Appl Clin Inform 2020; 11(01): 142-152
DOI: 10.1055/s-0040-1701256
Research Article
Georg Thieme Verlag KG Stuttgart · New York

Joint Design with Providers of Clinical Decision Support for Value-Based Advanced Shoulder Imaging

Michael C. Brunner
1  Department of Radiology, William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin, United States
2  Department of Radiology, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, United States
,
Scott E. Sheehan
1  Department of Radiology, William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin, United States
2  Department of Radiology, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, United States
,
Eric M. Yanke
3  Department of Medicine, William S. Middleton Memorial Veteran Hospital, Madison, Wisconsin, United States
,
Dean F. Sittig
4  Department of Biomedical Informatics, University of Texas Health Science Center, Houston, Texas, United States
,
Nasia Safdar
3  Department of Medicine, William S. Middleton Memorial Veteran Hospital, Madison, Wisconsin, United States
5  Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, United States
,
Barbara Hill
6  Population Health Sciences, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, United States
,
Kenneth S. Lee
2  Department of Radiology, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, United States
,
John F. Orwin
7  Department of Orthopedics and Rehabilitation, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, United States
,
David J. Vanness
8  Department of Health Policy and Administration, Pennsylvania State University, University Park, Pennsylvania, United States
,
Christopher J. Hildebrand
3  Department of Medicine, William S. Middleton Memorial Veteran Hospital, Madison, Wisconsin, United States
5  Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, United States
,
Michael A. Bruno
9  Department of Radiology, The Penn State Milton S. Hershey Medical Center and Penn State College of Medicine, Hershey, Pennsylvania, United States
,
Timothy J. Erickson
10  Department of Physical Medicine and Rehabilitation, William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin, United States
,
Ryan Zea
11  Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, Wisconsin, United States
,
D. Paul Moberg
6  Population Health Sciences, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, United States
› Author Affiliations
Funding This work was supported by Merit Pilot Project (Award # PPO 15–178) from the U.S. Department of Veterans Affairs Health Services Research and Development Service. The contents do not represent the views of the U.S. Department of Veterans Affairs or the United States Government.
Further Information

Publication History

28 October 2019

23 December 2019

Publication Date:
19 February 2020 (online)

Abstract

Background Provider orders for inappropriate advanced imaging, while rarely altering patient management, contribute enough to the strain on available health care resources, and therefore the United States Congress established the Appropriate Use Criteria Program.

Objectives To examine whether co-designing clinical decision support (CDS) with referring providers will reduce barriers to adoption and facilitate more appropriate shoulder ultrasound (US) over magnetic resonance imaging (MRI) in diagnosing Veteran shoulder pain, given similar efficacies and only 5% MRI follow-up rate after shoulder US.

Methods We used a theory-driven, convergent parallel mixed-methods approach to prospectively (1) determine medical providers' reasons for selecting MRI over US in diagnosing shoulder pain and identify barriers to ordering US, (2) co-design CDS, informed by provider interviews, to prompt appropriate US use, and (3) assess CDS impact on shoulder imaging use. CDS effectiveness in guiding appropriate shoulder imaging was evaluated through monthly monitoring of ordering data at our quaternary care Veterans Hospital. Key outcome measures were appropriate MRI/US use rates and transition to ordering US by both musculoskeletal specialist and generalist providers. We assessed differences in ordering using a generalized estimating equations logistic regression model. We compared continuous measures using mixed effects analysis of variance with log-transformed data.

Results During December 2016 to March 2018, 569 (395 MRI, 174 US) shoulder advanced imaging examinations were ordered by 111 providers. CDS “co-designed” in collaboration with providers increased US from 17% (58/335) to 50% (116/234) of all orders (p < 0.001), with concomitant decrease in MRI. Ordering appropriateness more than doubled from 31% (105/335) to 67% (157/234) following CDS (p < 0.001). Interviews confirmed that generalist providers want help in appropriately ordering advanced imaging.

Conclusion Partnering with medical providers to co-design CDS reduced barriers and prompted appropriate transition to US from MRI for shoulder pain diagnosis, promoting evidence-based practice. This approach can inform the development and implementation of other forms of CDS.

Protection of Human and Animal Subjects

The study was performed in compliance with the World Medical Association Declaration of Helsinki on Ethical Principles for Medical Research Involving Human Subjects and was approved by the University of Wisconsin Institutional Review Board.


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