Radiologist Point-of-Care Clinical Decision Support and Adherence to Guidelines for Incidental Lung Nodules.

PURPOSE To evaluate the effect of a workstation-integrated, point-of-care, clinical decision support (CDS) tool on radiologist adherence to radiology department guidelines for follow-up of incidental pulmonary nodules detected on abdominal CT. METHODS The CDS tool was developed to facilitate adherence to department guidelines for managing pulmonary nodules seen on abdominal CT. In October 2012, the tool was deployed within the radiology department of an academic medical center and could be used for a given abdominal CT at the discretion of the interpreting radiologist. We retrospectively identified consecutive patients who underwent abdominal CT (in the period from January 2012 to April 2013), had no comparison CT scans available, and were reported to have a solid, noncalcified, pulmonary nodule. Concordance between radiologist follow-up recommendation and department guidelines was compared among three groups: patients scanned before implementation of the CDS tool; and patients scanned after implementation, with versus without use of the tool. RESULTS A total of 409 patients were identified, including 268 for the control group. Overall, guideline concordance was higher after CDS tool implementation (92 of 141 [65%] versus 133 of 268 [50%], P = .003). This finding was driven by the subset of post-CDS implementation cases in which the CDS tool was used (57 of 141 [40%]). In these cases, guideline concordance was significantly higher (54 of 57 [95%]), compared with post-implementation cases in which CDS was not used (38 of 84 [45%], P < .001), and to a control group of patients from before implementation (133 of 268 [50%]; P < .001). CONCLUSIONS A point-of-care CDS tool was associated with improved adherence to guidelines for follow-up of incidental pulmonary nodules.

[1]  Carol C Wu,et al.  Does a clinical decision rule using D-dimer level improve the yield of pulmonary CT angiography? , 2011, AJR. American journal of roentgenology.

[2]  Michael Zalis,et al.  Advanced search of the electronic medical record: augmenting safety and efficiency in radiology. , 2010, Journal of the American College of Radiology : JACR.

[3]  James H Thrall,et al.  Decision support for radiologist report recommendations. , 2011, Journal of the American College of Radiology : JACR.

[4]  Bibb Allen.  Five reasons radiologists should embrace clinical decision support for diagnostic imaging. , 2014, Journal of the American College of Radiology : JACR.

[5]  Ramin Khorasani,et al.  Ten commandments for effective clinical decision support for imaging: enabling evidence-based practice to improve quality and reduce waste. , 2014, AJR. American journal of roentgenology.

[6]  G. Meyer,et al.  Massachusetts General Physicians Organization's quality incentive program produces encouraging results. , 2013, Health affairs.

[7]  J. Austin,et al.  Guidelines for management of small pulmonary nodules detected on CT scans: a statement from the Fleischner Society. , 2005, Radiology.

[8]  D. Noonan,et al.  A Think Tank of TINK/TANKs: Tumor-Infiltrating/Tumor-Associated Natural Killer Cells in Tumor Progression and Angiogenesis , 2014, Journal of the National Cancer Institute.

[9]  James A Brink,et al.  Managing incidental findings on abdominal CT: white paper of the ACR incidental findings committee. , 2010, Journal of the American College of Radiology : JACR.

[10]  P. Marcovici,et al.  Journal Club: Structured radiology reports are more complete and more effective than unstructured reports. , 2014, AJR. American journal of roentgenology.

[11]  R. Munden,et al.  Small Pulmonary Nodule Management: A Survey of the Members of the Society of Thoracic Radiology With Comparison to the Fleischner Society Guidelines , 2011, Journal of thoracic imaging.

[12]  D. Naidich,et al.  Clinical significance of lung nodules reported on abdominal CT. , 2012, AJR. American journal of roentgenology.

[13]  David F Yankelevitz,et al.  CT screening for lung cancer: alternative definitions of positive test result based on the national lung screening trial and international early lung cancer action program databases. , 2014, Radiology.

[14]  E. Kazerooni,et al.  Performance of Lung-RADS in the National Lung Screening Trial , 2015, Annals of Internal Medicine.

[15]  James H Thrall,et al.  Effect of computerized order entry with integrated decision support on the growth of outpatient procedure volumes: seven-year time series analysis. , 2009, Radiology.

[16]  R. Duszak,et al.  Delivery of appropriateness, quality, safety, efficiency and patient satisfaction. , 2014, Journal of the American College of Radiology : JACR.

[17]  Ronald L Eisenberg,et al.  Ways to improve radiologists' adherence to Fleischner Society guidelines for management of pulmonary nodules. , 2013, Journal of the American College of Radiology : JACR.

[18]  J. Thrall.  Appropriateness and imaging utilization: "computerized provider order entry and decision support". , 2014, Academic radiology.

[19]  M. Aronson,et al.  Incidentally Detected Lung Nodules: Clinical Predictors of Adherence to Fleischner Society Surveillance Guidelines , 2014, Journal of computer assisted tomography.

[20]  Carol C Wu,et al.  Managing incidental thyroid nodules detected on imaging: white paper of the ACR Incidental Thyroid Findings Committee. , 2015, Journal of the American College of Radiology : JACR.

[21]  Ramin Khorasani,et al.  Does clinical decision support reduce unwarranted variation in yield of CT pulmonary angiogram? , 2013, The American journal of medicine.

[22]  Fenghai Duan,et al.  Projected outcomes using different nodule sizes to define a positive CT lung cancer screening examination. , 2014, Journal of the National Cancer Institute.

[23]  Katherine P Andriole,et al.  Factors associated with radiologists' adherence to Fleischner Society guidelines for management of pulmonary nodules. , 2012, Journal of the American College of Radiology : JACR.

[24]  James L Mulshine,et al.  Lung cancer screening. , 2005, The oncologist.

[25]  Lisa M. Schwartz,et al.  Resource use and guideline concordance in evaluation of pulmonary nodules for cancer: too much and too little care. , 2014, JAMA internal medicine.

[26]  Mark Masciocchi,et al.  Quality review: Fleischner criteria adherence by radiologists in a large community hospital. , 2012, Journal of the American College of Radiology : JACR.

[27]  J. Brink.  Clinical decision-making tools for exam selection, reporting and dose tracking , 2014, Pediatric Radiology.

[28]  James H Thrall,et al.  Recommendations for additional imaging in radiology reports: multifactorial analysis of 5.9 million examinations. , 2009, Radiology.

[29]  M. Chatterji,et al.  When does a radiologist's recommendation for follow-up result in high-cost imaging? , 2012, Radiology.

[30]  Giles W Boland,et al.  Appropriateness, scheduling, and patient preparation. , 2014, Journal of the American College of Radiology : JACR.

[31]  M. Weinstein,et al.  Recommendations of the Panel on Cost-effectiveness in Health and Medicine. , 1996, JAMA.

[32]  D. Sahani,et al.  Incidental Pulmonary Nodules Detected on Abdominal Computed Tomography , 2012, Journal of computer assisted tomography.

[33]  Ella A. Kazerooni,et al.  Lung cancer screening: Clinical practice guidelines in oncology , 2012 .