The Impact of Clinical Decision Support (CDS) for Radiology: A Randomized Control Trial

With healthcare spending accounting for almost one-fifth of the U.S. economy and an even larger share of public sector budgets, there is substantial interest in innovations in healthcare delivery that can reduce the "over use" of resources that have no or low value to patients. As a result, there is a key need for rigorous evidence on scalable interventions aimed at improving the efficiency of the U.S. healthcare sector in general, and in the public sector in particular, which accounts for $1.25 trillion in annual healthcare spending.

In particular, there is widespread concern in both the medical profession and the public sector of the cost and health risks of "over-scanning". Estimates suggest that as many as 30% of imaging in the U.S. are unnecessary. Medicare direct spending on "high-cost" scans (e.g. MRs and CTs) was about $10 billion in 2012, or about 2% of total Medicare costs ; the indirect costs are likely considerably greater, since imaging often triggers additional follow up care. It is also estimated that about 2 percent of cancers in the U.S. are due to CT use.

Reflecting this concern, starting in 2018 Medicare will no longer reimburse for high-cost scans unless ordered using an "acceptable" Clinical Decision Support (CDS) system. Despite this upcoming policy change, the investigators know of no large-scale randomized trials on the impact of CDS for imaging.

The intervention in this study provides Clinical Decision Support (CDS) for targeted high-cost radiology orders, (MR, CT, NM, and PET scans), to healthcare providers treating patients in settings affiliated with the Aurora Health Care system headquartered in Wisconsin. CDS is a tool embedded in an order entry system that provides information and guidance to providers on whether their intended order is "appropriate" and whether there are more highly recommended alternatives. The randomization is at the provider level: half will receive the CDS, while the remaining half of providers in the study will serve as the control group.

The CDS will be delivered through the order-entry software, Epic, through ACR Select software, which is a leading decision support tool based on the American College of Radiology (ACR) Appropriateness Criteria.