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BMC Medical Informatics and Decision Making
Published in: BMC Medical Informatics and Decision Making 1/2018

Open Access 01-12-2018 | Research article

Effect of clinical decision rules, patient cost and malpractice information on clinician brain CT image ordering: a randomized controlled trial

Authors: Ronald W. Gimbel, Ronald G. Pirrallo, Steven C. Lowe, David W. Wright, Lu Zhang, Min-Jae Woo, Paul Fontelo, Fang Liu, Zachary Connor

Published in: BMC Medical Informatics and Decision Making | Issue 1/2018

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Abstract

Background

The frequency of head computed tomography (CT) imaging for mild head trauma patients has raised safety and cost concerns. Validated clinical decision rules exist in the published literature and on-line sources to guide medical image ordering but are often not used by emergency department (ED) clinicians. Using simulation, we explored whether the presentation of a clinical decision rule (i.e. Canadian CT Head Rule - CCHR), findings from malpractice cases related to clinicians not ordering CT imaging in mild head trauma cases, and estimated patient out-of-pocket cost might influence clinician brain CT ordering. Understanding what type and how information may influence clinical decision making in the ordering advanced medical imaging is important in shaping the optimal design and implementation of related clinical decision support systems.

Methods

Multi-center, double-blinded simulation-based randomized controlled trial. Following standardized clinical vignette presentation, clinicians made an initial imaging decision for the patient. This was followed by additional information on decision support rules, malpractice outcome review, and patient cost; each with opportunity to modify their initial order. The malpractice and cost information differed by assigned group to test the any temporal relationship. The simulation closed with a second vignette and an imaging decision.

Results

One hundred sixteen of the 167 participants (66.9%) initially ordered a brain CT scan. After CCHR presentation, the number of clinicians ordering a CT dropped to 76 (45.8%), representing a 21.1% reduction in CT ordering (P = 0.002). This reduction in CT ordering was maintained, in comparison to initial imaging orders, when presented with malpractice review information (p = 0.002) and patient cost information (p = 0.002). About 57% of clinicians changed their order during study, while 43% never modified their imaging order.

Conclusion

This study suggests that ED clinician brain CT imaging decisions may be influenced by clinical decision support rules, patient out-of-pocket cost information and findings from malpractice case review.

Trial registration

NCT03449862, February 27, 2018, Retrospectively registered.
Appendix
Available only for authorised users
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Metadata
Title
Effect of clinical decision rules, patient cost and malpractice information on clinician brain CT image ordering: a randomized controlled trial
Authors
Ronald W. Gimbel
Ronald G. Pirrallo
Steven C. Lowe
David W. Wright
Lu Zhang
Min-Jae Woo
Paul Fontelo
Fang Liu
Zachary Connor
Publication date
01-12-2018
Publisher
BioMed Central
Published in
BMC Medical Informatics and Decision Making / Issue 1/2018
Electronic ISSN: 1472-6947
DOI
https://doi.org/10.1186/s12911-018-0602-1

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