Inappropriate CT examinations: how much, who and where? Insights from a clinical decision support system (CDSS) analysis.

OBJECTIVE: To assess the appropriateness of Computed Tomography (CT) examinations, using the ESR-iGuide. MATERIAL AND METHODS: A retrospective study was conducted in 2022 in a medium-sized acute care teaching hospital. A total of 278 consecutive cases of CT referral were included. For each imaging referral, the ESR-iGuide provided an appropriateness score using a scale of 1-9 and the Relative Radiation Level using a scale of 0-5. These were then compared with the appropriateness score and the radiation level of the recommended ESR-iGuide exam. DATA ANALYSIS: Pearson's chi-square test or Fisher exact test was used to explore the correlation between ESR-iGuide appropriateness level and physician, patients, and shift characteristics. A stepwise logistic regression model was used to capture the contribution of each of these factors. RESULTS: Most of exams performed were CT head (63.67%) or CT abdominal pelvis (23.74%). Seventy percent of the actual imaging referrals resulted in an ESR-iGuide score corresponding to "usually appropriate." The mean radiation level for actual exam was 3.2 ± 0.45 compared with 2.16 ± 1.56 for the recommended exam. When using a stepwise logistic regression for modeling the probability of non-appropriate score, both physician specialty and status were significant (p = 0.0011, p = 0.0192 respectively). Non-surgical and specialist physicians were more likely to order inappropriate exams than surgical physicians. CONCLUSIONS: ESR-iGuide software indicates a substantial rate of inappropriate exams of CT head and CT abdominal-pelvis and unnecessary radiation exposure mainly in the ED department. Inappropriate exams were found to be related to physicians' specialty and seniority. CLINICAL RELEVANCE STATEMENT: These findings underscore the urgent need for improved imaging referral practices to ensure appropriate healthcare delivery and effective resource management. Additionally, they highlight the potential benefits and necessity of integrating CDSS as a standard medical practice. By implementing CDSS, healthcare providers can make more informed decisions, leading to enhanced patient care, optimized resource allocation, and improved overall healthcare outcomes. KEY POINTS: • The overall mean of appropriateness for the actual exam according to the ESR-iGuide was 6.62 ± 2.69 on a scale of 0-9. • Seventy percent of the actual imaging referrals resulted in an ESR-iGuide score corresponding to "usually appropriate." • Inappropriate examination is related to both the specialty of the physician who requested the exam and the seniority status of the physician.

Clinical decision support system recommendations: how often do radiologists and clinicians accept them?

OBJECTIVE: To assess the acceptance and reliability of clinical decision support system (CDSS) imaging referral scores (ESR iGuide). METHODS: A pilot study was conducted in a tertiary hospital. Four different experts were invited to rate 40 simulated clinical cases on a 5-level scale, for the level of agreement with the ESR iGuide's recommended procedures. In cases of disagreement, physicians were asked to indicate the reason. Descriptive measures were calculated for the level of agreement. We also explored the degree of agreement between four different specialists, and examined the cases in which clinicians disagreed with ESR iGuide best practice recommendations. RESULTS: The mean rating of the four experts for the 40 clinical simulated cases was 4.17 ± 0.65, median 4.25 (on a scale of 1-5). All four raters totally agreed with the system recommendation in 75% of cases. No significant relationship was found between the degree of agreement and the number of indications and the patient's age or gender. In an optimistic scenario, using a binary agree/disagree variable, the Overall Percentage Agreement for the rating of the 40 simulated cases between the four experts was 77.28%. There were a total of 20 disagreements out of 160 cases with the ESR iGuide, of which 7 were among the two radiologists. CONCLUSIONS: CDSS can be an effective tool for guiding the selection of appropriate imaging examinations, thus cutting costs due to unnecessary imaging scans. Since this is a pilot study, further research on a larger scale, preferably at national level, is required. KEY POINTS: • The average of the mean rating of the four experts was 4.17 ± 0.65, median 4.25, on a scale of 1-5 where 5 represents total agreement with the CDSS tool. • In an optimistic scenario, using a binary agree/disagree variable, the Overall Percentage Agreement between the four experts was 77.28%. • Radiologists had fewer disagreements with the recommendations of the CDSS tool than other physicians, indicating a better fit of the support system to radiology experts' perspective.

Exploring pre-MRI imaging tests: patient survey reveals potential implications for healthcare efficiency in Israel.

BACKGROUND: Medical imaging tests are vital in healthcare but can be costly, impacting national health expenditures. Magnetic resonance imaging (MRI) is a crucial diagnostic tool for assessing medical conditions. However, the rising demand for MRI scans has frequently strained available resources. This study aimed to estimate the prevalence of different imaging tests in individuals who eventually had an MRI, in the Israeli public health system. METHODS: An online survey of patient experience of scheduling an MRI was conducted in January-February 2023, among 557 Israeli adults, representing all four health maintenance organizations (HMOs). All participants had undergone an MRI in the public health system within the past year. RESULTS: Results showed that 60% of participants underwent other imaging tests before their MRI scan. Of those, computed tomography (CT) scans (43%), X-rays (39%), and ultrasounds (32%) were the most common additional imaging procedures. In addition, of the 60% of participants, 23% had undergone more than one prior imaging examination. CONCLUSIONS: These findings highlight the high prevalence of preliminary imaging tests prior to MRI, with many patients undergoing multiple tests for the same problem. The health system may need to evaluate whether current clinical guidelines defining the use of various imaging tests are cost-effective.

Advancing acceptance: assessing acceptance of the ESR iGuide clinical decision support system for improved computed tomography test justification.

Background: A clinical decision support system (CDSS), the European Society of Radiologists (ESR) iGuide, was developed to address gaps in the availability and use of effective imaging referral guidelines. Aim: This study aimed to assess the appropriateness of computed tomography (CT) exams with and without ESR iGuide use, as well as the usability and acceptance of the physician systems. Methods: A retrospective single-center study was conducted in which data from 278 consecutive CT tests referred by physicians were collected in the first phase (T1), and physicians used the ESR iGuide system for imaging referrals in the second phase (T2; n = 85). The appropriateness of imaging referrals in each phase was assessed by two experts, and physicians completed the System Usability Scale. Results: The mean appropriateness level on a scale of 0-9 was 6.62 ± 2.69 at T1 and 7.88 ± 1.4 at T2. When using a binary variable (0-6 = non-appropriate; 7-9 = appropriate), 70.14% of cases were found appropriate at T1 and 96.47% at T2. Surgery physician specialty and post-intervention phase showed a higher likelihood of ordering an appropriate test (p = 0.0045 and p = 0.0003, respectively). However, the questionnaire results indicated low system trust and minimal clinical value, with all physicians indicating they would not recommend collegial use (100%). Conclusion: The study suggests that ESR iGuide can effectively guide the selection of appropriate imaging tests. However, physicians showed low system trust and use, indicating a need for further understanding of CDSS acceptance properties. Maximizing CDSS potential could result in crucial decision-support compliance and promotion of appropriate imaging.

Does clinical decision support system promote expert consensus for appropriate imaging referrals? Chest-abdominal-pelvis CT as a case study.

OBJECTIVES: We assessed the appropriateness of chest-abdominal-pelvis (CAP) CT scan use in the Emergency Department (ED), based on expert physicians and the ESR iGuide, a clinical decision support system (CDSS). METHODS: A retrospective cross-study was conducted. We included 100 cases of CAP-CT scans ordered at the ED. Four experts rated the appropriateness of the cases on a 7-point scale, before and after using the decision support tool. RESULTS: Before using the ESR iGuide the overall mean rating of the experts was 5.2 ± 1.066, and it increased slightly after using the system (5.85 ± 0.911 (p < 0.01)). Using a threshold of 5 (on a 7-level scale), the experts considered only 63% of the tests appropriate before using the ESR iGuide. The number increased to 89% after consultation with the system. The degree of overall agreement among the experts was 0.388 before ESR iGuide consultation and 0.572 after consultation. According to the ESR iGuide, for 85% of the cases, CAP CT was not a recommended option (score 0). Abdominal-Pelvis CT was "usually appropriate" for 65 out of the 85 (76%) cases (score 7-9). 9% of the cases did not require CT as first exam modality. CONCLUSIONS: According to both the experts and the ESR iGuide, inappropriate testing was prevalent, in terms of both frequency of the scans and also inappropriately chosen body regions. These findings raise the need for unified workflows that might be achieved using a CDSS. Further studies are needed to investigate the CDSS contribution to the informed decision-making and increased uniformity among different expert physicians when ordering the appropriate test.

[Medical resonance imaging (MRI)--the technology, the regulation and the utilization pattern in Israel].

Medical resonance imaging (MRI) is a technology for imaging and diagnosis of tissues and organs which does not use ionizing radiation. It was developed in the 1960's and 1970's and has been in clinical use since the 1980's. Over the last two decades there has been a substantial increase in utilization of MRI due to: improvements in imaging technology and image processing, the development of new indications for its use, and the increase in availability and accessibility of MRI in several medical fields. However, there is also overutilization of this technology due to: the use of imaging as a substitute for regular physical examinations, repeated examinations for the same medical reason, "defensive" medicine, and due to the public's desire for sophisticated examinations. These issues are all responsible for the increased use of MRI. MRI is an expensive technology and therefore, cost-lowering medical and economic mechanisms are employed to Limit its use. Until recently there were ten MRI scanners in Israel and this review presents their utilization patterns. The number of MRI scanners will double in the coming years. This may improve accessibility in different regions of the country, shorten waiting times, and improve medical diagnosis due to implementation for new indications. An international comparison showed that the number of MRI scanners in Israel is lower than the average number of MRI scanners in OECD countries. However, the utilization of MRI scanners in Israel is high relative to other OECD countries, indicating the high level of efficiency of the Israeli healthcare system.

[The over the counter drugs reform in Israel--two years later].

INTRODUCTION: In the last two decades there has been a world wide increase in the number of drugs that are being switched from the prescription-only category to non-prescription categories. In Israel, until recently, non-prescription medicines were only permitted to be sold by a pharmacist in pharmacies. In May 2005, following amendments to the law, several non-prescription medicines which were previously sold under a pharmacist's supervision, were reclassified as general-sales-list (GSL) medicines and permitted to be displayed and sold directly off the shelves in pharmacies and in other places such as grocery stores and petrol stations. OBJECTIVE: To study the change in the patterns of consumption of non-prescription drugs in Israel two years after the reform began. METHODS: A representative sample of the population of Israel was chosen and interviews were conducted at two time points: before the reform commenced and two years after the beginning of the reform. Statistical processing was performed in order to examine the changes in patterns of consumption of non-prescription drugs in Israel between these two time points. RESULTS: In both surveys it was found that: approximately 70% of the Israeli public buys non-prescription medicines; 70% of the people interviewed said that they had been aware of the reform, but of these, about 75% continued buying nonprescription drugs from the pharmacist while 21% bought medicines off the shelves at the pharmacy and 4% purchased medications at grocery stores. The most common reasons for buying medicines off the shelves without a pharmacist were earlier knowLedge about the medication, convenience and availabiLity when the pharmacies were closed. An insignificant difference was observed for the purchase of non-prescription drugs from the different types of pharmacies: the health maintenance organizations (HMO) pharmacies continue to be the leading pharmacies from which the public purchased their non-prescription medicines, white there was a slight increase in the purchases from pharmacy chains. In the two surveys, the purchaser's personal experience was the biggest factor influencing the decision to buy a certain drug, followed by the doctor's and the pharmacist's recommendation. Only 15% thought that non-prescription medicines are not safe. IN CONCLUSION: Two years after the reform began no breakthrough was observed in the pattern of purchase of non-prescription medicines. Despite exposure to the reform, most Israelis continue to buy these medicines from the pharmacists. Therefore, it appears that more time will be needed for this reform to actually start making an impact and changing the habits of Israeli consumers when purchasing non-prescription drugs.

[Over the counter drugs--a new era in Israel].

The reformation in the marketing of non-prescription medicinal products has been launched. As of May 10th 2005, the pharmacist regulations 2004 (marketing of over-the-counter (OTC) drugs outside of pharmacies, as well as not by a pharmacist) will be in effect. This change aLlows the marketing of medicines outside of pharmacies, as has been the custom in the U.S.A., England and some of the European Union countries for many years. This reformation is incorporated in a policy that encourages self-medication by the use of non-prescription drugs. The self-medication policy originates from the point of view of the consumers who wish to be responsible for their own health and save precious time wasted on doctor visits; and the government's assumption that self-medication of OTC medicines by citizens wiLL decrease expenses for the HMOs in both doctor's billings as well as medication costs. In order to regulate the marketing terms of these medicinal products, regulations and complimentary guidelines were written and published. These documents encompass the following issues: the list of OTC medicines, marketing reguLations, packaging regulations, Licensed marketing Locations, storage regulations as well as display regulations, advertising regulations, monitoring and control. The medicinal products in this category only included medicines containing "safe" active ingredients with restrictions regarding the strength/concentration and packaging size; this category does not include medicines requiring special storage conditions (such as refrigeration or freezing), medicines containing an active ingredient that is addictive, medicines containing an active ingredient with danger of poisoning if misused, and medicines containing an active ingredient that has the potential to harm. The implementation of the regulations and guidelines will improve the consumer's ability to diagnose and treat oneself when sick with minor ailments, without consulting a doctor.

Reforming the MRI system: the Israeli National Program to shorten waiting times and increase efficiency.

BACKGROUND: Long waiting times (WT) for Magnetic Resonance Imaging (MRI) are a challenge in many countries and demand is forecast to increase with ageing populations. Since MRI is essential for diagnosis in numerous medical conditions, timely performance is of the utmost importance. OBJECTIVE: To describe the multi-faceted program developed by the Israel Ministry of Health (MoH) to shorten WT for MRI and increase efficiency, and to examine lessons that can be learned for other health systems. DATA SOURCES: Data were obtained from the Israel MoH from 2015-2019. METHODS: The plan used multiple strategies and comprised the following elements: providing additional scanners, dedicating additional personnel to MRI units, maximizing efficiency, establishing a training program for radiographers and a fellowship program for radiologists, introducing financial incentives to health maintenance organizations and implementing a computerized monitoring system. RESULTS: A substantial reduction in mean WT was demonstrated, from 52 days in 2015, to 24 days in 2016 and 2017. This was followed by a slight increase to 26 and 32 days in 2018 and 2019, respectively. The relative decline in WT from 2015 to 2019 was 38.5%. The number of scanners doubled during this period while the number of radiographers and radiologists with formal MRI training increased. CONCLUSIONS: The broad scope of this comprehensive reform was successful in addressing long WT and improving care provision from a wide perspective: economic, workforce and infrastructure. Bottlenecks in the MRI system cannot be addressed from a single angle, rather requiring a whole system approach.

National and regional trends in MRI utilization in the face of the ongoing COVID-19 pandemic.

BACKGROUND AND PURPOSE: Marked reductions in imaging exams have been documented during the COVID-19 pandemic. The study aimed to examine the effect of the two waves of COVID-19 on magnetic resonance imaging (MRI) utilization at the national and regional level. MATERIALS AND METHODS: A retrospective-archive study was conducted in Israel, comparing March-December 2020 with March-December 2018 and 2019. Data on MRI utilization were obtained from the national MRI registry, while data on confirmed COVID-19 cases, by place of residence, were obtained from the Israeli Ministry of Health open COVID-19 database. RESULTS: The number and rate of MRI examinations decreased during the first COVID-19 wave, with the steepest drop in April 2020: 47.5% relative decrease compared to April 2019, and 42.2% compared to 2018. This was followed by a compensatory increase between the waves and a return to almost pre-pandemic levels of use, with just a modest decrease, during the second, more intense COVID wave, compared with the previous year. Existing differences between regions increased during the pandemic. The rate ratio of MRI exams between Tel-Aviv and the Northern periphery increased from 2.89 in April 2019 to 3.94 in April 2020. Jerusalem metropolitan region, with the largest burden of COVID disease, demonstrated only a modest decrease (1%) in MRI utilization during the first 10 months of the pandemic. CONCLUSIONS: At the national level, time trends in reduced MRI utilization followed the first wave of COVID-19, and were accompanied by increased regional disparities. These changes were not explained by differences in the burden of COVID-19 disease but might be explained by unequal distribution of MRI scanners among regions. Reduced utilization was not evident during the second wave, nor at the beginning of the third wave, despite higher COVID-19 case load, demonstrating adaptation to the new normal. Patterns of MRI utilization might help policy-makers and healthcare managers predict the behavior of imaging as well as other sectors, such as elective surgical procedures, during an ongoing pandemic. This forecast might help to manage the lasting effects of the pandemic, including extended waiting times, in the months and years following its remission. In preparation for future national emergencies, timely and detailed data on MRI utilization can serve as a "sensor" for a wide array of diagnostic and interventional medical activities, providing policy-makers with an updated snapshot to guide their response at the regional and national levels.

A decade to the Israeli Center for Technology Assessment in Health Care.

The Israeli Center for Technology Assessment in Health Care (ICTAHC) was established in 1998 at the Gertner Institute for Epidemiology and Health Policy Research, on foundations set in 1992 by the Medical Technology Assessment Unit. The Center is defined as an independent multidisciplinary research center, whose main aims are to assist in developing processes for the adoption of new technologies, identify and propose health priorities, and serve as an educational center for all stakeholders. Moreover, the Center promotes working relations with overseas counterparts as an essential component for expansion and advancement of the field of health technology assessment. Throughout the years, ICTAHC had contributed significantly to the development of the discipline of health technology assessment in Israel and to actual decision making in the health care system. The Center had outlined the principles, guidelines and overall framework for technology assessment in the country, as well as substantiating the discipline through various research areas, which materialized into a variety of technology-related policy accomplishments. Today, the Center serves as a national focal point in the health care system in Israel, as well as maintaining an active position in the international milieu. It has been a decade since the establishment of ICTAHC. This paper reviews the evolution of the center, describes changes in the HTA field in Israel, identifies areas of focus and main research accomplishments, and illustrates the breadth of potential research scope and projections for the future.

[Parameters for allocation of expensive medical devices (EMD) as a national regulatory mechanism].

BACKGROUND: In an ever-growing environment of health expenditure, governments should consider methods to contain costs, for example: professional guidelines, appropriateness criteria, preauthorization mechanism and regulations. Certificate of Needs (CON), although controversial, was also considered as a tool to lower health costs by limiting the supply of health services. Therefore, expenditures on costly medical devices require the special attention of the Ministry of Health or regulatory authorities. AIMS: To define the relative importance of significant parameters in the decision-making model for the allocation of expensive medical devices in Israel. METHODS: A survey, using a structured questionnaire, was conducted among 50 participants from the Ministry of Health (medical technology assessors, and health economists), researchers in health policy and sociology of health, psychologists, epidemiologists, physicians (radiologists and general physicians), nurses and members of the "Health Parliament". DISCUSSION: Limiting the number of special devices and raising the device utilization levels constitute basic tools in the fight to restrain growing costs in the health system. The Certificate of Need methodology is a means of limiting health expenditures. Relevant allocation criteria include parameters of varying importance. Our study revealed that certain parameters are of greater importance in the decision-making process. These parameters include: emergency function of the institute, extent of activities, alternatives available and examination mix. Parameters of mediocre importance (utilization, geographic distribution, number of hospital beds, and specialized departments) and parameters of least importance (population characteristics, training and policy considerations) have a low impact. CONCLUSION: Defining the "weight" for these parameters can be translated to a model that assists in determining appropriate needs for expensive devices as a regulatory tool balancing health outcomes and resources.

Views of health system policymakers on the role of research in health policymaking in Israel.

BACKGROUND: The use of research evidence in health policymaking is an international challenge. Health systems, including that of Israel, are usually characterized by scarce resources and the necessity to make rapid policy decisions. Knowledge transfer and exchange (KTE) has emerged as a paradigm to start bridging the "know-do" gap. The purpose of this study was to explore the views of health system policymakers and senior executives involved in the policy development process in Israel regarding the role of health systems and policy research (HSPR) in health policymaking, the barriers and facilitators to the use of evidence in the policymaking process, and suggestions for improving the use of HSPR in the policymaking process. METHODS: A survey and an interview were verbally administered in a single face-to-face meeting with health system policymakers and senior executives involved in the policy development process in Israel. The data collection period was from July to October 2014. The potential participants included members of Knesset, officials from Israel's Ministry of Health, Ministry of Finance, health services organizations, and other stakeholder organizations (i.e., National Insurance Institute). The close-ended questions were based on previous surveys that had been conducted in this field. Interviews were tape recorded and transcribed. Descriptive statistics were conducted for close ended survey-questions and thematic analysis was conducted for open-ended interview questions. RESULTS: There were 32 participants in this study. Participants felt that the use of HSPR helps raise awareness on policy issues, yet the actual use of HSPR was hindered for many reasons. Facilitators do exist to support the use of HSPR in the policymaking process, such as a strong foundation of relationships between researchers and policymakers. However, many barriers exist such as the lack of relevance and timeliness of much of the currently available research to support decision-making and the paucity of funding to support research use. Suggestions to improve the use of HSPR focused on improving dissemination of research findings and ensuring that the research was more relevant and timely. CONCLUSIONS: This research demonstrated that health systems policymakers in Israel perceive having strong relationships and collaborations with researchers however there is room for improvement, e.g. partnering in research projects to ensure relevance and use. Furthermore, health system policymakers seem to be interested in receiving relevant research in a more useable format and are open to using research in decision making.

[Utilization patterns of CT and MRI in Israel].

BACKGROUND: One of the major factors contributing to the escalating increase in the costs of the health system is the accelerated utilization of health technologies such as Computed Tomography (CT) and Magnetic Resonance Imaging (MRI). Prior to this study in Israel, there was no available national database to ascertain the scope and utilization patterns of imaging technologies. A number of trends combine in the need to assess the utilization patterns in Israel. Firstly, imaging examinations constitute a larger and ever-growing predominate role in the diagnostic process. Secondly, these technologies can complement or supplement each other. Thirdly, the rising costs to the health system resulting from the numerous examinations conducted and finally, the importance of protecting public health from the damage caused by exposure to radiation during CT examinations. OBJECTIVES: 1. To describe the utilization patterns for CT and MRI examinations in Israel. 2. To compare the consumption of imaging services with that of other Western countries. METHODS: The initial stage was to identify all the institutions operating CT or MRI devices. Data was collected by means of a questionnaire from these organizations on the extent of use, characteristics of the utilization patterns, indications, accessibility, availability, and referents etc. during the period 1995-1999. RESULTS: In the year 2000, 38 CT and 9 MRI devices were operating in Israel. We observed an increase in the number of CT and MRI examinations between the years 1995-1999 and a rise in the level of examinations per 1,000 population. The rate of MRI examinations per person in Israel was found to be lower in comparison to other Western countries. Upon analysis of the distribution of indications it was found that approximately 37% of the CT examinations were cranial examinations and 18% were spinal examinations. In MRI examinations 38% were cranial and 30% spinal tests. CONCLUSION: The rising trends in the rate of CT and MRI examinations during the period 1995-1999 and their characteristics, match the comparable rise witnessed in most Western countries in recent years. Although the level of CT and MRI devices per population in Israel is low in comparison to the Western world, the devices operate intensively. In light of the high level of accessibility and availability of these imaging devices in Israel, the research findings corroborate the claim that the number of devices influences the scope of utilization and supports the supposition that these imaging devices are used efficiently in Israel.