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Displaying radiation exposure and cost information at order entry for outpatient diagnostic imaging: a strategy to inform clinician ordering
  1. Jenna F Kruger1,
  2. Alice Hm Chen2,
  3. Alex Rybkin3,
  4. Kiren Leeds2,
  5. David Guzman2,
  6. Eric Vittinghoff4,
  7. L Elizabeth Goldman2
  1. 1Center for Quality and Clinical Effectiveness, Lucile Packard Children's Hospital at Stanford, Palo Alto, California, USA
  2. 2Department of Medicine, University of California, San Francisco, San Francisco, California, USA
  3. 3Radiology and Biomedical Imaging, UCSF, San Francisco, California, USA
  4. 4UCSF, San Francisco, California, USA
  1. Correspondence to Dr L Elizabeth Goldman, Department of Medicine, University of California, San Francisco, 1001 Potrero Av, Ward 13, San Francisco, CA 94110, USA; legoldman{at}medsfgh.ucsf.edu

Abstract

Background Displaying radiation exposure and cost information at electronic order entry may encourage clinicians to consider the value of diagnostic imaging.

Methods An urban safety-net health system displayed radiation exposure information for CT and cost information for CT, MRI and ultrasound on an electronic referral system for outpatient ordering. We assessed whether there were differences in numbers of outpatient CT scans and MRIs per month relative to ultrasounds before and after the intervention, and evaluated primary care clinicians’ responses to the intervention.

Results There were 23 171 outpatient CTs, 15 052 MRIs and 43 266 ultrasounds from 2011 to 2014. The ratio of CTs to ultrasounds decreased by 15% (95% CI 9% to 21%), from 58.2 to 49.6 CTs per 100 ultrasounds; the ratio of MRIs to ultrasounds declined by 13% (95% CI 7% to 19%), from 37.5 to 32.5 per 100. Of 300 invited, 190 (63%) completed the web-based survey in 17 clinics. 154 (81%) noticed the radiation exposure information and 158 (83.2%) noticed the cost information. Clinicians believed radiation exposure information was more influential than cost information: when unsure clinically about ordering a test (radiation=69.7%; cost=46.4%), when a patient wanted a test not clinically indicated (radiation=77.5%; cost=54.8%), when they had a choice between imaging modalities (radiation=77.9%; cost=66.6%), in patient care discussions (radiation=71.9%; cost=43.2%) and in trainee discussions (radiation=56.5%; cost=53.7%). Resident physicians and nurse practitioners were more likely to report that the cost information influenced them (p<0.05).

Conclusions Displaying radiation exposure and cost information at order entry may improve clinician awareness about diagnostic imaging safety risks and costs. More clinicians reported the radiation information influenced their clinical practice.

  • Primary care
  • Patient safety
  • Decision making
  • Attitudes

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Footnotes

  • Contributors JFK contributed in concept and design, acquisition of the data, analysis and interpretation of the data, drafting the manuscript and obtaining funding. AHC contributed in concept and design, critical revision of the manuscript, technical support, supervision and obtaining funding. AR contributed in concept and design, critical revision of the manuscript, technical support and obtaining funding. KL contributed in acquisition of the data, critical revision of the manuscript and technical support. EV contributed in statistical analysis and interpretation of the data and critical revision of the manuscript. DG contributed in statistical analysis and interpretation of the data and critical revision of the manuscript. LEG contributed in concept and design, acquisition of the data, analysis and interpretation of the data, drafting and critical revision of manuscript, obtaining funding and supervision.

  • Funding Agency for Healthcare Research and Quality (K08 HS018090-01), National Institutes of Health National Center for Research Resources (Office of the Director UCSF-CTSI Grant Number KL2 RR024130), San Francisco General Hospital Foundation.

  • Competing interests None declared.

  • Ethics approval Institutional Review Board at the University of California, San Francisco.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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