Department of Public Health Sciences, Clemson University, 501 Edwards Hall, Clemson, SC, 29634-0745, USA.
Department of Emergency Medicine, Greenville Health System, Greenville, SC, USA.
BMC Med Inform Decis Mak. 2018 Mar 12;18(1):20. doi: 10.1186/s12911-018-0602-1.
The frequency of head computed tomography (CT) imaging for mild head trauma patients has raised safety and cost concerns. Validated clinical decision rules exist in the published literature and on-line sources to guide medical image ordering but are often not used by emergency department (ED) clinicians. Using simulation, we explored whether the presentation of a clinical decision rule (i.e. Canadian CT Head Rule - CCHR), findings from malpractice cases related to clinicians not ordering CT imaging in mild head trauma cases, and estimated patient out-of-pocket cost might influence clinician brain CT ordering. Understanding what type and how information may influence clinical decision making in the ordering advanced medical imaging is important in shaping the optimal design and implementation of related clinical decision support systems.
Multi-center, double-blinded simulation-based randomized controlled trial. Following standardized clinical vignette presentation, clinicians made an initial imaging decision for the patient. This was followed by additional information on decision support rules, malpractice outcome review, and patient cost; each with opportunity to modify their initial order. The malpractice and cost information differed by assigned group to test the any temporal relationship. The simulation closed with a second vignette and an imaging decision.
One hundred sixteen of the 167 participants (66.9%) initially ordered a brain CT scan. After CCHR presentation, the number of clinicians ordering a CT dropped to 76 (45.8%), representing a 21.1% reduction in CT ordering (P = 0.002). This reduction in CT ordering was maintained, in comparison to initial imaging orders, when presented with malpractice review information (p = 0.002) and patient cost information (p = 0.002). About 57% of clinicians changed their order during study, while 43% never modified their imaging order.
This study suggests that ED clinician brain CT imaging decisions may be influenced by clinical decision support rules, patient out-of-pocket cost information and findings from malpractice case review.
NCT03449862 , February 27, 2018, Retrospectively registered.
轻度头部创伤患者头部计算机断层扫描（CT）成像的频率引起了安全性和成本方面的关注。已在已发表的文献和在线资源中验证了临床决策规则，以指导医学影像的订购，但急诊科（ED）临床医生通常不使用这些规则。通过模拟，我们探讨了呈现临床决策规则（即加拿大 CT 头部规则-CCHR），轻度头部创伤病例中临床医生不进行 CT 成像的医疗事故案例的结果，以及估计患者自付费用是否会影响临床医生进行脑部 CT 检查。了解哪些类型的信息以及如何影响临床医生在订购高级医学影像时的决策，对于构建相关临床决策支持系统的最佳设计和实施非常重要。
多中心、双盲模拟随机对照试验。在呈现标准化临床病例后，临床医生对患者进行了初步的影像诊断。然后提供有关决策支持规则、医疗事故结果审查和患者费用的额外信息；每个信息都有机会修改他们的初始订单。根据分配的组，模拟测试了不同的时间关系，提供了不同的医疗事故和成本信息。模拟结束时呈现第二个病例，并做出影像诊断。
167 名参与者中有 116 名（66.9%）最初订购了脑部 CT 扫描。在呈现 CCHR 后，有 76 名临床医生（45.8%）订购了 CT，与初始影像检查相比，CT 检查的数量减少了 21.1%（P=0.002）。与初始影像检查相比，当呈现医疗事故审查信息（p=0.002）和患者费用信息（p=0.002）时，这种 CT 检查的减少得以维持。与研究开始时相比，约有 57%的临床医生改变了他们的检查顺序，而 43%的临床医生从未修改他们的影像检查顺序。
本研究表明，ED 临床医生的脑部 CT 成像决策可能受到临床决策支持规则、患者自付费用信息和医疗事故案例审查结果的影响。
NCT03449862，2018 年 2 月 27 日，回顾性注册。
