TY - JOUR
T1 - Impact of an automated multimodality point-of-order decision support tool on rates of appropriate testing and clinical decision making for individuals with suspected coronary artery disease
T2 - A prospective multicenter study
AU - Lin, Fay Y.
AU - Dunning, Allison M.
AU - Narula, Jagat
AU - Shaw, Leslee J.
AU - Gransar, Heidi
AU - Berman, Daniel S.
AU - Min, James K.
N1 - Funding Information:
United HealthCare provided exemption from the requirements of prior RBM authorization during the duration of the study. MDDX provided support for development of the AUC-DST and emissionic data capture. This work was funded, in part, by a generous gift from the Michael Wolk Foundation . The authors are indebted to Dr. Neil Jensen of United Healthcare, Dr. Tony DeFrance of HealthHelp, and Dan Gebow of MDDX for facilitating this project. The sponsors were not responsible for the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript. Dr. Min has received grant/research support from GE Healthcare and Vital Images ; is a consultant and/or has received honoraria from GE Healthcare; and has equity interest in MDDX. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Joseph Cacchione, MD, served as Guest Editor for this paper.
PY - 2013/7/23
Y1 - 2013/7/23
N2 - Objectives This study sought to evaluate the impact of a multimodality-appropriate use criteria decision support tool (AUC-DST) on rates of appropriate testing and clinical decision making. Background AUC have been developed to guide utilization of noninvasive imaging for individuals with suspected coronary artery disease (CAD). The effect of a point-of-order AUC-DST on rates of appropriateness and clinical decision making has not been examined. Methods We performed a prospective multicenter cohort study evaluating physicians who ordered CAD imaging tests for consecutive patients insured by 1 large private payer. During an 8-month study period, each study site was granted exemption from prior authorization requirements by radiology benefits managers. An AUC-DST was employed to determine appropriateness ratings for myocardial perfusion scintigraphy (MPS), stress echocardiography (STE), or coronary computed tomographic angiography (CCTA), as well as intended downstream testing and therapy. Results One hundred physicians used the AUC-DST for 472 patients (age 55.6 ± 9.6 years, 61% male, 52% prior known CAD) over 8 months for MPS (72%), STE (24%), and CCTA (5%). The AUC-DST required an average of 137 ± 360 s to determine the appropriateness category that, by American College of Cardiology AUC, was considered appropriate in 241 (51%), uncertain in 96 (20%), inappropriate in 85 (18%), and not addressed in 50 (11%). For tests ordered in the first 2 months compared with the last 2 months, appropriate tests increased from 49% to 61% (p = 0.02), whereas inappropriate tests decreased from 22% to 6% (p < 0.001). During this period, intended changes in medical therapy increased from 11% to 32% (p = 0.001). Conclusions A point-of-order AUC-DST enabled rapid determination of test appropriateness for CAD evaluation and was associated with increased and decreased testing for appropriate and inappropriate indications, respectively. These changes in test ordering were associated with greater intended changes in post-test medical therapy.
AB - Objectives This study sought to evaluate the impact of a multimodality-appropriate use criteria decision support tool (AUC-DST) on rates of appropriate testing and clinical decision making. Background AUC have been developed to guide utilization of noninvasive imaging for individuals with suspected coronary artery disease (CAD). The effect of a point-of-order AUC-DST on rates of appropriateness and clinical decision making has not been examined. Methods We performed a prospective multicenter cohort study evaluating physicians who ordered CAD imaging tests for consecutive patients insured by 1 large private payer. During an 8-month study period, each study site was granted exemption from prior authorization requirements by radiology benefits managers. An AUC-DST was employed to determine appropriateness ratings for myocardial perfusion scintigraphy (MPS), stress echocardiography (STE), or coronary computed tomographic angiography (CCTA), as well as intended downstream testing and therapy. Results One hundred physicians used the AUC-DST for 472 patients (age 55.6 ± 9.6 years, 61% male, 52% prior known CAD) over 8 months for MPS (72%), STE (24%), and CCTA (5%). The AUC-DST required an average of 137 ± 360 s to determine the appropriateness category that, by American College of Cardiology AUC, was considered appropriate in 241 (51%), uncertain in 96 (20%), inappropriate in 85 (18%), and not addressed in 50 (11%). For tests ordered in the first 2 months compared with the last 2 months, appropriate tests increased from 49% to 61% (p = 0.02), whereas inappropriate tests decreased from 22% to 6% (p < 0.001). During this period, intended changes in medical therapy increased from 11% to 32% (p = 0.001). Conclusions A point-of-order AUC-DST enabled rapid determination of test appropriateness for CAD evaluation and was associated with increased and decreased testing for appropriate and inappropriate indications, respectively. These changes in test ordering were associated with greater intended changes in post-test medical therapy.
KW - appropriate use criteria cardiac
KW - computed tomographic angiography
KW - decision support tool
KW - myocardial perfusion SPECT
KW - stress echocardiography
UR - http://www.scopus.com/inward/record.url?scp=84880274822&partnerID=8YFLogxK
U2 - 10.1016/j.jacc.2013.04.059
DO - 10.1016/j.jacc.2013.04.059
M3 - Article
C2 - 23707319
AN - SCOPUS:84880274822
SN - 0735-1097
VL - 62
SP - 308
EP - 316
JO - Journal of the American College of Cardiology
JF - Journal of the American College of Cardiology
IS - 4
ER -