L27: When to Image, and When Not to Image

Question 1

What is the Choosing Wisely program?

Answer 1

• over 70 medical specialty societies
• Choosing Wisely Canada (2014 - present)

aims to promote conversations between physicians and patients by helping patients choose care that is:

• supported by evidence
• not duplicative of other tests or procedures already received
• free from harm
• truly necessary

Question 2

Choosing Wisely

What are the Five Things Physicians and Patients Should Question (Canada)?

Answer 2

• do not do imaging for lower back pain unless red flags are present
• do not do imaging for minor head trauma unless red flags are present
• do not do imaging for uncomplicated headache unless red flags are present
• do not do computed tomography (CT) for the evaluation of suspected appendicitis in children until after ultrasound has been considered as an option
• do not do an ankle x-ray series in adults for minor injuries

Question 3

Choosing Wisely

What are the Ten Things Physicians and Patients Should Question (Canada)?

Answer 3

• do not order CT head scans in adults and children who have suffered minor head injuries (unless positive for a validated head injury clinical decision rule)
• do not prescribe antibiotics in adults with bronchitis/asthma and children with bronchiolitis
• do not order lumbosacral (low back) spinal imaging in patients with non-traumatic low back pain who have no red flags/pathologic indicators

Question 4

Choosing Wisely

What are the Five Things Physicians and Patients Should Question (USA)?

Answer 4

• do not do imaging for uncomplicated headache
• do not image for suspected pulmonary embolism (PE) without moderate or high pre-test probability of PE
• avoid admission or preoperative chest x-rays for ambulatory patients with unremarkable history and physical exam
• do not do computed tomography (CT) for the evaluation of suspected appendicitis in children until after ultrasound has been considered as an option
• do not recommend follow-up imaging for clinically inconsequential adnexal cysts

Question 5

What are clinical decision scoring systems?

Answer 5

algorithms designed to predict outcomes, aid decision making, support treatment options, manage clinical risk, or improve efficiency

Question 6

What does CDS decrease?

Answer 6

• decreased rate of CT for non-traumatic headaches from 15.3% to 9.5%, but did not increase yield
• (Wells criteria) decreased CT PE studies by 20.1% (26.4 to 21.2/1000 patients), and yield increased 69% (5.8% to 9.8%) – yield was 51.3% lower when MD over-rode CDS
• decreased pediatric CT in minor head trauma from 24.2% to 21.6%, with no change in positive findings
• decreases volume of imaging for low back pain in an urban emergency department

Question 7

How do ED visit times for minor head trauma patient differ with and without CTs?

Answer 7

• without head CT: 1.8
• with head CT: 3.7
• difference: 1.9
• efficiency – both the patient and emergency departyment staff save lots of time if imaging is ordered effectively
• cost decreases substantially

Question 8

Why should we care about medical imaging?

Answer 8

• cost: 2017 (CADTH), 5.6M CT’s and 1.9M MRIs performed on Canadian patients – annual operating costs for imaging alone are estimated to exceed $3 billion
• issue of access: inappropriate imaging lengthens wait times, delays appropriate examinations
• appropriate imaging can save substantial time/cost – avoids unnecessary additional investigations, shortens hospitalizations, and reduces the need for costly invasive procedures / imaging minor head trauma in ED increases average length of stay
• minimize risk to patients – unnecessary radiation, potentially invasive workup, and treatment of incidental findings
• ⅓ of all physicians acquiesce to patient requests for tests and procedures – even when they know they are not necessary
• MD decisions account for 80% of all healthcare expenditures – support for decisions

Question 9

How has research in BC shown a modest decrease in targeted exams without significant short-term negative impact on patient care?

Answer 9

• workflow must be simple, seamless
• point-of-care is most effective
• all members of dept/community must be on-side
• ensuring appropriateness down referral pathway, from NPs, family MDs, specialists
• patients as drivers for MI exams – must provide patients with educational material
• respect clinical judgment – data analytics to drive change must be handled with care (‘reducing practice variation’)

Question 10

CDS is not simply a software install. What is it?

Answer 10

a ‘culture change’

• when enterprise-wide CDS is available, patients and MDs will be ready