first visit, and increased body mass index were not found to be influential. Similarly, the release of CWR had no impact on the imaging usage (p=0.61). Utilization of pre-referral diagnostic imaging remains inappropriately high despite evidence demonstrating the ineffectiveness of the studies. Boys living closer to the medical center and those with non-inguinal testes are more likely to undergo these studies, but no other factors were found to have an effect. Further, the Choosing Wisely® recommendation has not improved rates of inappropriate imaging use in boys with cryptorchidism in our referral area. Our findings indicate the need for increased efforts to disseminate this evidence-based guideline more widely to primary care providers in order to promote more cost-effective and timely care of boys with undescended testes.

4192 Decreasing Inappropriate STAT Image Ordering

OBJECTIVES/GOALS: Currently physicians are able to order CT Chest/Abd/Pelvis images as STAT or Routine. STAT images denote an emergency and are done immediately. We aim to determine the percentage of CT images that are inappropriately ordered as STAT, determine physician image ordering habits, and develop targeted interventions to encourage appropriate STAT image ordering. METHODS/STUDY POPULATION: A fishbone diagram helped reveal possible causes of inappropriate STAT image ordering. Based on the fishbone diagram, a survey was created to assess CT image ordering habits amongst radiology and internal medicine residents and attending physicians. All CT Chest/Abd/Pelvis images ordered over a 3 month period of time (July-Oct 2017) was obtained. The dataset included whether the image was ordered Stat vs Routine, time of image order, physician name and location, and reason for the imaging study.The STAT images were evaluated based on the explanation provided in the CT image order. Currently 2 radiology residents, 2 internal medicine residents, and 2 internal medicine hospitalists are evaluating all STAT CT images to determine appropriateness and how long they are willing to wait for the image to result in a read. RESULTS/ANTICIPATED RESULTS: Analysis of all CT Chest/Abd/Pelvis imaging orders revealed that 51% (1710/3345) of them were ordered as STAT. The preliminary analysis of 227 STAT images showed that 6% were inappropriate. We anticipate results of our survey to show differences in how long a STAT vs Routine image orders should take amongst Radiology and Internal Medicine clinicians. We also anticipate our survey to show differences in factors that warrant STAT imaging amongst the different medical fields. We anticipate that the clinician manual evaluation of all STAT CT image will reveal a large percentage of imaging orders to be inappropriate. All STAT imaging that were flagged as inappropriate will be characterized by the department who ordered the image and the reason provided for the imaging to assess for common themes. DISCUSSION/SIGNIFICANCE OF IMPACT: STAT images are the new routine with more images ordered STAT than Routine. Inappropriate STAT imaging results in truly urgent patients not getting the medical care they need. Many images ordered stat could potentially be switched to routine. By evaluating why clinicians are ordering STAT CT image inappropriately, we will be able to develop targeted interventions to decrease inappropriate STAT CT imaging.

The clinical impact of ASCO “choosing wisely” recommendations on staging imaging for early stage breast cancers: An interrupted time-series analysis utilizing SEER-Medicare data.

2078 Background: The “Choosing Wisely” (CW) list, released by the American Society for Clinical Oncology (ASCO), highlights low-value procedures. In 2012, the CW recommendations advised against the use of staging imaging, including Positron Emission Tomography (PET), Computerized Tomography (CT) and radionuclide bone scans, for the staging of early breast cancer at low risk for metastasis. The objective of this study was therefore to assess the impact of the ASCO CW recommendations on staging imaging among early stage breast cancers. Methods: Women above the age of 66 with an early stage incident breast cancer diagnoses between 2010 and 2015 were identified within the linked SEER-Medicare data. The primary outcome of interest was the proportion of patients with a claim for staging imaging in the six months following the breast cancer diagnosis. Negative binomial regression, adjusting for pre-recommendation trends, was performed to estimate the changes in the rate of imaging staging within each year following the release of the recommendation. Results: A total of 50,004 women were identified during the study period. Prior to the release of the recommendations in 2012, the staging imaging rates among women newly diagnosed with early stage breast cancers were 5% greater in 2010 (p&lt;.01) and 4% greater in 2011 (p&lt;.01). Following the release of the recommendations, staging imaging rates did not decrease significantly in 2013 (2%;p=0.18). Imaging rates did, however, significantly decrease by 13% in 2014 (p&lt;0.01) and by 16% in 2015 (p&lt;0.01). Conclusions: The CW recommendation was associated with a significant decrease in unadvised staging imaging among incident early stage breast cancer diagnosis in the second and third year following its release. These findings demonstrate an improvement in the proportion of potentially inappropriate staging imaging in early stage breast cancers. The creation and dissemination of resources, such as the CW recommendations, serves as a powerful tool to improve clinical practice, quality of care, and patient safety from secondary malignancies, anxiety, and overdiagnosis.

Trends in Publicly Reported Quality Measures of Hospital Imaging Efficiency, 2011-2018.

OBJECTIVE. In 2011, the Centers for Medicare & Medicaid Services (CMS) initiated public reporting of outpatient imaging efficiency measures to reduce potentially inappropriate imaging and unnecessary exposure to ionizing radiation performed in hospital outpatient departments. Three CMS quality measures were designed to reduce duplicative CT in the Medicare population: OP-10, which CMS lists as "Abdomen Computed Tomography-Use of Contrast Material"; OP-11, which CMS lists as "Thorax CT-Use of Contrast Material"; and OP-14, which CMS lists as "Simultaneous Use of Brain CT and Sinus CT." We describe trends in hospital performance on these national hospital outpatient imaging efficiency measures since the inception of their public reporting. MATERIALS AND METHODS. This observational analysis used standard Medicare fee-for-service administrative claims to calculate hospital-specific scores for OP-10, OP-11, and OP-14. Consistent with CMS specifications, each measure was calculated as a percentage with appropriate exclusions and minimum case count requirements to ensure measure score validity and reliability. We report national performance as well as distributions of hospital performance scores for each annual public reporting period. Trend analyses were performed to examine changes in annual mean performance over time. Secondary analyses assessed trends and hospital performance by location (rural vs urban) and hospital characteristics. RESULTS. Between 2011 and 2018, the national mean rate of duplicate imaging declined for all three measures (OP-10, 18.9% vs 7.7%; OP-11, 5.6% vs 2.0%; OP-14, 2.5% vs 1.0%). For OP-10 and OP-11, most outlier hospitals were rural, small, and government-owned. For OP-10, rural facilities accounted for 32.2% of all facilities but 46.0% of outliers by the end of the study period. Similarly, for OP-11, rural facilities accounted for 30.1% of all facilities but 47.0% of outliers by the end of the study period. In general, the proportion of outliers located in rural areas decreased over time. CONCLUSION. National performance on CMS quality measures of duplicative CT has improved over time, with reduced variation observed between hospitals since the inception of public reporting. These successes support recent CMS policy initiatives to retire duplicative imaging measures from public reporting. Future work should seek to identify opportunities to use national public reporting initiatives to yield similar improvements across broader indications and settings.

Assessment of the Radiology Support, Communication and Alignment Network to Reduce Medical Imaging Overutilization: A Multipractice Cohort Study.

The aim of this study was to determine whether participation in Radiology Support, Communication and Alignment Network (R-SCAN) results in a reduction of inappropriate imaging in a wide range of real-world clinical environments. This quality improvement study used imaging data from 27 US academic and private practices that completed R-SCAN projects between January 25, 2015, and August 8, 2018. Each project consisted of baseline, educational (intervention), and posteducational phases. Baseline and posteducational imaging cases were rated as high, medium, or low value on the basis of validated ACR Appropriateness Criteria®. Four cohorts were generated: a comprehensive cohort that included all eligible practices and three topic-specific cohorts that included practices that completed projects of specific Choosing Wisely topics (pulmonary embolism, adnexal cyst, and low back pain). Changes in the proportion of high-value cases after R-SCAN intervention were assessed for each cohort using generalized estimating equation logistic regression, and changes in the number of low-value cases were analyzed using Poisson regression. Use of R-SCAN in the comprehensive cohort resulted in a greater proportion of high-value imaging cases (from 57% to 79%; odds ratio, 2.69; 95% confidence interval, 1.50-4.86; P= .001) and 345 fewer low-value cases after intervention (incidence rate ratio, 0.45; 95% confidence interval, 0.29-0.70; P < .001). Similar changes in proportion of high-value cases and number of low-value cases were found for the pulmonary embolism, adnexal cyst, and low back pain cohorts. R-SCAN participation was associated with a reduced likelihood of inappropriate imaging and is thus a promising tool to enhance the quality of patient care and promote wise use of health care resources.

A classification-based approach to low back pain in primary care \u2013 protocol for a benchmarking controlled trial

BackgroundGuidelines recommend a biopsychosocial framework for low back pain (LBP) management and the avoidance of inappropriate imaging. In clinical practice, care strategies are often inconsistent with evidence and guidelines, even though LBP is the most common disabling health condition worldwide. Unhelpful beliefs, attitudes and inappropriate imaging are common. LBP is understood to be a complex biopsychosocial phenomenon with many known multidimensional risk factors (symptom- and lifestyle-related, psychological and social) for persistent or prolonged disability, which should be identified and addressed by treatment. The STarT Back Tool (SBT) was developed for early identification of individual risk factors of LBP to enable targeted care. Stratified care according SBT has been shown to improve the effectiveness of care in a primary care setting. A biopsychosocially-oriented patient education booklet, which includes imaging guidelines and information, is one possible way to increase patients’ understanding of LBP and to reduce inappropriate imaging. Premeditated pathways, education of professionals, written material, and electronic patient registry support in health care organizations could help implement evidence-based care.MethodsWe will use a Benchmarking Controlled Trial (BCT) design in our study. We will prospectively collect data from three health care regions before and after the implementation of a classification-based approach to LBP in primary care. The primary outcome will be change in PROMIS (Patient-Reported Outcomes Measurement Information System) (short form 20a) over 12-month follow-up.DiscussionThe implementation of a classification-based biopsychosocial approach can potentially improve the care of LBP patients, reduce inappropriate imaging without increasing health-care costs, and decrease indirect costs by reducing work disability. Using the BCT we will be able to evaluate the effectiveness of the improvement strategy for the entire care pathway.Trial registrationISRCTN,ISRCTN13273552, retrospectively registered 13/05/2019.

MP66-15 MEASURING THE IMPACT OF A PHYSICIAN-LED COLLABORATIVE ON THE QUALITY OF PROSTATE CANCER CARE: 7 YEARS OF MAKING MUSIC

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Quality Improvement & Patient Safety III (MP66)1 Apr 2020MP66-15 MEASURING THE IMPACT OF A PHYSICIAN-LED COLLABORATIVE ON THE QUALITY OF PROSTATE CANCER CARE: 7 YEARS OF MAKING MUSIC Mahin Mirza*, Susan Linsell, Ji Qi, Richard Sarle, Arvin George, Khurshid Ghani, James Montie, David Miller, and for the Michigan Urological Surgery Improvement Collaborative Mahin Mirza*Mahin Mirza* More articles by this author , Susan LinsellSusan Linsell More articles by this author , Ji QiJi Qi More articles by this author , Richard SarleRichard Sarle More articles by this author , Arvin GeorgeArvin George More articles by this author , Khurshid GhaniKhurshid Ghani More articles by this author , James MontieJames Montie More articles by this author , David MillerDavid Miller More articles by this author , and for the Michigan Urological Surgery Improvement Collaborative More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000941.015AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Beginning in 2012, the Michigan Urological Surgery Improvement Collaborative (MUSIC) endeavored to build on the success of the Collaborative Quality Initiatives program of Blue Cross Blue Shield of Michigan and improve the quality of urologic care for patients in Michigan with an initial focus on prostate cancer (PCa). We sought to evaluate the effectiveness MUSIC’s prostate-related QI initiatives. METHODS: MUSIC is comprised of > 250 urologists representing 90% of the urologists in Michigan. Prospective data collection began in 2012 with more than 65,000 patients with, or at risk for, PCa in the registry to date. From 2012 - 2018 efforts to improve PCa care included reducing prostate biopsy-related infectious hospitalizations, optimizing the utilization of radiographic staging for men with newly diagnosed PCa, enhancing treatment appropriateness for favorable risk PCa patients, and establishing the MUSIC patient reported outcomes (PRO) program, an electronic infrastructure for measuring and improving functional outcomes after radical prostatectomy (RP). RESULTS: From 2012 - 2018, the overall rate of prostate biopsy-related infectious hospitalizations decreased from 1.2% pre-intervention to 0.7% post-intervention (p<0.001) representing the avoidance of 280 hospitalizations. The use of radiographic staging (i.e., CT scan and/or bone scan) for non-indicated patients (i.e., PSA ≤ 20 or Gleason < 8 or Clinical T stage < cT3) decreased from 16.4% to 5.9% (p<0.001) resulting in approximately 1750 patients avoiding inappropriate imaging. For favorable-risk PCa patients, verified active surveillance increased from 42.2% to 67.3% (p<0.001), equivalent to 1600 patients avoiding initial definitive treatment where its benefits are less apparent. The proportion of RP patients enrolled in PRO from 2014-2018 increased from 22.0% to 70.0% (p<0.001). (Refer to figure 1 below). CONCLUSIONS: By collecting credible data, sharing best practices and implementing system-level changes and modifications in clinical behavior, MUSIC is enhancing the quality, value, and outcomes of care for PCa patients in Michigan. Source of Funding: Blue Cross Blue Shield of Michigan © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e989-e989 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mahin Mirza* More articles by this author Susan Linsell More articles by this author Ji Qi More articles by this author Richard Sarle More articles by this author Arvin George More articles by this author Khurshid Ghani More articles by this author James Montie More articles by this author David Miller More articles by this author for the Michigan Urological Surgery Improvement Collaborative More articles by this author Expand All Advertisement PDF downloadLoading ...

Indications for abdominal imaging: When and what to choose?

Imaging has a very important role in evaluating abdominal pathology. A good knowledge of indications is of crucial importance in the management of the patient with abdominal pathology. Ultrasound, which on its own can lead to an accurate diagnosis, plays a pivotal role in the management of abdominal pathology. The use of ultrasound contrast agents has significantly improved ultrasound diagnostic capacities in both hepatic and non-hepatic pathology. The use of computed tomography should be limited due to the potential harmful side effects of ionizing radiation, but it has established roles in evaluating severe abdominal traumatic and non-traumatic emergencies as well as in staging oncologic patients. Magnetic resonance imaging has very limited utility in abdominal emergencies due to difficulty of accessing the scanner and the long duration of the examination compared to computed tomography or ultrasound. However, magnetic resonance imaging has well-established clinical roles particularly for evaluating diffuse or focal hepatic pathology, benign and malignant bile duct pathology, pancreatic tumors, inflammatory bowel disease and rectal tumors. The aims of the following paper are to familiarize the clinician with the indications for imaging in abdominal pathology, to guide the clinician and radiologist in choosing the correct technique for a particular clinical situation, to prevent the overuse of imaging techniques and to prevent misdiagnosis of disease and incorrect therapy resulting from inappropriate imaging.

Capsule Commentary on Young et al., Effects of Physician Experience, Specialty Training, and Self Referral on Inappropriate Diagnostic Imaging.

Capsule Commentary on Young et al., Effects of Physician Experience, Specialty Training, and Self Referral on Inappropriate Diagnostic Imaging.

Diagnostic imaging: Doing the right thing.

Inappropriate diagnostic imaging (DI) is a burgeoning issue and embraces its overuse and its misapplication. The obverse problem is one of underuse - that is when patients who should undergo imaging fail to do so. This article attempts to define these problems, examines the causes and effects and suggests some potential solutions.

Belgian multicentre study on lumbar spine imaging: Radiation dose and cost analysis; Evaluation of compliance with recommendations for efficient use of medical imaging

PurposeTo assess compliance of lumbar spine imaging referrals with national imaging recommendations and to evaluate the impact of inappropriate imaging on the collective radiation dose and health insurance costs. MethodIn 2011 and 2015, 633 lumbar spine imaging referrals were evaluated across 9 Belgian hospitals. For each patient, a new clinical anamnesis and physical examination were performed. Together with the referral, this data were confronted with the national imaging recommendations. Collective radiation dose was estimated for the radiography and CT procedures. Cost analysis was based on national reimbursement fees. Statistical analysis was performed using multilevel linear and logistic regression models. ResultsThe fraction of unjustified imaging referrals decreased from 50 % in 2011 to 41 % in 2015 (p = 0.255). The odds of a justified examination are 3.1 times higher when the referral is done by a specialist instead of a general practitioner. The highest percentage of unjustified examinations was found for CT (85 % in 2011, 81 % in 2015; p = 0.044). Seventy-five percent of the collective dose of both the 2011 and the 2015 study population was not justified. Adherence to the recommendations could result in an estimated 16 % and 5 % cost reduction for the 2011 and 2015 study samples, respectively. ConclusionsBetween 2011 and 2015, no significant improvement was found in requesting justified lumbar spine imaging procedures, although a positive trend was observed for CT. A shift from CT to MRI is necessary to improve the appropriateness of lumbar spine imaging referrals and to reduce the collective radiation dose.

Effects of Physician Experience, Specialty Training, and Self-referral on Inappropriate Diagnostic Imaging.

Although previous research has demonstrated high rates of inappropriate diagnostic imaging, the potential influence of several physician-level characteristics is not well established. To examine the influence of three types of physician characteristics on inappropriate imaging: experience, specialty training, and self-referral. A retrospective analysis of over 70,000 MRI claims submitted for commercially insured individuals. Physician characteristics were identified through a combination of administrative records and primary data collection. Multi-level modeling was used to assess relationships between physician characteristics and inappropriate MRIs. Massachusetts PARTICIPANTS: Commercially insured individuals who received an MRI between 2010 and 2013 for one of three conditions: low back pain, knee pain, and shoulder pain. Guidelines from the American College of Radiology were used to classify MRI referrals as appropriate/inappropriate. Experience was measured from the date of medical school graduation. Specialty training comprised three principal groups: general internal medicine, family medicine, and orthopedics. Two forms of self-referral were examined: (a) the same physician who ordered the procedure also performed it, and (b) the physicians who ordered and performed the procedure were members of the same group practice and the procedure was performed outside the hospital setting. Approximately 23% of claims were classified as inappropriate. Physicians with 10 or less years of experience had significantly higher odds of ordering inappropriate MRIs. Primary care physicians were almost twice as likely to order an inappropriate MRI as orthopedists. Self-referral was not associated with higher rates of inappropriate MRIs. Classification of MRIs was conducted with claims data. Not all self-referred MRIs could be detected. Inappropriate imaging continues to be a driver of wasteful health care spending. Both physician experience and specialty training were highly associated with inappropriate imaging.

A Review of Breast Pain: Causes, Imaging Recommendations, and Treatment.

Over two-thirds of women will experience breast pain in their lifetime. As one of the leading breast symptoms for which women seek medical attention, breast pain is suspected to be underreported and under-studied. Cyclical breast pain is related to hormonal changes. Noncyclical breast pain is independent of the menstrual cycle and can be idiopathic and related to chronic pain syndromes, infections, ill-fitting bras, musculoskeletal abnormalities, pregnancy, perimenopause, and postsurgical causes. Breast pain can also present in transgender patients and may require additional considerations as to the underlying cause. Imaging of mastalgia depends upon the suspected etiology. Inappropriate imaging for breast pain is associated with significant utilization of health care resources. Cyclical breast pain does not require an imaging work-up. The work-up of focal, noncyclical breast pain includes ultrasound for women aged younger than 40 years, and mammography and ultrasound for women aged 40 years and older. Management of breast pain is often supportive, as most breast pain resolves spontaneously. If pain persists, imaging and management should follow a step-wise approach. If conservative measures fail, second-line therapy is topical nonsteroidal anti-inflammatory drugs. If breast pain is severe and resistant to conservative methods, additional third-line therapies can be added by breast care specialists with specific knowledge of the potential deleterious side effects of these medications. While the causes of mastalgia are overwhelmingly benign, breast pain can significantly impact quality of life, and the breast radiologist should be familiar with causes, management, and treatment recommendations from a multidisciplinary approach.

Joint Design with Providers of Clinical Decision Support for Value-Based Advanced Shoulder Imaging.

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. 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. 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. 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. 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.

An Overview of Strategies Targeting Inappropriate Advanced Diagnostic Imaging in the Setting of Acute Uncomplicated Low Back Pain

The aims of this article are to review the driving forces for increased utilization of imaging within the US and to review the strategies currently being implemented to curtail the use of inappropriate advanced diagnostic imaging (ADI) in the setting of acute uncomplicated low back pain. Strategies aimed at reducing inappropriate ADI in the setting of uncomplicated low back pain, including guideline dissemination, clinical decision support (CDS), audit and feedback, prior authorization, and prior notification. Increasing utilization of inappropriate ADI is a multifactorial problem, and the solution is complex. Like many problems in medicine, it is unlikely that we will be able to identify a single intervention as a solution. Instead, a concerted effort grounded in physician education, CDS, and audit and feedback may be our best tool against inappropriate ADI in the setting of acute uncomplicated low back pain.

Transcultural adaption and preliminary evaluation of \u201cunderstanding low back pain\u201d patient education booklet

BackgroundLow back pain (LBP) is the number one cause of disability globally. LBP is a symptom associated with biological, psychological and social factors, and serious causes for pain are very rare. Unhelpful beliefs about LBP and inappropriate imaging are common. Practitioners report pressure from patients to provide inappropriate imaging. A recently developed patient education and management booklet, ‘Understanding low back pain’, was designed to target previously identified barriers for reducing inappropriate imaging. The booklet includes evidence-based information on LBP and supports communication between patients and practitioners. Our aim was to 1) describe the translation process into Finnish and 2) study patients’ and practitioners’ attitudes to the booklet and to evaluate if it improved patients’ understanding of LBP and practitioners’ ability to follow imaging guidelines.MethodsWe translated the booklet from English to Finnish. Preliminary evaluation of the booklet was obtained from LBP patients (n = 136) and practitioners (n = 32) using web-based questionnaires. Open-ended questions were analysed using thematic analysis.ResultsApproximately half of the patients reported that reading the booklet helped them to understand LBP, while a third thought it encouraged them to perform physical activity and decreased LBP-related fear. Eighty percent of practitioners reported that the booklet helped them to follow imaging guidelines. In addition, practitioners reported that they found the booklet helpful and that it decreased the need for imaging.ConclusionsThe booklet seemed to be helpful in LBP management and in decreasing the need for LBP imaging according to patients and practitioners. Further research on the clinical effectiveness of the booklet in controlled study settings is needed.Trial registrationISRCTN, ISRCTN14389368, Registered 4 April 2019 - Retrospectively registered; ISRCTN11875357, Registered 22 April 2019 - Retrospectively registered.

Investigating the appropriateness of physician-ordered diagnostic computed tomography for patient management in a rural hospital in New South Wales, Australia

To examine the performance of "appropriate" versus "inappropriate" computed tomography (CT) and to examine whether physicians who practise in a rural hospital in NSW Australia, achieved imaging appropriateness in their ordering of diagnostic CT examinations. An audit of the electronic medical records of medical ward inpatients (during the 2016/2017 financial year) was carried out. De-identified data were extracted for all patients who had undergone diagnostic CT while on admission. Using the SPSS analytical software, chi-square tests for independence were conducted to check for difference between appropriate and inappropriate CT imaging. Of all the CT procedures, 92% were found to be appropriate. Appropriate CT confirmed the provisional diagnosis in more instances than inappropriate CT (132 versus three). This observed difference was significant with a small size effect (chi-squared [1, n=362]=8.58, p=0.003, φ=0.16). Similarly, appropriate CT significantly facilitated a change in the proposed direction of care (140 versus 40) (chi-squared [1, n=362]=7.75, p=0.005, φ=0.16). In addition, appropriate CT which confirmed diagnosis, resulted in a change in the proposed direction of care as opposed to inappropriate CT (115 versus one; chi-squared [1, n=362]=8.11, p=0.004, Cramer's V=0.24). Specialist physicians who practise in a rural hospital setting achieved CT appropriateness. Appropriate CT is beneficial to patient care. Adhering to recommended imaging guidelines is essential for achieving imaging appropriateness.

Analyzing inappropriate magnetic resonance imaging (MRI) prescriptions and resulting economic burden on patients suffering from back pain.

Back pain is a common global disorder and magnetic resonance imaging (MRI) is one method of assessing its cause. The lack of official and general clinical guidelines is the cause of inadequate supervision of lumbar MRI prescriptions. The goal of this research was to analyze inappropriate lumbar MRI prescriptions and the resulting economic burden on individuals. This is a descriptive-analytical study carried out on a sample of 614 patients who visited four hospitals in Tehran. The appropriateness or inappropriateness of the MRI prescriptions was determined using clinical guidelines and a questionnaire based on previous studies. The economic burden created by inappropriate prescriptions for MRIs was determined after calculating the total direct and indirect costs. The total MRI prescription cost paid by the study sample was $26071, and the cost of inappropriate prescriptions was $10310. The MRI prescription rate had a significant relationship with gender, age, education, employment, primary insurance type, and supplemental health insurance. The research findings revealed relatively high rates of inappropriate MRI prescriptions in the private and public sectors. Hence, policymakers should design, create, and develop clinical guidelines and enforce the policies and rules to decrease inappropriate MRI prescriptions.