Impact of point-of-care clinical decision support on referrer behavior, imaging volume, patient radiation dose exposure, and sustainability.

ABSTRACT

OBJECTIVES: When referring patients to radiology, it is important that the most appropriate test is chosen to avoid inappropriate imaging that may lead to delayed diagnosis, unnecessary radiation dose, worse patient outcome, and poor patient experience. The current radiology appropriateness guidance standard at our institution is via access to a standalone web-based clinical decision support tool (CDST). A point-of-care (POC) CDST that incorporates guidance directly into the physician workflow was implemented within a subset of head and neck cancer specialist referrers. The purpose of this audit was to evaluate the imaging pathway, pre- and post-implementation to assess changes in referral behavior. METHODS: CT and MRI neck data were collected retrospectively to examine the relationship between imaging referrals pre- and post-POC CDST implementation. Effective radiation dose and estimated carbon emissions were also compared. RESULTS: There was an overall reduction in absolute advanced imaging volume by 8.2%, and a reduction in duplicate CT and MRI imaging by 61%, p < 0.0001. There was also a shift in ordering behavior in favor of MRI (OR [95% CI] = 1.50 [1.02-2.22], p = 0.049). These changes resulted in an effective radiation dose reduction of 0.27 mSv per patient, or 13 equivalent chest x-rays saved per patient, p < 0.0001. Additionally, the reduction in unnecessary duplicate imaging led to a 13.5% reduction in carbon emissions, p = 0.0002. CONCLUSIONS: Implementation of the POC CDST resulted in a significant impact on advanced imaging volume, saved effective dose, and reduction in carbon emissions. CRITICAL RELEVANCE STATEMENT The implementation of a point-of-care clinical decision support tool may reduce multimodality ordering and advanced imaging volume, manifesting in reduced effective dose per patient and reduced estimated carbon emissions. Widespread utilization of the point-of-care clinical decision support tool has the potential to reduce imaging wait times. KEY POINTS • Implementation of the point-of-care clinical decision support tool reduced the number of patients who simultaneously had a CT and MRI ordered for the same clinical indication compared to a standalone web-based clinical decision support tool. • The point-of-care clinical decision support tool reduced the absolute number of CT/MRI scans requested compared to the standalone web-based clinical decision support tool. • Utilization of the point-of-care clinical decision support tool led to a significant reduction in the effective dose per patient compared to the standalone web-based clinical decision support tool.