Prabhakar Anand M, Harvey H Benjamin, Misono Alexander S, Erwin Ann E, Jones Nan, Heffernan James, Rosenthal Daniel I, Brink James A, Saini Sanjay
Division of Cardiovascular Imaging, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts; Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
J Am Coll Radiol. 2016 Jun;13(6):606-10. doi: 10.1016/j.jacr.2016.01.004. Epub 2016 Feb 19.
Leakage (out-of-network referral) is undesirable because it limits ability to control costs of services. Clinical decision support (CDS) systems seek to ensure appropriate imaging of patients but theoretically could drive leakage if ordering providers attempt to circumvent CDS recommendations and obtain studies from other imaging providers. This study assessed the incidence of leakage of imaging studies that had low appropriateness scores.
We queried our outpatient CDS system over a three-year period (2011-2013) for studies that received a low CDS appropriateness score and were canceled by the ordering physician. For patients meeting these criteria and participating in risk-shared contracts, we cross-referenced their imaging utilization reports in the risk-contract insurance payment database to determine if they received outpatient imaging within 60 days of the index order, contrary to the decision support recommendation.
The risk-shared insurance database contained an average of 63,378 patients who had 18,008 MRIs and 18,014 CTs. A total of 11,234 (31.2%) studies were leaked: 3,513 (9.8%) to affiliated institutions; 7,721 (21.4%) to unaffiliated imaging facilities. Overall, 111 imaging studies received a low appropriateness score in the risk-shared patient population and were performed within 60 days despite the low score. Of these studies, 106 of 111 (95.5%) were ultimately performed within our hospital system (104 at the home institution; 2 at affiliated institutions); only 5 of 111 (4.5%) were performed outside of our hospital system.
Decision support systems for ordering providers do not seem to drive imaging referrals out of hospital systems to other institutions. Hospital systems can implement decision support without fear of this occurring.
渗漏（网络外转诊）是不可取的，因为它限制了控制服务成本的能力。临床决策支持（CDS）系统旨在确保对患者进行适当的影像检查，但从理论上讲，如果开单医生试图规避CDS建议并从其他影像检查提供者处获取检查，可能会导致渗漏。本研究评估了适宜性评分较低的影像检查的渗漏发生率。
我们在三年期间（2011 - 2013年）查询了门诊CDS系统，查找那些获得低CDS适宜性评分且被开单医生取消的检查。对于符合这些标准并参与风险共担合同的患者，我们在风险合同保险支付数据库中交叉引用他们的影像检查使用报告，以确定他们是否在索引订单后的60天内接受了门诊影像检查，这与决策支持建议相反。
风险共担保险数据库平均包含63378名患者，他们进行了18008次磁共振成像（MRI）和18014次计算机断层扫描（CT）。共有11234项（31.2%）检查发生了渗漏：3513项（9.8%）渗漏到附属机构；7721项（21.4%）渗漏到非附属影像设施。总体而言，在风险共担患者群体中，有111项影像检查获得了低适宜性评分，尽管评分较低，但仍在60天内进行了检查。在这些检查中，111项中的106项（95.5%）最终在我们的医院系统内进行（104项在本机构；2项在附属机构）；111项中只有5项（4.5%）在我们的医院系统外进行。
针对开单医生的决策支持系统似乎不会导致影像检查转诊出医院系统到其他机构。医院系统可以实施决策支持而不用担心这种情况发生。
