Decreasing inappropriate MRCP with contrast exams: impact of an EMR-Embedded clinical care pathway.

PURPOSE

Decrease unnecessary abdominal MRI with intravenous contrast with MRCP exams for emergency department and inpatients.

METHODS

Our institution's two MRCP orders were removed from the electronic medical record (one with intravenous (IV) contrast and the other without), with all providers directed to a new MRCP clinical care pathway containing clinical guidance and links to the appropriate orders based on indication and patient characteristics. Before and after deployment, a random set of MRCP with contrast orders were reviewed for clinical appropriateness of needing IV contrast. A manual tracking of "patient in room" time was performed to compare MRI resource use for MRCP exams with contrast vs. non-contrast. A commercial clinical decision support (CDS) tool was active throughout the study period. Statistical significance was assessed with Chi-square test.

RESULTS

At baseline, 71% (142/200) of MRCP exams were completed with contrast and 29% (58/200) without contrast. After two plan-do-study-act (PDSA) cycles, percentage of MRCPs performed with contrast decreased to 56% (p = 0.003), a 22% relative decrease, and MRCPs performed without contrast increased to 44%, a 53% relative increase. At baseline, contrast use was deemed inappropriate in 54% (29/54) of MRCP studies. Reassessment after PDSA cycle 1 showed a decrease in inappropriate MRCP with contrast orders to 25% (9/36), a 53% relative decrease (p = 0.007). Mean "in room" time was 11.5 min longer for MRCP with contrast exams.

CONCLUSION

Despite CDS, MRCP with contrast orders were deemed inappropriate 54% of the time at baseline. Redesigning the MRCP ordering process via creation of a pathway with embedded clinical guidance significantly decreased the proportion of contrast-enhanced MRCP exams by 22% and improved relative clinical appropriateness of MRCP with contrast exams by 62%. Properly directing ordering providers to non-contrast MRCP orders can help reduce healthcare costs, reduce unnecessary gadolinium exposure, and improve MR scanner efficiency.