Impact of a Clinical Decision Support System on CT Pulmonary Angiography Yield and Utilization in Hospitalized Patients

Amita Sharma; Mark Isabelle; Andetta Hunsaker; Sayon Dutta; David Lucier; Rachel P Rosovsky; Sanjay Saini; Adam Landman; Ali S Raja; Ramin Khorasani; Ronilda Lacson

doi:10.1016/j.jacr.2024.11.030

Impact of a Clinical Decision Support System on CT Pulmonary Angiography Yield and Utilization in Hospitalized Patients

J Am Coll Radiol. 2024 Dec 9:S1546-1440(24)00947-5. doi: 10.1016/j.jacr.2024.11.030. Online ahead of print.

Authors

Amita Sharma¹, Mark Isabelle², Andetta Hunsaker³, Sayon Dutta⁴, David Lucier⁵, Rachel P Rosovsky⁶, Sanjay Saini⁷, Adam Landman⁸, Ali S Raja⁹, Ramin Khorasani¹⁰, Ronilda Lacson¹¹

Affiliations

¹ Medical Director of CT, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
² Center for Evidence-Based Imaging, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts.
³ Harvard Medical School, Boston, Massachusetts; Chief, Division of Thoracic Imaging, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
⁴ Harvard Medical School, Boston, Massachusetts; Physician Lead for Emergency Medicine and Clinical Decision Support at Partners eCare, Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts.
⁵ Harvard Medical School, Boston, Massachusetts; Associate Chief Quality Officer and Vice President of Hospital Quality, Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts.
⁶ Harvard Medical School, Boston, Massachusetts; Director, Thrombosis Research, Co-Chair, Thrombosis Committee, and Co-Chair, Thrombosis and Hemostasis Management Quality Collaborative, Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.
⁷ Harvard Medical School, Boston, Massachusetts; Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts; Vice Chairman for Finance, Massachusetts General Hospital Imaging, Boston, Massachusetts.
⁸ Harvard Medical School, Boston, Massachusetts; Chief Information Officer and Senior Vice President, Digital, Mass General Brigham, Boston, Massachusetts.
⁹ Harvard Medical School, Boston, Massachusetts; Center for Evidence-Based Imaging, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts; Deputy Chair, Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts.
¹⁰ Harvard Medical School, Boston, Massachusetts; Center for Evidence-Based Imaging, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts; Vice Chair, Radiology Quality and Safety, Mass General Brigham, Boston, Massachusetts; Vice Chair of Radiology and Director of Center for Evidence Based Imaging, Brigham and Women's Hospital, Boston, Massachusetts.
¹¹ Harvard Medical School, Boston, Massachusetts; Associate Director, Center for Evidence-Based Imaging, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts. Electronic address: [email protected].

PMID: 39662713
DOI: 10.1016/j.jacr.2024.11.030

Abstract

Purpose: The aims of this study were to determine whether point-of-order clinical decision support (CDS) based on the Wells criteria improves CT pulmonary angiography (CTPA) yield and utilization in hospitalized patients in an enterprise-wide health system and to identify yield-related factors.

Methods: This retrospective, institutional review board-approved, cross-sectional study in an urban, multi-institution health system included hospitalized patients undergoing CTPA 12 months before and after CDS implementation (entire cohort). The χ² test was used to compare pulmonary embolism (PE) yield in patients in whom providers overrode versus followed CDS alerts after CDS implementation. It was also used to compare utilization and yield before- versus after the intervention. Univariate and multivariable regression analyses were performed on patient factors and post-CDS Wells scores to evaluate yield-related factors.

Results: For 2,429 inpatient CT pulmonary angiographic examinations after the intervention, CTPA yield was significantly higher when CDS recommendations were followed (18.3% [250 of 1,365]) compared with those overridden (14.2% [151 of 1,064]) (P < .01). For 5,372 CT pulmonary angiographic examinations in the entire cohort, there was no difference in PE yield before (448 of 2,943 [15.2%]) versus after (401 of 2,429 [16.5%]) CDS implementation (P = .20). However, in 340,146 admissions over the study period, a 7.4% relative decrease in CTPA utilization (from 17.5 to 16.2 CT pulmonary angiographic examinations per 1,000 admissions before and after CDS, respectively, P = .003) was observed.

Conclusions: When CDS recommendations were followed, the yield of CTPA was significantly higher than when clinicians overrode CDS alerts. In addition, point-of-order CDS to reduce unnecessary CTPA in hospitalized patients resulted in a significant decrease in CTPA utilization after CDS implementation, with a modest although nonsignificant increase in CTPA yield.

Keywords: CT pulmonary angiography; Pulmonary embolism; clinical decision support; quality improvement.