Keith Hentel

Ten Commandments for Effective Clinical Decision Support for Imaging: Enabling Evidence-Based Practice to Improve Quality and Reduce Waste

OBJECTIVEnWe describe best practices for effective imaging clinical decision support (CDS) derived from firsthand experience, extending the Ten Commandments for CDS published a decade ago. Our collective perspective is used to set expectations for providers, health systems, policy makers, payers, and health information technology developers.nnnCONCLUSIONnHighlighting unique attributes of effective imaging CDS will help radiologists to successfully lead and optimize the value of the substantial federal and local investments in health information technology in the United States.

Correlation Between Twinkling Artifact and Color Doppler Carrier Frequency: Preliminary Observations in Renal Calculi

Color Doppler twinkling is a well-defined but not well-understood phenomenon that may assist in the detection of renal calculi. However, the relationship between the appearance of color Doppler twinkling and color Doppler carrier frequency has not been described systematically. To evaluate this relationship, a retrospective review was performed on 20 cases of renal calculi detected by twinkling on renal color Doppler sonography and confirmed with unenhanced computed tomography. The variable strength of twinkling at and behind renal calculi was observed with color Doppler carrier frequencies ranging from 1.75-4.0 MHz. All 20 calculi (100%) demonstrated twinkling when a low color Doppler carrier frequency, 1.75 or 2 MHz, was applied, whereas 12 of 20 cases (60%) were absent of twinkling when the highest carrier frequencies tested-3.5 or 4 MHz-were used. Quantitatively, there was a significant correlation between the amount of twinkling and carrier frequency (pxa0= 0.002102). Hence, we conclude that the strength of the twinkling is color Doppler carrier frequency-dependent. The strength of the twinkling significantly increased when the color carrier frequency used for imaging decreased. Therefore, to improve renal calculi detection by enhancing the strength of the twinkling, the use of a lower color Doppler carrier frequency is recommended.

Manual Stress Ankle Radiography Has Poor Ability to Predict Deep Deltoid Ligament Integrity in a Supination External Rotation Fracture Cohort

Stress ankle radiographs are routinely performed to determine deep deltoid ligament integrity in supination external rotation (SER) ankle fractures. However, variability is present in the published data regarding what medial clear space (MCS) value constitutes a positive result. The purposes of the present study were to evaluate the diagnostic accuracy of different MCS cutoff values and determine whether this clinical test could accurately discriminate between patients with and without a deep deltoid ligament disruption. MCS measurements were recorded for stress ankle injury radiographs in an SER ankle fracture cohort. Preoperative ankle magnetic resonance imaging studies, obtained for all patients, were then read independently by 2 musculoskeletal attending radiologists to determine deep deltoid ligament integrity. The MCS measurements were compared with the magnetic resonance imaging diagnosis using receiver operating characteristic analyses to determine the sensitivity, specificity, and optimal data-driven cutoff values. SER II-III patients demonstrated a mean stress MCS distance of 4.3 ± 0.98 mm compared with 5.8 ± 1.76 mm in the SER IV cohort (p < .001). An analysis of differing MCS positive cutoff thresholds revealed that a stress MCS of 5.0 mm maximized the combined sensitivity and specificity of the external rotation test: 65.8% sensitive and 76.5% specific. Using the receiver operating characteristic curve analysis of the MCS measurement, the calculated area under the curve was 0.77, indicating inadequate discriminative ability for diagnosing SER pattern fractures with or without a deep deltoid ligament tear. Judicious use of additional diagnostic testing in patients with a stress MCS result between 4.0 mm and 5.5 mm is warranted.

The development and implementation of a patient-centered radiology consultation service: a focus on breast density and additional screening options

Increasingly, states are mandating notification to patients if they are found to have dense breast tissue. Information describes the increased risk of cancer and limitations of mammography for this patient group. Such notification often creates anxiety and results in uncertainty as no evidence-based guidelines for additional screening of dense breasts are available. Through an organized consultation service, patients and physicians were provided consultations with radiologists in order to ensure an appropriate screening plan based on individualized histories and preferences. This manuscript describes our dense breast consultation program, examines initial data, and provides lessons for practices interested in providing similar service.

JOURNAL CLUB: Predictors of Provider Response to Clinical Decision Support: Lessons Learned From the Medicare Imaging Demonstration

OBJECTIVEnThe efficacy of imaging clinical decision support (CDS) varies. Our objective was to identify CDS factors contributing to imaging order cancellation or modification.nnnSUBJECTS AND METHODSnThis pre-post study was performed across four institutions participating in the Medicare Imaging Demonstration. The intervention was CDS at order entry for selected outpatient imaging procedures. On the basis of the information entered, computerized alerts indicated to providers whether orders were not covered by guidelines, appropriate, of uncertain appropriateness, or inappropriate according to professional society guidelines. Ordering providers could override or accept CDS. We considered actionable alerts to be those that could generate an immediate order behavior change in the ordering physician (i.e., cancellation of inappropriate orders or modification of orders of uncertain appropriateness that had a recommended alternative). Chi-square and logistic regression identified predictors of order cancellation or modification after an alert.nnnRESULTSnA total of 98,894 radiology orders were entered (83,114 after the intervention). Providers ignored 98.9%, modified 1.1%, and cancelled 0.03% of orders in response to alerts. Actionable alerts had a 10 fold higher rate of modification (8.1% vs 0.7%; p < 0.0001) or cancellation (0.2% vs 0.02%; p < 0.0001) orders compared with nonactionable alerts. Orders from institutions with preexisting imaging CDS had a sevenfold lower rate of cancellation or modification than was seen at sites with newly implemented CDS (1.4% vs 0.2%; p < 0.0001). In multivariate analysis, actionable alerts were 12 times more likely to result in order cancellation or modification. Orders at sites with preexisting CDS were 7.7 times less likely to be cancelled or modified (p < 0.0001).nnnCONCLUSIONnUsing results from the Medicare Imaging Demonstration project, we identified potential factors that were associated with CDS effect on provider imaging ordering; these findings may have implications for future design of such computerized systems.

New CMS Clinical Decision Support Regulations: A Potential Opportunity with Major Challenges

Given the proposed implementation date of January 2018, radiology practitioners should carefully assess the requirements of the Protecting Access to Medicare Act 2014 to determine whether to apply to become qualified provider-led entities or choose to implement other standard-of-care and scope-of-imaging clinical decision support.

Mueller–Weiss syndrome: imaging and implications

Mueller-Weiss syndrome (MWS), or spontaneous osteonecrosis of the tarsal navicular in adults, is a rare cause of chronic medial midfoot pain. MWS has been described in orthopedic, podiatric, and radiologic literature without consensus agreement on its pathophysiology and treatment. We present the radiographic and magnetic resonance imaging of a case of MWS with reference to navicular biomechanical stressors and potential pathogenesis.

Medicare Imaging Demonstration: Assessing Attributes of Appropriate Use Criteria and Their Influence on Ordering Behavior

OBJECTIVEnPersistent concern exists about the variable and possibly inappropriate utilization of high-cost imaging tests. The purpose of this study is to assess the influence of appropriate use criteria attributes on altering ambulatory imaging orders deemed inappropriate.nnnMATERIALS AND METHODSnThis secondary analysis included Medicare Imaging Demonstration data collected from three health care systems in 2011-2013 via the use of clinical decision support (CDS) during ambulatory imaging order entry. The CDS system captured whether orders were inappropriate per the appropriate use criteria of professional societies and provided advice during the intervention period. For orders deemed inappropriate, we assessed the impact of the availability of alternative test recommendations, conflicts with local best practices, and the strength of evidence for appropriate use criteria on the primary outcome of cancellation or modification of inappropriate orders. Expert review determined conflicts with local best practices for 250 recommendations for abdominal and thoracic CT orders. Strength of evidence was assessed for the 15 most commonly triggered recommendations that were deemed inappropriate. A chi-square test was used for univariate analysis.nnnRESULTSnA total of 1691 of 63,222 imaging test orders (2.7%) were deemed inappropriate during the intervention period; this amount decreased from 364 of 11,675 test orders (3.1%) in the baseline period (p < 0.00001). Of 270 inappropriate recommendations with alternative test recommendations, 28 (10.4%) were modified, compared with four of 1024 inappropriate recommendations without alternatives (0.4%) (p < 0.0001). Seventy-eight of 250 recommendations (31%) conflicted with local best practices, but only six of 69 inappropriate recommendations (9%) conflicted (p < 0.001). No inappropriate recommendations that conflicted with local best practices were modified. All 15 commonly triggered recommendations had an Oxford Centre for Evidence-Based Medicine level of evidence of 5 (i.e., expert opinion).nnnCONCLUSIONnOrders for imaging tests that were deemed inappropriate were modified infrequently, more often with alternative recommendations present and only for appropriate use criteria consistent with local best practices.

Radiologists as Valued Consultants: IT Can Help

sicians did make use of other evidence-based resources, indicating their willingness to incorporate such into their decision-making processes and practice patterns. Finally, and most positively, the responses revealed that consultation with a radiologist was the most frequently used resource [4]. Despite the wide agreement within the radiology community on theneedforensuringappropriateimaging and the fact that ordering physicians continue to rely on radiologists to provide such guidance, there remains a large disparity in our own adherence to such guidelines in the advice and recommendations we provide to ordering physicians [5].

Benign osseous and articular abnormalities of the pelvis: a review of CT imaging findings.

Computed tomography (CT) has become the standard of care for evaluation and follow-up for a wide range of abdominal and pelvic pathology. Many incidental osseous and articular abnormalities of the pelvis are detected on these studies, most of which have a benign etiology. However, most of these studies are interpreted by nonmusculoskeletal radiologists, who may not be familiar with the CT appearances of these benign musculoskeletal abnormalities. Uncertainty often leads to mischaracterization or unnecessary follow-up, resulting in increased health care costs and patient anxiety. This article reviews the CT appearance of the benign musculoskeletal entities that occur in pelvis.