Deep learning of mammogram images to reduce unnecessary breast biopsies: a preliminary study.

BACKGROUND: Patients with a Breast Imaging Reporting and Data System (BI-RADS) 4 mammogram are currently recommended for biopsy. However, 70-80% of the biopsies are negative/benign. In this study, we developed a deep learning classification algorithm on mammogram images to classify BI-RADS 4 suspicious lesions aiming to reduce unnecessary breast biopsies. MATERIALS AND METHODS: This retrospective study included 847 patients with a BI-RADS 4 breast lesion that underwent biopsy at a single institution and included 200 invasive breast cancers, 200 ductal carcinoma in-situ (DCIS), 198 pure atypias, 194 benign, and 55 atypias upstaged to malignancy after excisional biopsy. We employed convolutional neural networks to perform 4 binary classification tasks: (I) benign vs. all atypia + invasive + DCIS, aiming to identify the benign cases for whom biopsy may be avoided; (II) benign + pure atypia vs. atypia-upstaged + invasive + DCIS, aiming to reduce excision of atypia that is not upgraded to cancer at surgery; (III) benign vs. each of the other 3 classes individually (atypia, DCIS, invasive), aiming for a precise diagnosis; and (IV) pure atypia vs. atypia-upstaged, aiming to reduce unnecessary excisional biopsies on atypia patients. RESULTS: A 95% sensitivity for the "higher stage disease" class was ensured for all tasks. The specificity value was 33% in Task I, and 25% in Task II, respectively. In Task III, the respective specificity value was 30% (vs. atypia), 30% (vs. DCIS), and 46% (vs. invasive tumor). In Task IV, the specificity was 35%. The AUC values for the 4 tasks were 0.72, 0.67, 0.70/0.73/0.72, and 0.67, respectively. CONCLUSION: Deep learning of digital mammograms containing BI-RADS 4 findings can identify lesions that may not need breast biopsy, leading to potential reduction of unnecessary procedures and the attendant costs and stress.

Combination of prostate volume and apparent diffusion coefficient can stratify patients with a PI-RADS score of 3 to reduce unnecessary prostate biopsies.

BACKGROUND: Nowadays, there are many patients who undergo unnecessary prostate biopsies after receiving a prostate imaging reporting and data system (PI-RADS) score of 3. Our purpose is to identify cutoff values of the prostate volume (PV) and minimum apparent diffusion coefficient (ADCmin) to stratify those patients to reduce unnecessary prostate biopsies. METHODS: Data from 224 qualified patients who received prostate biopsies from January 2019 to June 2023 were collected. The Mann-Whitney U test was used to compare non-normal distributed continuous variables, which were recorded as median (interquartile ranges). The correlation coefficients were calculated using Spearman's rank correlation analysis. Categorical variables are recorded by numbers (percentages) and compared by χ2 test. Both univariate and multivariate logistic regression analysis were used to determine the independent predictors. The receiver-operating characteristic curve and the area under the curve (AUC) were used to evaluate the diagnostic performance of clinical variables. RESULTS: Out of a total of 224 patients, 36 patients (16.07%) were diagnosed with clinically significant prostate cancer (csPCa), whereas 72 patients (32.14%) were diagnosed with any grade prostate cancer. The result of multivariate analysis demonstrated that the PV (p < 0.001, odds ratio [OR]: 0.952, 95% confidence interval [95% CI]: 0.927-0.978) and ADCmin (p < 0.01, OR: 0.993, 95% CI: 0.989-0.998) were the independent factors for predicting csPCa. The AUC values of the PV and ADCmin were 0.779 (95% CI: 0.718-0.831) and 0.799 (95% CI: 0.740-0.849), respectively, for diagnosing csPCa. After stratifying patients by PV and ADCmin, 24 patients (47.06%) with "PV < 55 mL and ADCmin < 685 µm2/s" were diagnosed with csPCa. However, only one patient (1.25%) with PV ≥ 55 mL and ADCmin ≥ 685 µm2/s were diagnosed with csPCa. CONCLUSIONS: In this study, we found the combination of PV and ADCmin can stratify patients with a PI-RADS score of 3 to reduce unnecessary prostate biopsies. These patients with "PV ≥ 55 mL and ADCmin ≥ 685 µm2/s" may safely avoid prostate biopsies.

Teleconsulting in wound care: Connecting the primary care to the wound specialist reduces unnecessary referrals.

In the Netherlands the primary care (General Practitioner or homecare nurse) encounter a variety of wounds ranging from traumatic to diabetic foot ulcers. According to a recent study 82.4% of the patients with a wound can be treated in a primary setting with the GP as medical supervisor. The remaining 17.6% of patients need more extensive care including advice by a specialised doctor, diagnosis and treatment. Prompt analyses and treatment of underlying causes by specialised doctors in a multidisciplinary setting is necessary for treating patients with complicated wound. This article describes the impact of Electronic Health Consultation on all wounds treated in the primary care. And describes the effect on the duration until referral to the hospital and the influence on the amount of unnecessary referrals to the hospital. All data was collected prospectively from June 2020 until October 2021. The study involved a process where primary care could seek advice from a Wound Physician at the Alrijne Wound Centre through a specialised Electronic Health Consultation. A total of 118 patients were analysed. 41/118 (34.7%) patients required a physical consultation with analysis and treatment in the hospital, after teleconsultation. The remaining 77/118 (65.3%) could be treated in primary care after Electronic Health Consultation. The mean duration of wound existence until Electronic Health Consultation was 39.3 days (range 5-271, SD: 38.5). 3/41 (7.3%) of the referrals were unnecessary. Electronic Health Consultation serves as a valuable and efficient tool for enhancing wound care, ultimately contributing to improved patient management and resource allocation within the healthcare system. This article describes the impact of Electronic Health Consultation on all wounds treated in the primary care and the influence on the duration until referral to the hospital and the influence on the amount of unnecessary referrals to the hospital.

Recommendations for Choosing Wisely in Pediatric Emergency Medicine: Five Opportunities to Improve Value.

Unnecessary diagnostic tests and treatments in children cared for in emergency departments (EDs) do not benefit patients, increase costs, and may result in harm. To address this low-value care, a taskforce of pediatric emergency medicine (PEM) physicians was formed to create the first PEM Choosing Wisely recommendations. Using a systematic, iterative process, the taskforce collected suggested items from an interprofessional group of 33 ED clinicians from 6 academic pediatric EDs. An initial review of 219 suggested items yielded 72 unique items. Taskforce members independently scored each item for its extent of overuse, strength of evidence, and potential for harm. The 25 highest-rated items were sent in an electronic survey to all 89 members of the American Academy of Pediatrics PEM Committee on Quality Transformation (AAP COQT) to select their top ten recommendations. The AAP COQT survey had a 63% response rate. The five most selected items were circulated to over 100 stakeholder and specialty groups (within the AAP, CW Canada, and CW USA organizations) for review, iterative feedback, and approval. The final 5 items were simultaneously published by Choosing Wisely United States and Choosing Wisely Canada on December 1, 2022. All recommendations focused on decreasing diagnostic testing related to respiratory conditions, medical clearance for psychiatric conditions, seizures, constipation, and viral respiratory tract infections. A multinational PEM taskforce developed the first Choosing Wisely recommendation list for pediatric patients in the ED setting. Future activities will include dissemination efforts and interventions to improve the quality and value of care specific to recommendations.

A Canadian survey of perceptions and practices related to ordering of blood tests in the intensive care unit.

PURPOSE: The ordering of routine blood test panels in advance is common in intensive care units (ICUs), with limited consideration of the pretest probability of finding abnormalities. This practice contributes to anemia, false positive results, and health care costs. We sought to understand practices and attitudes of Canadian adult intensivists regarding ordering of blood tests in critically ill patients. METHODS: We conducted a nationwide Canadian cross-sectional survey consisting of 15 questions assessing three domains (global perceptions, test ordering, daily practice), plus 11 demographic questions. The target sample was one intensivist per adult ICU in Canada. We summarized responses using descriptive statistics and present data as mean with standard deviation (SD) or count with percentage as appropriate. RESULTS: Over seven months, 80/131 (61%) physicians responded from 77 ICUs, 50% of which were from Ontario. Respondents had a mean (SD) clinical experience of 12 (9) years, and 61% worked in academic centres. When asked about their perceptions of how frequently unnecessary blood tests are ordered, 61% responded "sometimes" and 23% responded "almost always." Fifty-seven percent favoured ordering complete blood counts one day in advance. Only 24% of respondents believed that advanced blood test ordering frequently led to changes in management. The most common factors perceived to influence blood test ordering in the ICU were physician preferences, institutional patterns, and order sets. CONCLUSION: Most respondents to this survey perceived that unnecessary blood testing occurs in the ICU. The survey identified possible strategies to decrease the number of blood tests.

RéSUMé: OBJECTIF: La prescription à l'avance de tests sanguins de routine est courante dans les unités de soins intensifs (USI), avec une prise en compte limitée de la probabilité de découverte d'anomalies avant le test. Cette pratique contribue à l'anémie, aux résultats faussement positifs et aux coûts des soins de santé. Nous avons cherché à comprendre les pratiques et les attitudes des intensivistes pour adultes au Canada en ce qui concerne la prescription d'analyses sanguines chez la patientèle gravement malade. MéTHODE: Nous avons mené un sondage transversal à l'échelle nationale au Canada en posant 15 questions évaluant trois domaines (perceptions globales, commande de tests, pratique quotidienne), ainsi que 11 questions démographiques. L'échantillon cible était composé d'un·e intensiviste par unité de soins intensifs pour adultes au Canada. Nous avons résumé les réponses à l'aide de statistiques descriptives et présenté les données sous forme de moyennes avec écarts type (ET) ou de dénombrements avec pourcentages, selon le cas. RéSULTATS: Sur une période de sept mois, 80 médecins sur 131 (61%) ont répondu dans 77 unités de soins intensifs, dont 50% en Ontario. Les répondant·es avaient une expérience clinique moyenne (ET) de 12 (9) ans, et 61% travaillaient dans des centres universitaires. Lorsqu'on leur a demandé ce qu'ils ou elles pensaient de la fréquence à laquelle des tests sanguins inutiles étaient prescrits, 61% ont répondu « parfois ¼ et 23% ont répondu « presque toujours ¼. Cinquante-sept pour cent étaient en faveur de la réalisation d'une formule sanguine complète un jour à l'avance. Seulement 24% des personnes interrogées estimaient que la prescription de tests sanguins à l'avance entraînait fréquemment des changements dans la prise en charge. Les facteurs les plus souvent perçus comme influençant la prescription d'analyses sanguines à l'unité de soins intensifs étaient les préférences des médecins, les habitudes institutionnelles et les ensembles d'ordonnances. CONCLUSION: La plupart des répondant·es à ce sondage ont l'impression que des tests sanguins inutiles sont prescrits aux soins intensifs. L'enquête a permis d'identifier des stratégies possibles pour réduire le nombre de tests sanguins.

Reducing unwarranted chest x-rays in bronchiolitis: Importance of a robust analysis.

AIM: Bronchiolitis is the commonest reason for hospitalisation amongst infants and is often a target for low-value care (LVC) reduction. We aimed to assess the impact of a multifaceted intervention (clinician education, parent engagement, audit-feedback) on rates of chest x-rays (CXR) in bronchiolitis. METHODS: Longitudinal study of CXRs ordered in infants (1-12 months) diagnosed with bronchiolitis in the Emergency Department (ED) of an Australian paediatric hospital between May 2016 and February 2023. We used logistic regression to measure the impact of the intervention on unwarranted CXR orders, controlling for other potential impacting variables such as time, patient characteristics (age/sex), clinical variables (fever, hypoxia, tachypnoea), seasonal factors (month, day of the week, business hours) and time passed since intervention. RESULTS: Ten thousand one hundred and nine infants were diagnosed with bronchiolitis in the ED over the study period, with 939 (9.3%) receiving a CXR, of which 69% (n = 651) were considered unwarranted. Rates of unwarranted CXRs reduced from 7.9% to 5.4% post-intervention (P < 0.0001). Logistic regression showed the intervention had no significant effect (OR 0.89, 95% CI 0.65-1.23) once other variables and underlying time-based trends were accounted for. CONCLUSIONS: Although pre-post rates appeared significantly improved, a robust analysis demonstrated that our multi-faceted intervention was not effective in reducing CXRs in bronchiolitis. The decision to order CXR was associated with clinical features that overlap with pneumonia suggesting ongoing misconceptions regarding the role of CXR for this indication. Our study highlights the value of large electronic medical record datasets and robust methodology to avoid falsely attributing underlying trends to the LVC intervention.

Unnecessary Explantation of IDEAL IMPLANT Structured Saline Breast Implants Prompted byRadiologic Misdiagnosis of Rupture.

ABSTRACT: The unique dual-lumen and baffle design of the IDEAL IMPLANT Structured Saline breast implant gives it specific advantages over both silicone gel-filled and the original saline-filled implants. This internal baffle structure also gives it an appearance on various radiologic imaging studies that may be misinterpreted as a rupture because of similarities to the well-known radiologic appearance of a ruptured silicone gel implant. Patients may present with various misinterpreted imaging studies, highlighting the need for plastic surgeons and radiologists to be familiar with the normal appearance of the intact IDEAL IMPLANT and be able to distinguish it from a ruptured IDEAL IMPLANT. The radiology findings must be correlated with the clinical findings, or an intact IDEAL IMPLANT misdiagnosed as ruptured, may cause unnecessary patient worry, and may prompt unnecessary surgery for removal or replacement.

Multisystem factors contributing to redundant intracranial vascular imaging in the ED.

PURPOSE: To evaluate the multisystem factors contributing to redundant neurovascular orders in the ED. METHODS: This was an IRB-approved, retrospective study, performed at a single institution examining a 5-year history of redundant CTA/MRA head and neck (HN) exams performed in the ED for patients with no documented clinical change in mental status/neurological exam necessitating additional imaging. Factors contributing to redundant ordering including provider experience, synchronous order placement, and radiologist recommendations were examined. Additionally, the impact of duplicative imaging in terms of medical cost and ED length of stay was evaluated. RESULTS: 250 patients met inclusion criteria with both CTA/MRA of the HN performed during a single ED encounter (total 500 exams). 190 (76%) redundant exams were not recommended by a radiologist and contributed to an added ED length of stay of 3.6 h on average. Provider experience was not a significant contributing factor. 60 (24%) of redundant exams were recommended by a radiologist and were most frequently CTAs needed to clarify an area of artifact/high-grade stenosis/occlusion on a primary MRA exam. CONCLUSION: Evaluation of contributing factors to redundant CTA/MRA HN exams ordering has highlighted multiple associated factors including provider experience, recommendations by radiologists for clarification of MRA findings, as well as systems processes related to synchronous CTA/MRA order placement.

Appropriateness and imaging outcomes of ultrasound, CT, and MR in the emergency department: a retrospective analysis from an urban academic center.

PURPOSE: To evaluate the appropriateness and outcomes of ultrasound (US), computed tomography (CT), and magnetic resonance (MR) orders in the ED. METHODS: We retrospectively reviewed consecutive US, CT, and MR orders for adult ED patients at a tertiary care urban academic center from January to March 2019. The American College of Radiology Appropriateness Criteria (ACRAC) guidelines were primarily used to classify imaging orders as "appropriate" or "inappropriate". Two radiologists in consensus judged specific clinical scenarios that were unavailable in the ACRAC. Final imaging reports were compared with the initial clinical suspicion for imaging and categorized into "normal", "compatible with initial diagnosis", "alternative diagnosis", or "inconclusive". The sample was powered to show a prevalence of inappropriate orders of 30% with a margin of error of 5%. RESULTS: The rate of inappropriate orders was 59.4% for US, 29.1% for CT, and 33.3% for MR. The most commonly imaged systems for each modality were neuro (130/330) and gastrointestinal (95/330) for CT, genitourinary (132/330) and gastrointestinal (121/330) for US, neuro (273/330) and gastrointestinal (37/330) for MR. Compared to inappropriately ordered tests, the final reports of appropriate orders were nearly three times more likely to demonstrate findings compatible with the initial diagnosis for all modalities: US (45.5 vs. 14.3%, p < 0.001), CT (46.6 vs. 14.6%, p < 0.001), and MR (56.3 vs. 21.8%, p < 0.001). Inappropriate orders were more likely to show no abnormalities compared to appropriate orders: US (65.8 vs. 38.8%, p < 0.001), CT (62.5 vs. 34.2%, p < 0.001), and MR (61.8 vs. 38.7%, p < 0.001). CONCLUSION: The prevalence of inappropriate imaging orders in the ED was 59.4% for US, 29.1% for CT, and 33.3% for MR. Appropriately ordered imaging was three times more likely to yield findings compatible with the initial diagnosis across all modalities.

Unnecessary interventions for the management of hip osteoarthritis: a population-based cohort study.

BACKGROUND: Patients aged 40-60 years who require total hip arthroplasty (THA) often first receive unindicated hip arthroscopy or magnetic resonance imaging (MRI). Our objective was to identify potentially inappropriate resource utilization before THA, specifically reporting on the proportion of patients aged 40-60 years who underwent hip arthroscopy or MRI in the year before THA. METHODS: We conducted a retrospective, population-based study at the provincial level. We retrieved data from the Canadian Institute for Health Information (CIHI). We included all Ontario residents who underwent an elective, primary THA for osteoarthritis between Apr. 1, 2004, and Mar. 31, 2016. We identified the rates and timing of patients who underwent an MRI or hip arthroscopy before their index THA. RESULTS: The percentage of patients who underwent an MRI before THA increased significantly over the study period, from 8.7% in 2004 to 23.8% in 2015. There was also a significant but variable trend in the percentage of patients who underwent a hip arthroscopy before THA. CONCLUSION: Our results demonstrate a high, gradually increasing proportion of patients who received a hip MRI and a low but increasing proportion of patients who received hip arthroscopy in close proximity to THA. Multidisciplinary collaboration may improve knowledge translation and help reduce the rate of clinically unnecessary diagnostic and therapeutic interventions in this population of patients who require THA.

Current practice of pre-operative assessment at a public sector hospital in Pakistan - a clinical audit.

Objective: To assess the practice of ordering unnecessary laboratory investigations by primary surgical teams. METHODS: The clinical audit was conducted from December 17, 2022, to January 15, 2023, at the Civil Hospital, Karachi, and comprised primary surgeons working in different surgical units who ordered laboratory investigations for patients as a part of preoperative assessment. Data was collected using a self-administered questionnaire. Data was analysed using SPSS 20. RESULTS: Of the 280 surgeons approached, 249(89%) responded. The units covered were General surgery 96(38.5%), Gynaecology 74(29.7%), Neurosurgery 5(2.0%), Ear, Nose and Throat 19(7.6%), Plastic surgery 15(6.02%), Paediatric surgery 13(5.2%), Vascular surgery 8(3.21%), Oromaxilofacial 9(3.61%), Opthalmology 6(2.4%), and Orthopaedics 4(1.60%).As part of baseline investigations, 244(98%) surgeons ordered complete blood count, 173(69.5%) ordered urea and creatinine, 229(92%) ordered viral markers, 197(78.7%) ordered fasting and random blood glucose, and 178(71.5%) focussed on cardiac fitness. Conclusion: A need was found to establish standard protocols for pre-surgery evaluation so that unnecessary investigations may be avoided.

Environmental impact of a blood test reduction intervention in adult intensive care units: A before and after quality improvement project.

BACKGROUND: Pathology testing is a very common investigation in the intensive care unit (ICU). Many tests are ordered on a routine basis rather than for a specific clinical indication, resulting in potential patient harm and unnecessary financial and environmental costs. OBJECTIVE: The objective of this study was to determine whether a multifaceted intervention based on the principles of education, audit, and feedback can result in a decrease in unnecessary pathology tests without a commensurate increase in adverse patient outcomes and to measure this decrease in terms of the associated reduction in environmental and financial costs. METHODS: A before and after quality improvement project was conducted between 2017 and 2019 across four ICUs in three 12-month phases, divided according to baseline, intervention implementation, and follow-up. Local clinician champions from each site partnered with the project coordinating centre to develop and implement a range of interventions based on the principles of education, audit, and feedback. Data were collected for the number of pathology tests performed and the clinical characteristics of patients admitted to a participating ICU across the three phases. RESULTS: A total of 196 323 arterial blood gases and 460 258 other tests across eight categories were performed on the 22 210 patients admitted to participating ICUs during the project. A decrease in testing was observed across all but one category, with the greatest reduction seen in arterial blood gases (31.2% reduction in tests per bed-day). Across all categories, this equated to a mean reduction of 1.8 tCO2e (tonnes of carbon dioxide equivalent), a potential estimated total saving of Australian dollar $918 497.50. No increase in adverse clinical outcomes was observed. CONCLUSION: A multifaceted intervention based on the principles of education, audit, and feedback can produce a significant decrease in the number of unnecessary pathology tests performed. This reduction translates to substantial environmental and financial savings without any associated increase in adverse patient outcomes.

Identifying Strategies to Reduce Low-Value Preoperative Testing for Low-Risk Procedures: a Qualitative Study of Facilities with High or Recently Improved Levels of Testing.

BACKGROUND: Healthcare agencies and perioperative professional organizations recommend avoiding preoperative screening tests for low-risk surgical procedures. However, low-value preoperative tests are still commonly ordered even for generally healthy patients and active strategies to reduce this testing have not been adequately described. OBJECTIVE: We sought to learn from hospitals with either high levels of testing or that had recently reduced use of low-value screening tests (aka "delta sites") about reasons for testing and active deimplementation strategies they used to effectively improve practice. DESIGN: Qualitative study of semi-structured telephone interviews. PARTICIPANTS: We identified facilities in the US Veterans Health Administration (VHA) with high or recently improved burden of potentially low-value preoperative testing for carpal tunnel release and cataract surgery. We recruited perioperative clinicians to participate. APPROACH: Questions focused on reasons to order preoperative screening tests for patients undergoing low-risk surgery and, more importantly, what strategies had been successfully used to reduce testing. A framework method was used to identify common improvement strategies and specific care delivery innovations. KEY RESULTS: Thirty-five perioperative clinicians (e.g., hand surgeons, ophthalmologists, anesthesiologists, primary care providers, directors of preoperative clinics, nurses) from 29 VHA facilities participated. Facilities that successfully reduced the burden of low-value testing shared many improvement strategies (e.g., building consensus among stakeholders; using evidence/norm-based education and persuasion; clarifying responsibility for ordering tests) to implement different care delivery innovations (e.g., pre-screening to decide if a preop clinic evaluation is necessary; establishing a dedicated preop clinic for low-risk procedures). CONCLUSIONS: We identified a menu of common improvement strategies and specific care delivery innovations that might be helpful for institutions trying to design their own quality improvement programs to reduce low-value preoperative testing given their unique structure, resources, and constraints.

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.

Appropriateness of lumbar spine radiography and factors influencing imaging ordering patterns: paving the path toward value-driven health care.

The demand for diagnostic imaging continues to rise. Against the backdrop of rising health care costs and finite resources, this has prompted a paradigm shift toward value-driven patient care. Inappropriate imaging is a barrier toward achieving this goal, which runs counter to prevailing evidence-based guidelines and contributes to rising healthcare costs. Our objective was to evaluate the appropriateness of lumbar spine X-rays in a tertiary referral Emergency Department (ED) and assess whether physicians' specialization and years of experience influence appropriateness. A total of 1030 lumbar spine radiographs performed in the ED of an academic medical center over a consecutive 3-month period were reviewed retrospectively. Referral indications were reviewed for adherence to 2021 American College of Radiology appropriateness guidelines for lower back pain, and referral patterns were evaluated among physician groups based on specialists' training and years in practice. 63.8% of lumbar spine radiographs were appropriate, with trauma being the most common indication. 36.2% of orders were inappropriate, with lower back pain of <6 weeks duration being the most common indication. Significant differences in inappropriate orders were found (P < .001) across physician groups: qualified Emergency Medicine specialists (20.9% inappropriate orders), specialists in training (27.8%), and non-specialists with ≥3 (60.0%) and <3 (36.9%) years in practice, respectively. Approximately one-third of lumbar spine radiographs performed in the ED were inappropriately ordered by American College of Radiology guidelines; specialists training and years in practice affected referral patterns. Integrating evidence-based appropriateness guidelines into the physician order workflow and targeting older non-specialists may promote more judicious imaging and reduce health care costs.

Choosing Wisely® in Japanese Emergency Medicine: Nine Recommendations to Improve The Value of Health Care.

BACKGROUND: The overuse of diagnostic and therapeutic modalities has become an issue in the field of emergency medicine. The health care system of Japan aims to provide the most appropriate quality and quantity of care at the right price, while focusing on patient value. The Choosing Wisely® campaign was launched in Japan and other countries. OBJECTIVE: In this article, recommendations were discussed to improve the field of emergency medicine based on the state of the Japanese health care system. METHODS: The modified Delphi method, a consensus-building method, was used in this study. The final recommendations were developed by a working group of 20 medical professionals, students, and patients, consisting of members of the emergency physician electronic mailing list. RESULTS: From the 80 candidates recommended and excessive actions gathered, nine recommendations were formulated after two Delphi rounds. The recommendations included the suppression of excessive behavior and the implementation of appropriate medical treatment, like rapid pain relief and the application of ultrasonography during central venous catheter placement. CONCLUSIONS: This study formulated recommendations to improve the field of Japanese emergency medicine, based on the feedback of patients and health care professionals. The nine recommendations will be helpful for all people involved in emergency care in Japan because they have the potential to prevent the overuse of diagnostic and therapeutic modalities, while maintaining the appropriate quality of patient care.

Reducing Unnecessary Oophorectomies for Benign Ovarian Neoplasms in Pediatric Patients.

Importance: Although most ovarian masses in children and adolescents are benign, many are managed with oophorectomy, which may be unnecessary and can have lifelong negative effects on health. Objective: To evaluate the ability of a consensus-based preoperative risk stratification algorithm to discriminate between benign and malignant ovarian pathology and decrease unnecessary oophorectomies. Design, Setting, and Participants: Pre/post interventional study of a risk stratification algorithm in patients aged 6 to 21 years undergoing surgery for an ovarian mass in an inpatient setting in 11 children's hospitals in the United States between August 2018 and January 2021, with 1-year follow-up. Intervention: Implementation of a consensus-based, preoperative risk stratification algorithm with 6 months of preintervention assessment, 6 months of intervention adoption, and 18 months of intervention. The intervention adoption cohort was excluded from statistical comparisons. Main Outcomes and Measures: Unnecessary oophorectomies, defined as oophorectomy for a benign ovarian neoplasm based on final pathology or mass resolution. Results: A total of 519 patients with a median age of 15.1 (IQR, 13.0-16.8) years were included in 3 phases: 96 in the preintervention phase (median age, 15.4 [IQR, 13.4-17.2] years; 11.5% non-Hispanic Black; 68.8% non-Hispanic White); 105 in the adoption phase; and 318 in the intervention phase (median age, 15.0 [IQR, 12.9-16.6)] years; 13.8% non-Hispanic Black; 53.5% non-Hispanic White). Benign disease was present in 93 (96.9%) in the preintervention cohort and 298 (93.7%) in the intervention cohort. The percentage of unnecessary oophorectomies decreased from 16.1% (15/93) preintervention to 8.4% (25/298) during the intervention (absolute reduction, 7.7% [95% CI, 0.4%-15.9%]; P = .03). Algorithm test performance for identifying benign lesions in the intervention cohort resulted in a sensitivity of 91.6% (95% CI, 88.5%-94.8%), a specificity of 90.0% (95% CI, 76.9%-100%), a positive predictive value of 99.3% (95% CI, 98.3%-100%), and a negative predictive value of 41.9% (95% CI, 27.1%-56.6%). The proportion of misclassification in the intervention phase (malignant disease treated with ovary-sparing surgery) was 0.7%. Algorithm adherence during the intervention phase was 95.0%, with fidelity of 81.8%. Conclusions and Relevance: Unnecessary oophorectomies decreased with use of a preoperative risk stratification algorithm to identify lesions with a high likelihood of benign pathology that are appropriate for ovary-sparing surgery. Adoption of this algorithm might prevent unnecessary oophorectomy during adolescence and its lifelong consequences. Further studies are needed to determine barriers to algorithm adherence.

Prostate cancer detection rate in men undergoing transperineal template-guided saturation and targeted prostate biopsy.

OBJECTIVES: To compare prostate cancer (PCa) detection rate of transperineal template-guided saturation prostate biopsy (SBx) and multiparametric magnetic resonance imaging (mpMRI)/transrectal ultrasound fusion guided targeted biopsy (TBx). MATERIALS AND METHODS: We prospectively enrolled 392 men who underwent SBx and TBx in case of suspicious lesions from November 2016 to October 2019. Triggers for a biopsy were an elevated prostate-specific antigen (PSA) and/or positive digital rectal examination and only treatment naïve patients without a previous diagnosis of PCa were included. Study inclusion occurred before biopsy and a prebiopsy mpMRI was available in all men. SBx were taken from 20 different locations according to the modified Barzell zones. The primary endpoint was the detection rate of clinically significant PCa (csPCa) and insignificant PCa (ciPCa) by SBx and/or TBx by comparing the two methods alone and in combination. Additional TBx were taken for any prostate imaging-reporting and data system (PI-RADS) lesion ≥3 seen on the mpMRI. csPCa was defined as any Gleason score ≥7 and ciPCa as Gleason score 6. RESULTS: A total of 392 men with a median age of 64 years (interquartile range [IQR]: 58-69), a median PSA of 7.0 ng/ml (IQR: 4.8-10.1) were enrolled. Overall, PCa was found in 200 (51%) of all biopsied men, with 158 (79%) being csPCa and 42 (21%) ciPCa. A total of 268 (68%) men with a suspicious mpMRI and underwent a combined TBx and SBx, of whom csPCa was found in 139 (52%). In this subgroup, 116/139 (83%) csPCa would have been detected by TBx alone, and an additional 23 (17%) were found by SBx. Men with a negative mpMRI (PI-RADS < 3, n = 124, 32%) were found to have csPCa in 19 (15%) cases. In patients with a negative mpMRI in combination with a PSA density <0.1 ng/ml2 , only 8% (3/36) had csPCa. If only TBx would have been performed and all men with a negative mpMRI would not have been biopsed, 42/158 (27%) of csPCa would have been missed, and 38/42 (90%) ciPCa would have not been detected. On multivariable analysis, significant predictors of csPCa were increasing PSA (odds ratio, OR: 1.07 [95% confidence interval, CI: 1.03-1.11]), increasing age (OR: 1.07 [95% CI: 1.03-1.11]), PI-RADS score ≥ 3 (OR: 6.49 [95% CI: 3.55-11.89]), and smaller prostate volume (OR: 0.96 [95% CI: 0.95 -0.97] (p < 0.05 for all parameters). CONCLUSION: In comparison to SBx, TBx alone detects csPCa in only ¾ of all men with a positive mpMRI lesion. Thus, systematic biopsies in addition to TBx have to be considered at least in some who undergo a prostate biopsy. In men with a negative mpMRI, SBx still detects 15% csPCa, but similarly overdetecting ciPCa. According to our results, low PSA density and negative mpMRI findings could be used to decide which men can safely avoid biopsy.

Optimization of clinical risk-factor interpretation and radiological findings with machine learning for PIRADS category 3 patients.

BACKGROUND: Due to the low cancer-detection rate in patients with PIRADS category 3 lesions, we created machine learning (ML) models to facilitate decision-making about whether to perform prostate biopsies or monitor clinical information without biopsy results. METHODS: In our retrospective, single-center study, 101 eligible patients with at least one PIRADS category 3 lesion but no higher PIRADS lesions underwent MRI/US fusion biopsies between September 2017 and June 2020. Thirty additional patients were included as the validation cohort from the next chronological period from June 2020 to October 2020. Our ML research was a supervised classification problem, with a binary output based on pathological reports of cancerous or benign tissue. The clinical inputs were age, prostate-specific antigen (PSA), prostate volume, prostate-specific antigen density (PSAD), and the number of previous biopsies. The radiology-report inputs were the number of lesions, maximum lesion diameter, lesion location, and lesion zone. We subsequently removed the inputs with low importance. Logistic Regression, Support Vector Machine, Naive Bayes, Decision Tree, Random Forest, and eXtreme Gradient Boosting Tree (XGBoost) were employed. From receiver operating characteristic (ROC) curves, we determined Area Under the ROC Curve (AUC), the cut-off point, and sensitivity score (recall score) to evaluate the ML-model performance. RESULTS: Twenty-four adenocarcinoma patients had a mean age of 70 ± 5.79 years, a mean PSA of 12.42 ± 6.67 ng/ml, a mean prostate volume of 46.49 ± 23.13 ml, and a mean PSAD of 0.31 ± 0.22 ng/ml2 . Seventy-seven patients with benign tissue reports had a mean age of 66.39 ± 6.66 years, a mean PSA of 11.31 ± 7.50 ng/ml, a mean prostate volume of 65.25 ± 35.88 ml, and a mean PSAD of 0.19 ± 0.13 ng/ml2 . On the validation cohort, XGBoost had the best AUC of 0.76, which considered 80% sensitivity and 72% specificity at a probability cutoff of 57%. The remaining possible ML models performed worse with lesser AUC. The worst was Naïve Bayes, with AUC of 0.50. CONCLUSIONS: ML models facilitate PIRADS 3 patient selection for MRI/US fusion biopsies. ML could optimize how we use previously known clinical risk factors to their full potential.

No Benefit of Wearing Compression Stockings after Endovenous Thermal Ablation of Varicose Veins: A Systematic Review and Meta-Analysis.

OBJECTIVE: This meta-analysis was conducted to investigate whether compression stockings were necessary after endovenous thermal ablation of varicose veins. DATA SOURCES: Electronic databases, including MEDLINE, EMBASE, and the Cochrane Library database, were searched from inception to 10 March 2021 to identify all the related trials. METHODS: Random or fixed effects models were used to generate pooled mean difference (MD) or standardised mean difference (SMD) for continuous data, risk ratios (RRs) for dichotomous data, and related 95% confidence intervals (95% CIs). The quality of evidence was graded with a specific tool (GRADEpro GDT) from the GRADE working group. RESULTS: A total of seven randomised controlled trials (RCTs) comprising 1 146 patients were included in this meta-analysis. Wearing compression stockings was correlated with lower post-operative pain scores from a 0 to 100 mm visual analogue scale (MD -8.00; 95% CI -12.01 - -3.99; p < .001). No difference was observed between wearing compression stockings or not in quality of life (SMD 0.45; 95% CI 0.14 - 1.04), major complications (RR 0.64; 95% CI 0.26 -1.59), target vein occlusion rates (RR 0.99; 95% CI 0.96 - 1.02), or time to return to work (MD -0.43; 95% CI 1.06 - 0.19). CONCLUSION: After endovenous thermal ablation of varicose veins, wearing compression stockings was not associated with a better outcome except for mild pain relief. Post-operative compression stockings may be unnecessary after endovenous thermal ablation.