Emergency residents struggle to order appropriate imaging tests – FierceMedicalImaging

Emergency residents struggle to order appropriate imaging tests

Research published in the October issue of the American Journal of Roentgenology has found that over their course of residency, emergency medicine residents fail to show significant improvement in their ability to choose appropriate imaging studies.

For purposes of the study, researchers from the department of radiology at the Albert Einstein College of Medicine and Montefiore Medical Center created an online multiple-choice questionnaire that included 10 clinical scenarios taken from the American College of Radiology appropriateness guidelines. An invitation and link to the survey was sent to directors and coordinators of American Council for Graduate Medical Education-accredited emergency medicine residence training programs with the request that they forward the survey to their current residents.

The residents were asked to select the most appropriate imaging study for each of the ten scenarios. The scenarios included:

  • Acute onset flank pain and hematuria with otherwise normal laboratories and physical, suspected stone disease
  • Acute chest pain and shortness of breath, suspected pulmonary embolus
  • Acute right upper quadrant pain, fever, elevated WBC count and positive Murphy’s sign, suspected acute cholecystitis
  • Acute respiratory illness (cough, dyspnea, chest pain and fever) in HIV-positive patient
  • Hemodynamically stable 25-year-old man after blunt abdominal trauma, moderate clinical suspicion of intra-abdominal injury, FAST scan (Focused Assessment with Sonography for Trauma) positive for intraperitoneal fluid
  • Acute low back pain in an otherwise healthy 18 year old with recent minor trauma
  • Soft tissue edema and ulcer of the foot in patient with diabetes-suspected osteomyelitis
  • Painful palpable mass in the breast of a 14-year-old girl
  • Febrile seizure (one episode lasting 10 minutes) in a previously healthy 2-year-old child, now with normal neurological examination
  • Clinical laboratory results and examination consistent with recurrent sinusitis

According to the researchers, 583 emergency residents participated in the survey. The overall number of questions answered correctly was 7.1 out of the 10. First-year through fourth-year residents respectively answered 6.9 , 7.1, 7.1, and 7.5 correctly.

“This finding suggests that there is a role for a more-rigorous focused instruction to better familiarize residents with appropriateness guidelines for diagnostic imaging selection,” the researchers concluded.

Interestingly, the results of the study differed only slightly from similar research undertaken 10 years earlier and published in the journal Academic Radiology.

To learn more:
– see the study in the American Journal of Roentgenology
– check out the 2003 study in Academic Radiology

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Appropriateness education may not reduce unnecessary CTPA imaging
Reducing unnecessary pediatric scans cuts future cancer risk
CDS tool cuts inappropriate heart imaging tests

National Decision Support Company and TransformativeMed Partner for Cerner Integration

National Decision Support Company and TransformativeMed Partner for Cerner Integration

Integration with Cerner EMR Delivers Safer, More Cost-Effective Medical Imaging

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Andover, MA (PRWEB) September 24, 2013

National Decision Support Company (NDSC) has entered into an agreement with TransformativeMed, a publisher of EMR-connected smart health apps, to provide seamless integration of ACR Select into Cerner Millennium as part of it’s Smart Medicine portfolio. ACR Select’s clinical content provides structured reasons for radiology procedures at the point-of-order and guides clinicians to the most appropriate imaging orders based on American College of Radiology (ACR) Appropriateness Criteria®.

TransformativeMed’s integration capability enables physicians to utilize the ACR Select decision support content within their existing PowerChart ordering workflow. “Integration of imaging guidelines at the point-of-order, directly within the EMR workflow is a cornerstone to improving the quality of imaging orders,” said Bob Cooke, VP of Marketing, NDSC. “TransformativeMed’s solution provides an optimal experience with our content and Cerner’s EMR.”

TransformativeMed has been successfully providing best-in-class healthcare apps for years. “We enable better care by connecting innovative and impactful solutions to the clinical data and workflow that is otherwise locked inside the EMR. We are excited to offer the ability for Cerner users to access ACR Select,” said David Stone, CEO of TransformativeMed.

TransformativeMed will leverage the company’s extensive experience with Cerner’s Application Programming Interfaces (API’s) to provide the best-possible decision support workflow for physicians, including integrated analytics, in order to maximize the impact of ACR Select content. “We are pleased to be working with TransformativeMed,” said Michael Mardini, CEO, NDSC. “This new relationship allows us to continue our world-changing mission of delivering ‘smart medicine’ through broad access to ‘national standard’ imaging guidelines.”

About National Decision Support Company
National Decision Support Company (NDSC) is the exclusive distributor of national standards clinical decision support (CDS) imaging guidelines. NDSC provides the technical platform, support, and licensing of digitally consumable CDS that continuously educates providers regarding the latest evidence-based approach to medicine without disrupting the doctor-patient relationship or delaying needed care. For more information, visithttp://www.NationalDecisionSupport.com.

About ACR Select
ACR Select, provided by National Decision Support Company, is the complete web service version of American College of Radiology (ACR) Appropriateness Criteria® (AC). ACR AC is a comprehensive national standards clinical decision support database that provide evidence-based guidance for the appropriate utilization of all medical imaging procedures. More than 300 volunteer physicians, representing more than 20 radiology and non-radiology specialty organizations, participate on the ACR AC expert panels, continuously updating these nationally transparent guidelines, and providing real-time access to the latest medical imaging procedure guidance. The ACR Select platform can be easily integrated with computerized ordering and electronic health record (EHR) systems so healthcare organizations can effortlessly consume ACR AC guidelines and ensure that the right patient gets the right scan for the right indication. For more information, visit http://www.ACRselect.org.

About TransformativeMed
TransformativeMed is driving a revolution in health information technology by seamlessly linking healthcare software applications to healthcare data and physician workflow. By enabling complete and easy integration with EMRs, TransformativeMed makes smart health apps possible. We partner with research institutions and cutting-edge developers to provide innovative clinical applications, including our Smart Handoffs and Smart Glucose solutions. For more information, visit http://www.TransformativeMed.com.

Inappropriate use drags on SPECT MPI’s prognostic value | Cardiovascular Business

Inappropriate use drags on SPECT MPI’s prognostic value

 - heart puzzle

An abnormal SPECT MPI does an excellent job stratifying risk in patients with appropriate indications for known or suspected heart disease but its value is diminished in cases of inappropriate use. These findings from a community-based evaluation validate the use of SPECT MPI, according to researchers, but they may apply only to low-risk patient populations.

In 2009, the American College of Cardiology, American Society of Nuclear Cardiology, the American College of Radiology and other groups created a set of appropriate use criteria (AUC) to help guide physicians in SPECT MPI’s use in patient care. That prompted Rami Doukky, MD, of Rush University Medical Center in Chicago, and colleagues to evaluate the impact of AUC on SPECT MPI’s prognostic value using a prospective cohort study. They published their results online Sept. 10 in  Circulation.

Twenty-two physicians from 11 practices in metro Chicago participated in the study. The study included 1,511 consecutive patients who underwent outpatient SPECT MPI between Aug. 15, 2007, and May 15, 2010. Applying the 2009 AUC, patients were stratified as having either appropriate or uncertain appropriateness tests (combined under the term appropriate in the analysis) or inappropriate tests. The primary endpoint was all-cause mortality and secondary endpoints were the composite of death or MI or the composite of cardiac death or MI.

Patients were followed for a mean 27 months. Of the total MPI referrals, 51.6 percent were appropriate, 2.9 percent uncertain and 45.5 percent inappropriate. Eleven percent of patients had myocardial perfusion defects.

In patients who had an appropriate or uncertain SPECT MPI, an abnormal scan predicted an increase in the risk of death, cardiac death, the composite of death or MI and the composite of cardiac death or MI. An abnormal SPECT MPI scan did not predict major adverse cardiac events compared with patients who had a normal scan.

Doukky and colleagues acknowledged that the rate of inappropriate use in their analysis was higher than results from other studies. They noted that in their study most of the scans were performed before the 2009 AUC were published and integrated into practice.

They emphasized the cost and health consequences of inappropriate use. “[A]lthough MPI is considered cost-effective overall, the diminished prognostic value with inappropriate testing could have serious implications on the overall cost-effectiveness of MPI, not to mention unnecessary radiation exposure,” they wrote. “In fact, minimizing inappropriate use is probably the best and most cost-efficient way to limit the radiation exposure in the community.”

Their analysis showed that patients in the inappropriate group were more likely to be asymptomatic with a lower likelihood of coronary artery disease and a lower 10-year Framingham coronary heart disease risk. In an accompanying editorial, Raymond J. Gibbons, MD, and Todd D. Miller, MD, of the Mayo Clinic in Rochester, wrote that consequently the results likely apply only to similar low-risk patient populations.

The editorial writers also pointed to the high variability between the inappropriate use rates for physicians, which ranged from 10 percent to 77 percent. “To the degree that there is similar, if not greater, variability in physicians across the country, the ‘group’ results presented here may not apply to many individual physicians or many practices with higher or lower rates of inappropriate studies,” they suggested.

Gibbons and Miller added that the issue of limited generalizability hounds other AUC studies. “This study is one step along the road to quality improvement, the ultimate goal of the AUC.”

The study was funded by a grant from Astellas Pharma U.S.

Why the evolution of Radiology includes social media | Common Sense

Why the evolution of Radiology includes social media

Posted by:  in Social Media Insights & Trends on September 22, 2013

We need to come out of the reading room – both literally and figuratively – to engage more proactively and meaningfully with referring physicians and patients. The fact is that patients will receive better care – and outcomes – with a more engaged radiologist.

Roger Eng, MD – President-Elect of the California Radiological Society

OK – Raise your hand if you LOVE your radiologist. [If you are married to a radiologist, you’re disqualified – put your hand down.] I’m not seeing many hands. What’s that? You don’t know who your radiologist is? If you don’t, you’re not unique. Yet radiologists have become increasingly important in the healthcare delivery system. For those of you who aren’t “medically inclined,” Radiologists are medical doctors (MDs) or doctors of osteopathic medicine (DOs) who specialize in diagnosing and treating diseases and injuries using medical imaging techniques, such as x-rays, computed tomography (CT), magnetic resonance imaging (MRI), nuclear medicine, positron emission tomography (PET) and ultrasound (Definition courtesy of the American College of Radiology).

I’m guessing that a few bells are starting to ring now – we’re all familiar with X-rays, MRIs and CT scans at this point. But what most of us don’t realize is that radiologists are usually behind the scenes – completely invisible to the patient. Most of their work is done in a “reading room” that’s completely separated from the exam rooms frequented by patients. It’s quite common for the radiologist to make an analysis of the test results they’re shown, write a report for the referring physician, and send the report back – and that’s the sum total of the engagement in the process.

Yet now, more than ever, the expertise of the radiologist needs to be an integrated part of the continuum of care. Dr. Cynthia Sherry chairs the Radiology Department at Texas Health Presbyterian hospital in Dallas, and is also the Chief Medical Director for the Radiology Leadership Institute. The RLI, a program of the American College of Radiology, is designed to reshape the future of the practice of Radiology.

The old stereotype of the “disengaged radiologist” in the back room absolutely needs to change. Imaging has become such an important part of health care delivery today that virtually all patients have an imaging test of some kind. When the situation calls for it and the patient has an advanced test early in the process, they have measurably better outcomes … the radiologist needs to be more engaged, earlier in the process.

Cynthia Sherry, MD – Medical Director, the Radiology Leadership Institute

That sentiment correlates well with a survey that was announced this week by GE Healthcare* as a part of their MIND Initiative (Making an Impact on Neurological Disorders). That survey, which focused on diagnoses of Multiple Sclerosis, Alzheimer’s Disease and Parkinson’s Disease, was able to quantify significant advantages (financial and otherwise) to reducing delays in diagnosis.

The RLI has developed a comprehensive curriculum that is designed to equip radiologists for leadership in the evolving model for delivering healthcare in the US. Underlying all of that leadership development is that radiologists are being trained and equipped to have a voice – and that’s where social media begins to come into play.

For a function that’s traditionally perceived as being a part of the “back office,” a surprising number of radiologists have taken to social media as a mechanism to build those broader connections with referring physicians and patients. We’re tracking over 200 online radiologists through our MDigitalLIfe initiative (you can find a list of them, along with other important members of the radiology community, in this twitter list). One of the most active of them is Garry Choy, a staff radiologist at Mass General Hospital and an instructor at Harvard Medical School. He’s also the founder of a proprietary social network for radiologists called radRounds – that now has over 12,000 members from around the world.

But Garry is also a huge proponent of Twitter – and when I asked him why, his response was, “because it saves me so much time.” Yes, you read that right. Since most non-Twitter-users seem to think of it as a huge time-suck, I was a little surprised myself. So I asked him to elaborate.

“As a radiologist, it’s critically important for me to be connected to all of the latest advancements in process and technology as it relates to medicine. The people I follow on Twitter act as a human filter for the best information. It also allows me to access the top experts in the world, in real time, when I have a question.”

Garry Choy, MD – Mass General Hospital’s Division of Emergency Radiology and Teleradiology

I’m lucky enough to be spending the weekend with some incredibly inspiring radiologists this weekend at the annual meeting of the California Radiological Society – where I’ll be making a presentation with Dr. James Chen on Radiology and Social Media on Sunday the 22nd at 12:00 PDT. We’ll be sharing some data on how Radiologists are using social media for the very first time, which is always exciting. And I’ll also be doing 1×1 “Online Activation” coaching with a couple of dozen radiologists who are ready to take that next step into the future. You can follow all the action through the hashtag #CalRad13.

There’s much more to come as radiologists embrace the future of their field – and as online communication looms large in that process, we’ll all be able to follow along. Enjoy the ride!

*GE Healthcare is a client of WCG.

– See more at: http://blog.wcgworld.com/2013/09/why-the-evolution-of-radiology-includes-social-media?utm_content=bufferfac9f&utm_source=buffer&utm_medium=twitter&utm_campaign=Buffer#sthash.CpjqRFZ0.dpuf

X-Ray Vision–can Radiologists perceive what others do not see? « Radiology Issues in a Changing World

X-Ray Vision–can Radiologists perceive what others do not see?

A cell phone lost, gone since when?  Last used earlier in the morning….

Where had it gone?  My husband, a farsighted intelligent man looked and looked everywhere he had been and anywhere it might have fallen.  Unhappy about the loss, he was determined to look long and hard in an attempt to recover it.   He believes I have x-ray vision, and sure that it would work its usual magic, he entreated me to look with him.  I, more skeptical, thought it a waste of time.   Reluctantly I relented, and followed in his footsteps to try and find it.  I am short sighted and even with glasses can’t see very well in the distance.  Yet I am a trained radiologist and one with years of reading cases.  He was sure that my systematic approach to looking for radiographic findings would allow me to find what he had not.

 We scoured the grocery store parking lot, asked at customer service and did all the things one should do to try and retrieve a hopelessly lost phone.  The next stop was the post office lot, which closed on a Sunday and thus empty.  I scanned the lot, looking for a black phone, on black asphalt.  A flat black rectangle, hard to see, and only possibly there…. I deliberately looked across the parking lot in the fashion I would use to systematically look for a finding on a case—first a glace across the ground, then deliberate looking back and forth up and down to capture the abnormality, however subtle and distinguish it from the background noise.

Much as one looks for the 2mm nodule at a lung base, described on the last report, but not immediately seen, I scanned the asphalt.  Looking for black phone on the parking lot, scanning back and forth.  No phone.  Almost defeated, I said –where did you park, where did you stand: retrace your steps.  I began the search on the road itself, a last ditch effort.  Cars passing by at some speed and there, on the road, black upon black was the outline of a small rectangular object, distinguished by a shiny exterior, a different texture, a subtle finding indeed, hidden in plain view.   Smashed beyond usefulness into the pavement, was the missing phone.

How does one search for a finding– almost imperceptible, yet there, real and once seen, obvious.  There have been many studies to look at a Radiologist’s eye motions, not predictable, not easily characterized. Yet the mature Radiologist has been shown for some time to look differently at an image than a novice.[i]  I believe we do look at images differently when we have experience, and can often recognize important abnormalities at a glance, yet I feel that we must also systematically target our search to overcome perception bias. We must see it all, but perceive and recognize the key the key findings—ALL of them!  We all know about the ”Instant Happiness Syndrome” where when we find the obvious abnormality, we stop looking for more…  Yet when one looks for this in Google Scholar there is inly one reference cited[ii].  We don’t have all that much insight into how we perceive images, despite looking at thousands a day.

Understanding how radiologists detect and interpret images is complex and key to training new Radiologists,  improving our own performance, and to learn how to best integrating computer aided diagnosis into our diagnostic armamentarium.    Given a case with thousands of images, we cannot look carefully at every pixel, yet we are tasked with finding every significant finding.  How can we do this if we can’t even find the Gorilla in the picture?[iii]  How do we actually do it?

That seems to depend on depends on our level of training, experience and subject matter expertise. Thinking about how we recognize an ”Aunt Minnie” or how we  “Gestalt” a case is fascinating, and indeed a real phenomenon!  “Gestalt Theory: Implications for Radiology Education” by Koontz and Gunderman i[iv]s a thought provoking must-read for all of us! Their integration of Art, Radiology, Gestalt Theory and our lives as physicians begins to explain how we “see.” Examples of how and why we perceive images, suggest such features as the similarity and proximity of objects change our perception of the relationship of one to the other, and make some things easier to see than others. He suggests that this explains why it is harder to see pulmonary nodules in the lung fields because we are distracted by the heart shadow—bright and bold in the center.  On some level, I think we know this, almost instinctively, after years of plying our profession.

How do I look at a case?  I think I “gestalt” it, and then go back, and do a targeted search, looking carefully for findings I am expecting to see.  That is where the old reports are crucial—if someone saw something the last time, I will make sure to look especially hard to see it again.  The history is key!  If I know the patient has right lower quadrant pain, fever and an elevated white count, I will certainly make sure the appendix is normal!  And then I will look again, just to be sure!

Does experience help?  It seems so!  It seems that novice Radiologists eyes search haphazardly for findings, while more experienced Radiologists exhibit more concise eye movements, finding pertinent abnormalities faster[v]. Yet it has been demonstrated that, as a profession, we are no better than others at finding WALDO.[vi] I can’t argue with science—but I like to think we would be more skilled…

It seems that despite our ability to perceive abnormalities in a flash on cases, and to find more abnormalities than non-Radiologists, we still don’t really know why.  We don’t know how we do it, nor why we make mistakes.  Distractions, poor working conditions, poor technique, fatigue, lack of training, lack of knowledge may be invoked[vii][viii]; yet errors in perception are real, and not well understood as well.  How can we teach our Residents that which we do not ourselves understand? How can we perform better, if we don’t understand our process?  How can we make sure we always see the gorilla in the CT?

Do you think we have x-ray vision?  Or was I just lucky to find that cell phone?

Should I avoid talking to my doctor and jump right to tests?

Should I avoid talking to my doctor and jump right to tests?

Should I avoid talking to my doctor and jump right to tests?
An excerpt from 
The Thrifty Patient – Vital Insider Tips for Saving Money and Staying Healthy.

Do I really need an MRI?  Do I really need blood work? This often? Should I avoid talking to my doctor and jump right to tests?

Americans love technology, whether it’s carrying the latest iPhone or buying the newest flat-screen TV with 3D technology. Naturally, our fascination with technology has spilled over into medical care, where everyone, including doctors in training, seems focused on what the x-ray, CT scan, MRI, or blood work showed.

Sadly, this trend is seriously misguided. More testing does not lead to better care. More testing does not lead to more accurate diagnoses. Research has shown that Americans receive too many tests and procedures compared to other countries. If anything, more testing seems to be associated with worsening health. The leading cause of radiation exposure is too many medical scans, such as CTs. The worst part? With all of the additional testing, as a country we spend more and are less healthy than other nations!

The truth is that a test, whether through blood work or imaging studies, is merely a tool and a clue. The test results are not the absolute truth. They do require some interpretation. People are far more complex than a simple blood count, an x-ray, or other lab test. In isolation without a patient story, these results are meaningless and not helpful. In the hands of a good doctor, these clues can be tremendously helpful. In the hands of a less-skilled doctor, they can result in unnecessary additional testing, worry, and misdiagnoses.

Where did this false faith in the power of testing come from? Perhaps it has been due to the popularity of medical dramas such as ER and House, where the public witnesses the dizzying array of tests being ordered. No one leaves the hospital without something being done. Perhaps we feel compelled to get testing done because co-workers, friends, or family members who talk about their health issues seem to get a lot of tests done. Are we doing something wrong if we don’t get tested? It’s extraordinarily hard to go against popular trends, even if they are wrong for both doctors and patients. Although some doctors argue that overtesting is to prevent malpractice suits, this is only part of the story.

Doctors are also prone to this misconception that tests reveal the absolute truth. In the book The Empowered Patient, CNN Senior Medical Correspondent Elizabeth Cohen highlights two misdiagnoses by doctors because they relied only on a test result, the biopsy report. They didn’t interpret the result in the context of the patient. The results didn’t make sense given the patient’s medical history. Thankfully, both patients avoided unnecessary and potentially dangerous therapies because the patients discovered their diagnosis didn’t fit the typical profile. As noted previously, a test result is simply a test result. It doesn’t give you or your doctor the truth. It is merely a piece in the puzzle. In the previous examples, the piece was for an entirely difference puzzle! Even doctors can rely on these tools too frequently and make serious errors.

Why is this important to you?

In the future, you will be more responsible for costs, including blood work and imaging studies. Your doctor probably won’t ask you if you can afford to do the test. If you don’t stop him, you might get tests you really don’t need. Help your doctor pick what tests are absolutely necessary by asking the following:

What is your diagnosis?

How will testing help with the diagnosis? Are there other alternative diagnoses or possibilities you are considering? What are the consequences of not testing? Do I need it now? Can I safely wait or postpone testing to see if the condition improves? Will the testing change the treatment plan? If so, how?

Davis Liu is a family physician who blogs at Saving Money and Surviving the Healthcare Crisis and is the author of The Thrifty Patient – Vital Insider Tips for Saving Money and Staying Healthy and Stay Healthy, Live Longer, Spend Wisely.

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