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Decision support for computed tomography in the emergency department: a multicenter cluster-randomized controlled trial

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Abstract

Objectives

Clinical decision support may facilitate evidence-based imaging, but most studies to date examining the impact of decision support have used non-randomized designs which limit the conclusions that can be drawn from them. This randomized trial examines if decision support can reduce computed tomography (CT) utilization for patients with mild traumatic brain injuries and suspected pulmonary embolism in the emergency department. This study was funded by a competitive public research grant and registered on ClinicalTrials.gov (NCT02410941).

Methods

Emergency physicians at five urban sites were assigned to voluntary decision support for CT imaging of patients with either head injuries or suspected pulmonary embolism using a cluster-randomized design over a 1-year intervention period. The co-primary outcomes were CT head and CT pulmonary angiography utilization. CT pulmonary angiography diagnostic yield (proportion of studies diagnostic for acute pulmonary embolism) was a secondary outcome.

Results

A total of 225 physicians were randomized and studied over a 2-year baseline and 1-year intervention period. Physicians interacted with the decision support in 38.0% and 45.0% of eligible head injury and suspected pulmonary embolism cases, respectively. A mixed effects logistic regression model demonstrated no significant impact of decision support on head CT utilization (OR 0.93, 95% CI 0.79–1.10, p = 0.31), CT pulmonary angiography utilization (OR 0.98, 95% CI 0.88–1.11, p = 0.74) or diagnostic yield (OR 1.23, 95% CI 0.96–1.65, p = 0.10). However, overall CT pulmonary diagnostic yield (17.7%) was almost three times higher than that reported by a recent large US study, suggesting that selective imaging was already being employed.

Conclusion

Voluntary decision support addressing many commonly cited barriers to evidence-based imaging did not significantly reduce CT utilization or improve diagnostic yield but was limited by low rates of participation and high baseline rates of selective imaging. Demonstrating value to clinicians through interventions that improve workflow is likely necessary to meaningfully change imaging practices.

Résumé

Objectifs

Le soutien à la décision clinique peut faciliter l’imagerie fondée sur des données probantes, mais la plupart des études à ce jour examinant l’impact du soutien à la décision ont utilisé des modèles non randomisés qui limitent les conclusions qui peuvent en être tirées. Cet essai randomisé examine si l’aide à la décision peut réduire l’utilisation de la tomodensitométrie chez les patients présentant des lésions cérébrales traumatiques légères et une embolie pulmonaire présumée au service des urgences. Cette étude a été financée par une subvention de recherche publique compétitive et enregistrée sur ClinicalTrials.gov (NCT02410941).

Méthodes

Les médecins urgentistes de cinq sites urbains ont été assignés à une aide à la décision volontaire pour l'imagerie par tomodensitométrie des patients présentant soit un traumatisme crânien, soit une suspicion d'embolie pulmonaire, selon une conception randomisée en grappes sur une période d'intervention d'un an. Les résultats co-primaires étaient l’utilisation de la tomodensitométrie de la tête et de la tomodensitométrie par angiographie pulmonaire. Le rendement diagnostique de l'angiographie pulmonaire par TDM (proportion d'études diagnostiquant une embolie pulmonaire aiguë) était un résultat secondaire.

Résultats

Au total, 225 médecins ont été randomisés et étudiés au cours d’une période de référence de deux ans et d’une période d’intervention d’un an. Les médecins ont interagi avec l’aide à la décision dans 38,0 % et 45,0 % des cas admissibles de blessure à la tête et d’embolie pulmonaire soupçonnée, respectivement. Un modèle de régression logistique à effets mixtes n'a démontré aucun impact significatif de l'aide à la décision sur l'utilisation de la tomodensitométrie de la tête (OR 0,93, IC 95 % 0,79-1,10, p = 0,31), l'utilisation de l'angiographie pulmonaire par tomodensitométrie (OR 0,98, IC 95 % 0,88-1,11, p = 0,74) ou le rendement diagnostique (OR 1,23, IC 95 % 0,96-1,65, p = 0,10). Toutefois, le rendement global du diagnostic pulmonaire par TDM (17,7 %) était près de trois fois supérieur à celui rapporté par une étude récente aux États-Unis, ce qui laisse supposer que l’imagerie sélective était déjà utilisée.

Conclusions

L’aide à la décision volontaire visant à éliminer de nombreux obstacles fréquemment cités à l’imagerie fondée sur des données probantes n’a pas réduit de façon significative l’utilisation de la tomodensitométrie ni amélioré le rendement diagnostique, mais a été limitée par de faibles taux de participation et des taux de base élevés d’imagerie sélective. La démonstration de la valeur pour les cliniciens par des interventions qui améliorent le flux de travail est probablement nécessaire pour changer de manière significative les pratiques d'imagerie.

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Availability of data and materials

The data underlying this article cannot be shared publicly to protect the privacy of individuals that participated in the study. The data will be shared on reasonable request to the corresponding author with permission of Alberta Health Services and the University of Calgary Conjoint Health Research Ethics Board.

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Acknowledgements

We would like to acknowledge the significant contributions of Katrina Koger in assisting with data collection and review to make this study possible.

Funding

This study was funded by a competitive unrestricted research Grant (201300468) from Alberta Innovates Health Solutions (AIHS): Partnership for Research and Innovation in the Health System (PRIHS).

Author information

Authors and Affiliations

  1. Department of Emergency Medicine, University of Calgary Cumming School of Medicine, Foothills Medical Centre Room C-231, 1403-29st NW, Calgary, AB, T2N 2T9, Canada

    James E. Andruchow, Andrew D. McRae, Grant Innes, Shabnam Vatanpour, Dongmei Wang & Eddy Lang

  2. Alberta Health Services, Calgary, AB, Canada

    Daniel Grigat

  3. Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada

    James E. Andruchow, Andrew D. McRae, Grant Innes & Eddy Lang

  4. Ottawa Hospital Research Institute, Ottawa, ON, Canada

    Monica Taljaard

  5. School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada

    Monica Taljaard

Authors
  1. James E. Andruchow
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  2. Daniel Grigat
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  4. Grant Innes
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  6. Dongmei Wang
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  7. Monica Taljaard
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  8. Eddy Lang
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Contributions

All authors participated in research design, execution, analysis and manuscript preparation. Study concept and design—JA, DG, AM, GI, SV, DW, MT, EL. Acquisition of the data—JA, DG, SV, DW. Analysis and interpretation of the data—JA, DG, AM, GI, SV, DW, MT, EL. Drafting of the manuscript—JA, DG, AM, GI, MT, EL. Critical revision of the manuscript—JA, DG, AM, GI, SV, DW, MT, EL. Statistical expertise—JA, SV, DW, MT. Acquisition of funding—JA, DG, AM, GI, DW, EL.

Corresponding author

Correspondence to James E. Andruchow.

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Andruchow, J.E., Grigat, D., McRae, A.D. et al. Decision support for computed tomography in the emergency department: a multicenter cluster-randomized controlled trial. Can J Emerg Med 23, 631–640 (2021). https://doi.org/10.1007/s43678-021-00170-3

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  • DOI: https://doi.org/10.1007/s43678-021-00170-3

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