Clinical decision support: the role of ACR Appropriateness Criteria.

Clinical decision support is a way to decrease inappropriate imaging exams and promote judicious use of imaging resources. The adoption of clinical decision support will be incentivized by requiring the use of approved mechanisms to qualify for Medicare reimbursement starting in January 2020. Insurance providers base their reimbursement policies on Medicare, so clinical decision support could soon become relevant to pediatric imaging. We present the process behind the American College of Radiology (ACR) Appropriateness Criteria (a set of appropriate use criteria developed by the ACR) that will form the basis for software that can be used to fulfill the criteria for clinical decision support. For most organizations, this software is expected to be the easiest way to implement clinical decision support. Clinical decision support will affect how providers order imaging exams. This article should help readers understand how clinical decision support is expected to change the practice of the ordering providers, how the ACR Appropriateness Criteria are related to clinical decision support and how the ACR Appropriateness Criteria are developed. This will help the interpreting radiologist better communicate with the referring clinician, including informing the latter about how the clinical decision support software is making decisions.

ACR Appropriateness Criteria® Methodology.

The ACR Appropriateness Criteria® (AC) are evidence-based guidelines that guide physicians on appropriate image ordering. The AC development and revision process follows a transparent methodology that includes the systematic analysis of current medical literature from peer-reviewed journals and the application of well-established guidelines standards (the Institute of Medicine's Clinical Practice Guidelines We Can Trust) and methodologies (the RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development and Evaluation) to rate the benefits and potential risks, or appropriateness, of imaging and treatment procedures for specific clinical scenarios. In the October 2020 release, the methodology is applied in the development of 198 AC documents covering 1,760 clinical scenarios to make more than 8,815 recommendations, authored by more than 600 members representing multiple expert societies, and using more than 6,200 references. The ACR is recognized as a qualified provider-led entity by CMS for the development of appropriate use criteria. This paper describes the methodology and illustrates adherence to the process in the development of the AC.

ACR Appropriateness Criteria® Hematuria-Child.

Hematuria is the presence of red blood cells in the urine, either visible to the eye (macroscopic hematuria) or as viewed under the microscope (microscopic hematuria). The clinical evaluation of children and adolescents with any form of hematuria begins with a meticulous history and thorough evaluation of the urine. The need for imaging evaluation depends on the clinical scenario in which hematuria presents, including the suspected etiology. Ultrasound and CT are the most common imaging methods used to assess hematuria in children, although other imaging modalities may be appropriate in certain instances. This review focuses on the following clinical variations of childhood hematuria: isolated hematuria (nonpainful, nontraumatic, and microscopic versus macroscopic), painful hematuria (ie, suspected nephrolithiasis or urolithiasis), and renal trauma with hematuria (microscopic versus macroscopic). The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria® Headache-Child.

Headaches in children are not uncommon and have various causes. Proper neuroimaging of these children is very specific to the headache type. Care must be taken to choose and perform the most appropriate initial imaging examination in order to maximize the ability to properly determine the cause with minimum risk to the child. This evidence-based report discusses the different headache types in children and provides appropriate guidelines for imaging these children. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria® Suspected Physical Abuse-Child.

The youngest children, particularly in the first year of life, are the most vulnerable to physical abuse. Skeletal survey is the universal screening examination in children 24 months of age and younger. Fractures occur in over half of abused children. Rib fractures may be the only abnormality in about 30%. A repeat limited skeletal survey after 2 weeks can detect additional fractures and can provide fracture dating information. The type and extent of additional imaging for pediatric patients being evaluated for suspected physical abuse depends on the age of the child, the presence of neurologic signs and symptoms, evidence of thoracic or abdominopelvic injuries, and social considerations. Unenhanced CT of the head is the initial study for suspected intracranial injury. Clinically occult abusive head trauma can occur, especially in young infants. Therefore, head CT should be performed in selected neurologically asymptomatic physical abuse patients. Contrast-enhanced CT of the abdomen/pelvis is utilized for suspected intra-abdominal or pelvic injury. Particular attention should be paid to discrepancies between the patterns of injury and the reported clinical history. Making the diagnosis of child abuse also requires differentiation from anatomical and developmental variants and possible underlying metabolic and genetic conditions. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria® Urinary Tract Infection-Child.

Urinary tract infection (UTI) is common in young children and may cause pyelonephritis and renal scarring. Long-term complications from renal scarring are low. The role of imaging is to evaluate for underlying urologic abnormalities and guide treatment. In neonates there is increased risk for underlying urologic abnormalities. Evaluation for vesicoureteral reflux (VUR) may be appropriate especially in boys because of higher prevalence of VUR and to exclude posterior urethral valve. In children older than 2 months with first episode of uncomplicated UTI, there is no clear benefit of prophylactic antibiotic. Ultrasound is the only study that is usually appropriate. After the age of 6 years, UTIs are infrequent. There is no need for routine imaging as VUR is less common. In children with recurrent or complicated UTI, in addition to ultrasound, imaging of VUR is usually appropriate. Renal cortical scintigraphy may be appropriate in children with VUR, as renal scarring may support surgical intervention. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria Fever Without Source or Unknown Origin-Child.

The cause of fever in a child can often be determined from history, physical examination, and laboratory tests; infections account for the majority of cases. Yet in 20%, no apparent cause can be found, designated as fever without source (FWS). The yield of chest radiography in children with FWS is low, and it is usually not appropriate. However, in children with respiratory signs, high fever (>39°C), or marked leukocytosis (≥20,000/mm(3)), chest radiography is usually appropriate, as it has a higher yield in detecting clinically occult pneumonia. In newborns with FWS, there is higher risk for serious bacterial infection, and the routine use of chest radiography is controversial. In children with neutropenia, fever is a major concern. In some clinical circumstances, such as after hematopoietic stem cell transplantation, chest CT scan may be appropriate even if the results of chest radiography are negative or nonspecific, as it has higher sensitivity and can demonstrate specific findings (such as lung nodule and "halo sign") that can guide management. In a child with prolonged fever of unknown origin despite extensive medical workup (fever of unknown origin), diagnosis is usually dependent on clinical and laboratory studies, and imaging tests have low yield. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria on developmental dysplasia of the hip--child.

Developmental dysplasia of the hip (DDH) affects 1.5 of every 1,000 caucasian Americans and less frequently affects African Americans. Developmental dysplasia of the hip comprises a spectrum of abnormalities, ranging from laxity of the joint and mild subluxation to fixed dislocation. Early diagnosis of DDH usually leads to low-risk treatment with a harness. Late diagnosis of DDH in children may lead to increased surgical intervention and complications. Late diagnosis of DDH in adults can result in debilitating end-stage degenerative hip joint disease. Screening decreases the incidence of late diagnosis of DDH. Clinical evaluation for DDH should be performed periodically at each well-baby visit until the age of 12 months. There is no consensus on imaging screening for DDH. Consideration for screening with ultrasound is balanced between the benefits of early detection of DDH and the increased treatment and cost factors. In addition, randomized trials evaluating primary ultrasound screening did not find significant decrease in late diagnosis of DDH. In the United States, hip ultrasound is selectively performed in infants with risk factors, such as family history of DDH, breech presentation, and inconclusive findings on physical examination. Ultrasound for DDH should be performed after 2 weeks of age because laxity is common after birth and often resolves itself. A pelvic radiograph can optimally be performed after the age of 4 months, when most infants will have ossification centers of the femoral heads.