Ivan Ip | Harvard Medical School (original) (raw)

Papers by Ivan Ip

JAMA internal medicine, 2015

American Journal of Roentgenology, 2015

The purpose of this study was to assess whether implementing emergency department (ED) physician ... more The purpose of this study was to assess whether implementing emergency department (ED) physician performance feedback reports improves adherence to evidence-based guidelines for use of CT for evaluation of pulmonary embolism (PE) beyond that achieved with clinical decision support (CDS) alone. This prospective randomized controlled trial was conducted from January 1, 2012, to December 31, 2013, at an urban level 1 adult trauma center ED. Attending physicians were stratified into quartiles by use of CT for evaluation of PE in 2012 and were randomized to receive quarterly feedback reporting or not, beginning January 2013. Reports consisted of individual and anonymized group data on guideline adherence (using the Wells criteria), use of CT for PE (number of CT examinations for PE per 1000 patients), and yield (percentage of CT examinations for PE with positive findings). We compared guideline adherence (primary outcome) and use and yield (secondary outcomes) of CT for PE between the control and intervention groups in 2013 and with historical imaging data from 2012. Of 109,793 ED patients during the control and intervention periods, 2167 (2.0%) underwent CT for evaluation of PE. In the control group, guideline adherence remained unchanged between 2012 (78.8% [476/604]) and 2013 (77.2% [421/545]) (p = 0.5); in the intervention group, guideline adherence increased 8.8% after feedback report implementation, from 78.3% (426/544) to 85.2% (404/474) (p < 0.05). Use and yield were unchanged in both groups. Implementation of quarterly feedback reporting resulted in a modest but significant increase in adherence to evidence-based guidelines for use of CT for evaluation of PE in ED patients, enhancing the impact of CDS alone. These results suggest potentially synergistic effects of traditional performance improvement tools with CDS to improve guideline adherence.

PURPOSE We have previously reported inpatient imaging utilization trends at our institution from ... more PURPOSE We have previously reported inpatient imaging utilization trends at our institution from fiscal years (FY) 1984 through 2002. In this study, we assessed the trends in imaging utilization for inpatients from FY 2003 through 2012. METHOD AND MATERIALS In this institutional review board-approved, retrospective study performed at a 793-bed tertiary care academic institution, we reviewed imaging utilization in adult inpatients from October 1, 2002 through September 30, 2012 (FY 2003 through 2012) and recorded the gross number of imaging studies coded by modality (conventional [plain films and fluoroscopy], sonography, nuclear medicine [NM], CT, and MRI) and associated relative value units (RVUs). We used linear regression to assess trends in number of imaging studies and RVUs per case-mix-adjusted admissions (CMAA). RESULTS The total number of imaging studies as well as CT, NM and conventional studies adjusted for CMAA decreased (p=0.02, p=0.0006, p=0.0008 and p=0.001 respectivel...

JAMA Internal Medicine, 2015

The Wells score to determine the pretest probability of deep vein thrombosis (DVT) was validated ... more The Wells score to determine the pretest probability of deep vein thrombosis (DVT) was validated in outpatient settings, but it is unclear whether it applies to inpatients. To evaluate the utility of the Wells score for risk stratification of inpatients with suspected DVT. A prospective study was conducted in a 793-bed quaternary care, academic hospital using Wells score clinical predictor findings entered by health care professionals in a computerized physician order entry system at the time lower-extremity venous duplex ultrasound studies were ordered. All adult inpatients suspected of having lower-extremity DVT who underwent lower-extremity venous duplex ultrasound studies between November 1, 2012, and December 31, 2013, were included. Patients with DVT diagnosed within the prior 3 months were excluded. For patients undergoing multiple lower-extremity venous duplex ultrasound studies, only the first was included. Our primary outcome was the Wells score's utility for risk stratification among inpatients with suspected DVT as measured by the difference in incidence of proximal DVT among the 3 Wells score categories (low, moderate, and high pretest probability), the discrimination accuracy of the Wells score categories as the area under the receiver operating characteristics curve, the failure rate of Wells score prediction, and the efficiency of the Wells score to exclude DVT. In a study cohort of 1135 inpatients, 137 (12.1%) had proximal DVT. Proximal DVT incidence in low, moderate, and high pretest probability groups was 5.9% (8 of 135), 9.5% (48 of 506), and 16.4% (81 of 494), respectively (P < .001). The area under the receiver operating characteristics curve for the discriminatory accuracy of the Wells score for risk of proximal DVT identified on lower-extremity venous duplex ultrasound studies was 0.60. The failure rate of the Wells score to classify patients with a low pretest probability was 5.9% (95% CI, 3.0%-11.3%); the efficiency was 11.9% (95% CI, 10.1%-13.9%). The Wells score performed only slightly better than chance for discrimination of risk for DVT in hospitalized patients. It had a higher failure rate and a lower efficiency in the inpatient setting compared with that reported in the outpatient literature. Therefore, the Wells score risk stratification is not sufficient to rule out DVT or influence management decisions in the inpatient setting.

Radiology, 2015

To identify the frequency of and variables associated with thoracic metastasis in patients with g... more To identify the frequency of and variables associated with thoracic metastasis in patients with gastrointestinal stromal tumor (GIST) to help optimize the use of cross-sectional chest imaging. This retrospective institutional review board-approved study included 631 patients (343 men; mean age, 55 years; range, 19-94 years) with pathologically confirmed GIST who were identified with a natural language processing algorithm in a review of radiologic reports from January 2004 through October 2012, followed by manual confirmation. The requirement for informed consent was waived. Available imaging, pathologic, and clinical records were reviewed to confirm the presence of abdominal and thoracic metastases. The association of age; sex; size, location, mitotic count, and risk stratification of the primary tumor; initial treatment; presence of abdominal metastases; and bulky abdominal metastases (more than 10 lesions larger than 1 cm, or more than five lesions with at least one larger than 5 cm) with development of thoracic metastases, the primary outcome measure, was studied by using logistic regression. During median follow-up of 61.4 months (interquartile range, 37.8-93 months), 401 of 631 (63.5%) patients developed metastatic disease (median interval, 6.9 months; interquartile range, 0-25.6 months), all with peritoneal (n = 324) and/or hepatic metastases (n = 303). Bulky abdominal metastases were found in 218 (34.5%) patients. Although 579 (91.8%) patients underwent chest imaging, only 64 of 631 (10.1%) developed thoracic metastases (median, 51.4 months; interquartile range, 36-78.7 months); all had bulky abdominal metastases except one patient who presented with symptomatic scapular metastasis. Only bulky abdominal metastasis was significantly associated with the development of thoracic metastasis (P < .0001; odds ratio, 42.6; range, 8.6-211.5). Thoracic metastases are relatively uncommon in patients with GIST and are significantly associated only with presence of bulky abdominal metastases.

Radiology, 2015

Purpose To determine the effect of clinical decision support (CDS) on the use and yield of inpati... more Purpose To determine the effect of clinical decision support (CDS) on the use and yield of inpatient computed tomographic (CT) pulmonary angiography for acute pulmonary embolism (PE). Materials and Methods This HIPAA-compliant, institutional review board-approved study with waiver of informed consent included all adults admitted to a 793-bed teaching hospital from April 1, 2007, to June 30, 2012. The CDS intervention, implemented after a baseline observation period, informed providers who placed an order for CT pulmonary angiographic imaging about the pretest probability of the study based on a validated decision rule. Use of CT pulmonary angiographic and admission data from administrative databases was obtained for this study. By using a validated natural language processing algorithm on radiology reports, each CT pulmonary angiographic examination was classified as positive or negative for acute PE. Primary outcome measure was monthly use of CT pulmonary angiography per 1000 admissions. Secondary outcome was CT pulmonary angiography yield (percentage of CT pulmonary angiographic examinations that were positive for acute PE). Linear trend analysis was used to assess for effect and trend differences in use and yield of CT pulmonary angiographic imaging before and after CDS. Results In 272 374 admissions over the study period, 5287 patients underwent 5892 CT pulmonary angiographic examinations. A 12.3% decrease in monthly use of CT pulmonary angiography (26.0 to 22.8 CT pulmonary angiographic examinations per 1000 admissions before and after CDS, respectively; P = .008) observed 1 month after CDS implementation was sustained over the ensuing 32-month period. There was a nonsignificant 16.3% increase in monthly yield of CT pulmonary angiography or percentage of CT pulmonary angiographic examinations positive for acute PE after CDS (P = .65). Conclusion Implementation of evidence-based CDS for inpatients was associated with a 12.3% immediate and sustained decrease in use of CT pulmonary angiographic examinations in the evaluation of inpatients for acute PE. (©) RSNA, 2015 Online supplemental material is available for this article.

The American journal of medicine, 2014

AJR. American journal of roentgenology, 2014

The objective of our study was to assess radiology utilization trends for emergency department (E... more The objective of our study was to assess radiology utilization trends for emergency department (ED) patients from 1993 through 2012. For this retrospective study, we reviewed radiology utilization at a 793-bed quaternary care academic medical center from January 1, 1993, through December 31, 2012, during which time the number of ED patient visits increased from approximately 48,000 to 61,000, and determined the number of imaging studies by modality (radiography, sonography, CT, MRI, other) and associated relative value units (RVUs). We used linear regression to assess for trends in the number of imaging RVUs and imaging accession numbers, our primary and secondary outcomes, respectively. The total RVUs attributable to ED imaging per 1000 ED visits increased 208% from 1993 to 2007 (p < 0.0001) and then decreased 24.7% by 2012 (p = 0.0019). The total number of imaging accession numbers per 1000 ED visits increased 47.8% from 1993 until 2005 (p = 0.0003) and then decreased 26.9% by ...

Radiology, Jan 5, 2015

Purpose To examine geographic variation in providers' use of diagnostic imaging to identify p... more Purpose To examine geographic variation in providers' use of diagnostic imaging to identify potential targets for quality improvement initiatives after adjusting for imaging referral across hospital referral regions (HRRs). Materials and Methods Using two Centers for Medicare and Medicaid Services datasets, the authors included all claims for beneficiaries enrolled in the Medicare fee-for-service program. Diagnostic imaging procedures were selected on the basis of common procedure coding system codes, excluding interventional procedures. The authors assessed providers' use of imaging for each HRR after creating an imaging referral index (IRI) to adjust for imaging referral rates across HRRs. Relative risk statistics were used to assess geographic variation. The authors calculated two imaging measures for computed tomography (CT) and magnetic resonance (MR) imaging: IRI-adjusted utilization intensity (number of examinations per 1000 beneficiaries) and total payments (in dolla...

American Journal of Roentgenology, 2014

Repeat imaging is common, an uncertain proportion of which likely represents overuse . Overuse co... more Repeat imaging is common, an uncertain proportion of which likely represents overuse . Overuse contributes to the waste in health care that cost the United States up to $226 billion in 2011 alone and, in the case of CT examinations, exposes patients to unnecessary and potentially harmful ionizing radiation . Early work on the impact of CDS in reducing redundant imaging is promising. In one study, CDS led to the cancellation of 5% of repeat CT orders . However, users chose to override and thus ignore 95% of the repeat CT CDS alerts and proceed with the CT request, highlighting a potential opportunity to find strategies to optimize the impact of CDS on repeat testing. One such strategy reported in the nonimaging decision support literature requires users to document a clinical justification to override CDS alerts . Such interventions were found to have an 11-fold increase in the odds of modifying physician behavior compared with information-only CDS alerts E lectronic clinical decision support (CDS) promises to enhance evidence-based practice; reduce unnecessary, unsafe, or otherwise inappropriate testing; improve quality; and reduce waste [1]. In medical imaging, CDS tools are typically triggered at the time of order entry to guide ordering providers in selecting the optimal imaging strategy (or no imaging at all) [1]. Although best practices for effective imaging CDS may be debated, the successful implementation and early impact of CDS, including systems guiding imaging orders [2], has led to the incorporation of CDS provisions into two sets of federal regulations. The first provides modest financial incentives for adoption of CDS as a major focus of meaningful-use stage II regulation for health care information technology , and the second mandates the use of imaging CDS for targeted ambulatory procedures beginning January 1, 2017, as part of the Protecting Access to Medicare Act of 2014 [8].

American Journal of Roentgenology, 2014

We describe best practices for effective imaging clinical decision support (CDS) derived from fir... more We describe best practices for effective imaging clinical decision support (CDS) derived from firsthand experience, extending the Ten Commandments for CDS published a decade ago. Our collective perspective is used to set expectations for providers, health systems, policy makers, payers, and health information technology developers. Highlighting unique attributes of effective imaging CDS will help radiologists to successfully lead and optimize the value of the substantial federal and local investments in health information technology in the United States.

Abdominal Imaging, 2014

Assess the utility of CT and MRI in patients with acute pancreatitis (AP) presenting to emergency... more Assess the utility of CT and MRI in patients with acute pancreatitis (AP) presenting to emergency department (ED). In this Institutional Review Board-approved retrospective study, we identified all patients with AP from March 2012 through February 2013 in ED of a teaching hospital with approximately 60,000 annual visits. Patients were initially identified via ICD-9 code for AP (577.0); diagnosis was confirmed by chart review using established diagnostic criteria (presence of two of the following: typical abdominal pain, elevated lipase/amylase &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;3 times normal, or imaging findings of pancreatitis). Abdominal CT or MRI obtained in the ED and within 24 h of admission was reviewed by a fellowship-trained abdominal radiologist. Of 101 patients admitted with AP (60 women, 41 men; mean age 52 years, range 20-89), 63 (62.4%) underwent imaging; only one (1.6%) showed pancreatic necrosis. 88 (87.1%) patients could have been clinically diagnosed without imaging based on presence of abdominal pain and elevated laboratory values; 13 (12.9%) required imaging for diagnosis. Of 88 patients who met AP diagnostic criteria without imaging, 50 (56.8%) nonetheless underwent imaging, with AP without necrosis seen in 34 (68.0%), pancreatic necrosis in one (2.0%), sequelae of prior AP in four (8.0%), and no abnormality in 11 (22.0%). Early imaging is common in patients with AP, even when the diagnosis can be established based on non-imaging criteria, rarely demonstrating pancreatic necrosis. Reducing overuse of early imaging in patients with confident diagnosis of AP may improve quality and reduce waste.

The American journal of emergency medicine, 2014

Validate the sensitivity and specificity of 2 age adjustment strategies for d-dimer values in ide... more Validate the sensitivity and specificity of 2 age adjustment strategies for d-dimer values in identifying patients at risk for pulmonary embolism (PE) compared with traditional d-dimer cutoff value (500 ng/mL) to decrease inappropriate computed tomography pulmonary angiography (CTPA) use. This institutional review board-approved, Health Insurance Portability and Accountability Act-compliant retrospective study included all adult emergency department patients evaluated for PE over a 32-month period (1/1/11-8/30/13). Only patients undergoing CTPA and d-dimer testing were included. We used a validated natural language processing algorithm to parse CTPA radiology reports and determine the presence of acute PE. Outcome measures were sensitivity and specificity of 2 age-adjusted d-dimer cutoffs compared with the traditional cutoff. We used χ(2) tests with proportional analyses to assess differences in traditional and age-adjusted (age × 10 ng/mL) d-dimer cutoffs, adjusting both by decade ...

The American journal of emergency medicine, Jan 13, 2014

Reduction of unnecessary head computed tomographies (CTs) in patients with mild traumatic brain i... more Reduction of unnecessary head computed tomographies (CTs) in patients with mild traumatic brain injury (MTBI) was recently endorsed by American College of Emergency Physicians (ACEP) in the "Choosing Wisely" campaign. We examined the impact of computerized clinical decision support (CDS) on head CT utilization in MTBI emergency department (ED) visits. We conducted a 2-year cohort study at a level 1 trauma center and compared our results with the National Hospital Ambulatory Medical Care Survey from 2009 to 2010. All adult patients discharged from the ED with MTBI-associated diagnoses were included. After a baseline observation period at our institution, real-time CDS was implemented. Based upon the clinical history entered, low utility orders triggered an alert to clinicians, suggesting imaging studies might not adhere to evidence-based guidelines. Clinicians could cancel the order or ignore the alert. Primary outcome was intensity of head CT use in MTBI ED visits. Seconda...

Evidence-Based Neuroimaging Diagnosis and Treatment, 2013

ABSTRACT

Radiology, 2013

To determine renal cancer incidence in simple cyst-appearing renal masses detected at unenhanced ... more To determine renal cancer incidence in simple cyst-appearing renal masses detected at unenhanced computed tomography (CT). Institutional review board approval and an informed consent waiver for this retrospective HIPAA-compliant study were obtained. Patients who had renal masses with homogeneous water attenuation, hairline-thin smooth walls, and no calcifications or septations were identified by applying a validated natural language processing algorithm to radiology reports for 15 695 unique patients who underwent unenhanced abdominal CT at our institution between 2000 and 2005. Reports that included renal masses were selected, then categorized through manual report review as pertaining to simple cyst-appearing renal masses, nonsimple or solid renal masses, or no renal masses. Medical records were reviewed for subsequent renal cancer diagnoses. Patients without renal cancer were evaluated for a minimum of 5 years (mean, 8 years; range, 5-12 years). The Cox proportional hazards regression model was used to compare renal cancer incidence for patients who had simple cyst-appearing renal masses with those who had nonsimple cystic or solid renal masses and those who had no renal masses. Simple cyst-appearing renal masses were identified in 2669 patients (17%), no renal masses in 11844 (75%), and nonsimple cystic or solid renal masses in 1182 (8%). Of 1159 patients with simple cyst-appearing renal masses and a minimum of 5 years of follow-up, six (0.52%) subsequently developed renal cancers, all of which were separate from the simple cyst-appearing renal mass, rather than within it. Of 446 patients with nonsimple or solid renal masses and sufficient follow-up, 50 (11%) developed renal cancer. There was no difference in renal cancer incidence in patients with simple cyst-appearing renal masses versus those without renal masses (P = .54). The incidence of renal cancer was significantly lower in patients with simple cyst-appearing renal masses than that in nonsimple cystic or solid renal masses (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .0001). Simple cyst-appearing renal masses are unlikely to be malignant. These data support foregoing further imaging evaluation of these common masses.

Journal of the American Medical Informatics Association, 2014

Imaging utilization in emergency departments (EDs) has increased significantly. More than half of... more Imaging utilization in emergency departments (EDs) has increased significantly. More than half of the 1.2 million patients with mild traumatic brain injury (MTBI) presenting to US EDs receive head CT. While evidencebased guidelines can help emergency clinicians decide whether to obtain head CT in these patients, adoption of these guidelines has been highly variable. Promulgation of imaging efficiency guidelines by the National Quality Forum has intensified the need for performance reporting, but measuring adherence to these imaging guidelines currently requires laborintensive and potentially inaccurate manual chart review. We implemented clinical decision support (CDS) based on published evidence to guide emergency clinicians towards appropriate head CT use in patients with MTBI and automated data capture needed for unambiguous guideline adherence metrics. Implementation of the CDS was associated with a 56% relative increase in documented adherence to evidence-based guidelines for imaging in ED patients with MTBI.

Journal of the American College of Radiology, 2012

Purpose: Physician Quality Reporting System (PQRS) measure 10 assesses the percentage of radiolog... more Purpose: Physician Quality Reporting System (PQRS) measure 10 assesses the percentage of radiology reports for possible stroke that document the presence or absence of hemorrhage, mass, and acute infarction. Although it is an important report quality metric, determining adherence to this measure is often laborious, limiting its practical use. The aim of this study was to assess adherence to PQRS measure 10 using an automated approach to facilitate continuous measurement. A secondary goal was to identify explanatory variables that may affect adherence.

JAMA internal medicine, 2015

American Journal of Roentgenology, 2015

The purpose of this study was to assess whether implementing emergency department (ED) physician ... more The purpose of this study was to assess whether implementing emergency department (ED) physician performance feedback reports improves adherence to evidence-based guidelines for use of CT for evaluation of pulmonary embolism (PE) beyond that achieved with clinical decision support (CDS) alone. This prospective randomized controlled trial was conducted from January 1, 2012, to December 31, 2013, at an urban level 1 adult trauma center ED. Attending physicians were stratified into quartiles by use of CT for evaluation of PE in 2012 and were randomized to receive quarterly feedback reporting or not, beginning January 2013. Reports consisted of individual and anonymized group data on guideline adherence (using the Wells criteria), use of CT for PE (number of CT examinations for PE per 1000 patients), and yield (percentage of CT examinations for PE with positive findings). We compared guideline adherence (primary outcome) and use and yield (secondary outcomes) of CT for PE between the control and intervention groups in 2013 and with historical imaging data from 2012. Of 109,793 ED patients during the control and intervention periods, 2167 (2.0%) underwent CT for evaluation of PE. In the control group, guideline adherence remained unchanged between 2012 (78.8% [476/604]) and 2013 (77.2% [421/545]) (p = 0.5); in the intervention group, guideline adherence increased 8.8% after feedback report implementation, from 78.3% (426/544) to 85.2% (404/474) (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.05). Use and yield were unchanged in both groups. Implementation of quarterly feedback reporting resulted in a modest but significant increase in adherence to evidence-based guidelines for use of CT for evaluation of PE in ED patients, enhancing the impact of CDS alone. These results suggest potentially synergistic effects of traditional performance improvement tools with CDS to improve guideline adherence.

PURPOSE We have previously reported inpatient imaging utilization trends at our institution from ... more PURPOSE We have previously reported inpatient imaging utilization trends at our institution from fiscal years (FY) 1984 through 2002. In this study, we assessed the trends in imaging utilization for inpatients from FY 2003 through 2012. METHOD AND MATERIALS In this institutional review board-approved, retrospective study performed at a 793-bed tertiary care academic institution, we reviewed imaging utilization in adult inpatients from October 1, 2002 through September 30, 2012 (FY 2003 through 2012) and recorded the gross number of imaging studies coded by modality (conventional [plain films and fluoroscopy], sonography, nuclear medicine [NM], CT, and MRI) and associated relative value units (RVUs). We used linear regression to assess trends in number of imaging studies and RVUs per case-mix-adjusted admissions (CMAA). RESULTS The total number of imaging studies as well as CT, NM and conventional studies adjusted for CMAA decreased (p=0.02, p=0.0006, p=0.0008 and p=0.001 respectivel...

JAMA Internal Medicine, 2015

The Wells score to determine the pretest probability of deep vein thrombosis (DVT) was validated ... more The Wells score to determine the pretest probability of deep vein thrombosis (DVT) was validated in outpatient settings, but it is unclear whether it applies to inpatients. To evaluate the utility of the Wells score for risk stratification of inpatients with suspected DVT. A prospective study was conducted in a 793-bed quaternary care, academic hospital using Wells score clinical predictor findings entered by health care professionals in a computerized physician order entry system at the time lower-extremity venous duplex ultrasound studies were ordered. All adult inpatients suspected of having lower-extremity DVT who underwent lower-extremity venous duplex ultrasound studies between November 1, 2012, and December 31, 2013, were included. Patients with DVT diagnosed within the prior 3 months were excluded. For patients undergoing multiple lower-extremity venous duplex ultrasound studies, only the first was included. Our primary outcome was the Wells score&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s utility for risk stratification among inpatients with suspected DVT as measured by the difference in incidence of proximal DVT among the 3 Wells score categories (low, moderate, and high pretest probability), the discrimination accuracy of the Wells score categories as the area under the receiver operating characteristics curve, the failure rate of Wells score prediction, and the efficiency of the Wells score to exclude DVT. In a study cohort of 1135 inpatients, 137 (12.1%) had proximal DVT. Proximal DVT incidence in low, moderate, and high pretest probability groups was 5.9% (8 of 135), 9.5% (48 of 506), and 16.4% (81 of 494), respectively (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001). The area under the receiver operating characteristics curve for the discriminatory accuracy of the Wells score for risk of proximal DVT identified on lower-extremity venous duplex ultrasound studies was 0.60. The failure rate of the Wells score to classify patients with a low pretest probability was 5.9% (95% CI, 3.0%-11.3%); the efficiency was 11.9% (95% CI, 10.1%-13.9%). The Wells score performed only slightly better than chance for discrimination of risk for DVT in hospitalized patients. It had a higher failure rate and a lower efficiency in the inpatient setting compared with that reported in the outpatient literature. Therefore, the Wells score risk stratification is not sufficient to rule out DVT or influence management decisions in the inpatient setting.

Radiology, 2015

To identify the frequency of and variables associated with thoracic metastasis in patients with g... more To identify the frequency of and variables associated with thoracic metastasis in patients with gastrointestinal stromal tumor (GIST) to help optimize the use of cross-sectional chest imaging. This retrospective institutional review board-approved study included 631 patients (343 men; mean age, 55 years; range, 19-94 years) with pathologically confirmed GIST who were identified with a natural language processing algorithm in a review of radiologic reports from January 2004 through October 2012, followed by manual confirmation. The requirement for informed consent was waived. Available imaging, pathologic, and clinical records were reviewed to confirm the presence of abdominal and thoracic metastases. The association of age; sex; size, location, mitotic count, and risk stratification of the primary tumor; initial treatment; presence of abdominal metastases; and bulky abdominal metastases (more than 10 lesions larger than 1 cm, or more than five lesions with at least one larger than 5 cm) with development of thoracic metastases, the primary outcome measure, was studied by using logistic regression. During median follow-up of 61.4 months (interquartile range, 37.8-93 months), 401 of 631 (63.5%) patients developed metastatic disease (median interval, 6.9 months; interquartile range, 0-25.6 months), all with peritoneal (n = 324) and/or hepatic metastases (n = 303). Bulky abdominal metastases were found in 218 (34.5%) patients. Although 579 (91.8%) patients underwent chest imaging, only 64 of 631 (10.1%) developed thoracic metastases (median, 51.4 months; interquartile range, 36-78.7 months); all had bulky abdominal metastases except one patient who presented with symptomatic scapular metastasis. Only bulky abdominal metastasis was significantly associated with the development of thoracic metastasis (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .0001; odds ratio, 42.6; range, 8.6-211.5). Thoracic metastases are relatively uncommon in patients with GIST and are significantly associated only with presence of bulky abdominal metastases.

Radiology, 2015

Purpose To determine the effect of clinical decision support (CDS) on the use and yield of inpati... more Purpose To determine the effect of clinical decision support (CDS) on the use and yield of inpatient computed tomographic (CT) pulmonary angiography for acute pulmonary embolism (PE). Materials and Methods This HIPAA-compliant, institutional review board-approved study with waiver of informed consent included all adults admitted to a 793-bed teaching hospital from April 1, 2007, to June 30, 2012. The CDS intervention, implemented after a baseline observation period, informed providers who placed an order for CT pulmonary angiographic imaging about the pretest probability of the study based on a validated decision rule. Use of CT pulmonary angiographic and admission data from administrative databases was obtained for this study. By using a validated natural language processing algorithm on radiology reports, each CT pulmonary angiographic examination was classified as positive or negative for acute PE. Primary outcome measure was monthly use of CT pulmonary angiography per 1000 admissions. Secondary outcome was CT pulmonary angiography yield (percentage of CT pulmonary angiographic examinations that were positive for acute PE). Linear trend analysis was used to assess for effect and trend differences in use and yield of CT pulmonary angiographic imaging before and after CDS. Results In 272 374 admissions over the study period, 5287 patients underwent 5892 CT pulmonary angiographic examinations. A 12.3% decrease in monthly use of CT pulmonary angiography (26.0 to 22.8 CT pulmonary angiographic examinations per 1000 admissions before and after CDS, respectively; P = .008) observed 1 month after CDS implementation was sustained over the ensuing 32-month period. There was a nonsignificant 16.3% increase in monthly yield of CT pulmonary angiography or percentage of CT pulmonary angiographic examinations positive for acute PE after CDS (P = .65). Conclusion Implementation of evidence-based CDS for inpatients was associated with a 12.3% immediate and sustained decrease in use of CT pulmonary angiographic examinations in the evaluation of inpatients for acute PE. (©) RSNA, 2015 Online supplemental material is available for this article.

The American journal of medicine, 2014

AJR. American journal of roentgenology, 2014

The objective of our study was to assess radiology utilization trends for emergency department (E... more The objective of our study was to assess radiology utilization trends for emergency department (ED) patients from 1993 through 2012. For this retrospective study, we reviewed radiology utilization at a 793-bed quaternary care academic medical center from January 1, 1993, through December 31, 2012, during which time the number of ED patient visits increased from approximately 48,000 to 61,000, and determined the number of imaging studies by modality (radiography, sonography, CT, MRI, other) and associated relative value units (RVUs). We used linear regression to assess for trends in the number of imaging RVUs and imaging accession numbers, our primary and secondary outcomes, respectively. The total RVUs attributable to ED imaging per 1000 ED visits increased 208% from 1993 to 2007 (p < 0.0001) and then decreased 24.7% by 2012 (p = 0.0019). The total number of imaging accession numbers per 1000 ED visits increased 47.8% from 1993 until 2005 (p = 0.0003) and then decreased 26.9% by ...

Radiology, Jan 5, 2015

Purpose To examine geographic variation in providers' use of diagnostic imaging to identify p... more Purpose To examine geographic variation in providers' use of diagnostic imaging to identify potential targets for quality improvement initiatives after adjusting for imaging referral across hospital referral regions (HRRs). Materials and Methods Using two Centers for Medicare and Medicaid Services datasets, the authors included all claims for beneficiaries enrolled in the Medicare fee-for-service program. Diagnostic imaging procedures were selected on the basis of common procedure coding system codes, excluding interventional procedures. The authors assessed providers' use of imaging for each HRR after creating an imaging referral index (IRI) to adjust for imaging referral rates across HRRs. Relative risk statistics were used to assess geographic variation. The authors calculated two imaging measures for computed tomography (CT) and magnetic resonance (MR) imaging: IRI-adjusted utilization intensity (number of examinations per 1000 beneficiaries) and total payments (in dolla...

American Journal of Roentgenology, 2014

Repeat imaging is common, an uncertain proportion of which likely represents overuse . Overuse co... more Repeat imaging is common, an uncertain proportion of which likely represents overuse . Overuse contributes to the waste in health care that cost the United States up to $226 billion in 2011 alone and, in the case of CT examinations, exposes patients to unnecessary and potentially harmful ionizing radiation . Early work on the impact of CDS in reducing redundant imaging is promising. In one study, CDS led to the cancellation of 5% of repeat CT orders . However, users chose to override and thus ignore 95% of the repeat CT CDS alerts and proceed with the CT request, highlighting a potential opportunity to find strategies to optimize the impact of CDS on repeat testing. One such strategy reported in the nonimaging decision support literature requires users to document a clinical justification to override CDS alerts . Such interventions were found to have an 11-fold increase in the odds of modifying physician behavior compared with information-only CDS alerts E lectronic clinical decision support (CDS) promises to enhance evidence-based practice; reduce unnecessary, unsafe, or otherwise inappropriate testing; improve quality; and reduce waste [1]. In medical imaging, CDS tools are typically triggered at the time of order entry to guide ordering providers in selecting the optimal imaging strategy (or no imaging at all) [1]. Although best practices for effective imaging CDS may be debated, the successful implementation and early impact of CDS, including systems guiding imaging orders [2], has led to the incorporation of CDS provisions into two sets of federal regulations. The first provides modest financial incentives for adoption of CDS as a major focus of meaningful-use stage II regulation for health care information technology , and the second mandates the use of imaging CDS for targeted ambulatory procedures beginning January 1, 2017, as part of the Protecting Access to Medicare Act of 2014 [8].

American Journal of Roentgenology, 2014

We describe best practices for effective imaging clinical decision support (CDS) derived from fir... more We describe best practices for effective imaging clinical decision support (CDS) derived from firsthand experience, extending the Ten Commandments for CDS published a decade ago. Our collective perspective is used to set expectations for providers, health systems, policy makers, payers, and health information technology developers. Highlighting unique attributes of effective imaging CDS will help radiologists to successfully lead and optimize the value of the substantial federal and local investments in health information technology in the United States.

Abdominal Imaging, 2014

Assess the utility of CT and MRI in patients with acute pancreatitis (AP) presenting to emergency... more Assess the utility of CT and MRI in patients with acute pancreatitis (AP) presenting to emergency department (ED). In this Institutional Review Board-approved retrospective study, we identified all patients with AP from March 2012 through February 2013 in ED of a teaching hospital with approximately 60,000 annual visits. Patients were initially identified via ICD-9 code for AP (577.0); diagnosis was confirmed by chart review using established diagnostic criteria (presence of two of the following: typical abdominal pain, elevated lipase/amylase &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;3 times normal, or imaging findings of pancreatitis). Abdominal CT or MRI obtained in the ED and within 24 h of admission was reviewed by a fellowship-trained abdominal radiologist. Of 101 patients admitted with AP (60 women, 41 men; mean age 52 years, range 20-89), 63 (62.4%) underwent imaging; only one (1.6%) showed pancreatic necrosis. 88 (87.1%) patients could have been clinically diagnosed without imaging based on presence of abdominal pain and elevated laboratory values; 13 (12.9%) required imaging for diagnosis. Of 88 patients who met AP diagnostic criteria without imaging, 50 (56.8%) nonetheless underwent imaging, with AP without necrosis seen in 34 (68.0%), pancreatic necrosis in one (2.0%), sequelae of prior AP in four (8.0%), and no abnormality in 11 (22.0%). Early imaging is common in patients with AP, even when the diagnosis can be established based on non-imaging criteria, rarely demonstrating pancreatic necrosis. Reducing overuse of early imaging in patients with confident diagnosis of AP may improve quality and reduce waste.

The American journal of emergency medicine, 2014

Validate the sensitivity and specificity of 2 age adjustment strategies for d-dimer values in ide... more Validate the sensitivity and specificity of 2 age adjustment strategies for d-dimer values in identifying patients at risk for pulmonary embolism (PE) compared with traditional d-dimer cutoff value (500 ng/mL) to decrease inappropriate computed tomography pulmonary angiography (CTPA) use. This institutional review board-approved, Health Insurance Portability and Accountability Act-compliant retrospective study included all adult emergency department patients evaluated for PE over a 32-month period (1/1/11-8/30/13). Only patients undergoing CTPA and d-dimer testing were included. We used a validated natural language processing algorithm to parse CTPA radiology reports and determine the presence of acute PE. Outcome measures were sensitivity and specificity of 2 age-adjusted d-dimer cutoffs compared with the traditional cutoff. We used χ(2) tests with proportional analyses to assess differences in traditional and age-adjusted (age × 10 ng/mL) d-dimer cutoffs, adjusting both by decade ...

The American journal of emergency medicine, Jan 13, 2014

Reduction of unnecessary head computed tomographies (CTs) in patients with mild traumatic brain i... more Reduction of unnecessary head computed tomographies (CTs) in patients with mild traumatic brain injury (MTBI) was recently endorsed by American College of Emergency Physicians (ACEP) in the "Choosing Wisely" campaign. We examined the impact of computerized clinical decision support (CDS) on head CT utilization in MTBI emergency department (ED) visits. We conducted a 2-year cohort study at a level 1 trauma center and compared our results with the National Hospital Ambulatory Medical Care Survey from 2009 to 2010. All adult patients discharged from the ED with MTBI-associated diagnoses were included. After a baseline observation period at our institution, real-time CDS was implemented. Based upon the clinical history entered, low utility orders triggered an alert to clinicians, suggesting imaging studies might not adhere to evidence-based guidelines. Clinicians could cancel the order or ignore the alert. Primary outcome was intensity of head CT use in MTBI ED visits. Seconda...

Evidence-Based Neuroimaging Diagnosis and Treatment, 2013

ABSTRACT

Radiology, 2013

To determine renal cancer incidence in simple cyst-appearing renal masses detected at unenhanced ... more To determine renal cancer incidence in simple cyst-appearing renal masses detected at unenhanced computed tomography (CT). Institutional review board approval and an informed consent waiver for this retrospective HIPAA-compliant study were obtained. Patients who had renal masses with homogeneous water attenuation, hairline-thin smooth walls, and no calcifications or septations were identified by applying a validated natural language processing algorithm to radiology reports for 15 695 unique patients who underwent unenhanced abdominal CT at our institution between 2000 and 2005. Reports that included renal masses were selected, then categorized through manual report review as pertaining to simple cyst-appearing renal masses, nonsimple or solid renal masses, or no renal masses. Medical records were reviewed for subsequent renal cancer diagnoses. Patients without renal cancer were evaluated for a minimum of 5 years (mean, 8 years; range, 5-12 years). The Cox proportional hazards regression model was used to compare renal cancer incidence for patients who had simple cyst-appearing renal masses with those who had nonsimple cystic or solid renal masses and those who had no renal masses. Simple cyst-appearing renal masses were identified in 2669 patients (17%), no renal masses in 11844 (75%), and nonsimple cystic or solid renal masses in 1182 (8%). Of 1159 patients with simple cyst-appearing renal masses and a minimum of 5 years of follow-up, six (0.52%) subsequently developed renal cancers, all of which were separate from the simple cyst-appearing renal mass, rather than within it. Of 446 patients with nonsimple or solid renal masses and sufficient follow-up, 50 (11%) developed renal cancer. There was no difference in renal cancer incidence in patients with simple cyst-appearing renal masses versus those without renal masses (P = .54). The incidence of renal cancer was significantly lower in patients with simple cyst-appearing renal masses than that in nonsimple cystic or solid renal masses (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .0001). Simple cyst-appearing renal masses are unlikely to be malignant. These data support foregoing further imaging evaluation of these common masses.

Journal of the American Medical Informatics Association, 2014

Imaging utilization in emergency departments (EDs) has increased significantly. More than half of... more Imaging utilization in emergency departments (EDs) has increased significantly. More than half of the 1.2 million patients with mild traumatic brain injury (MTBI) presenting to US EDs receive head CT. While evidencebased guidelines can help emergency clinicians decide whether to obtain head CT in these patients, adoption of these guidelines has been highly variable. Promulgation of imaging efficiency guidelines by the National Quality Forum has intensified the need for performance reporting, but measuring adherence to these imaging guidelines currently requires laborintensive and potentially inaccurate manual chart review. We implemented clinical decision support (CDS) based on published evidence to guide emergency clinicians towards appropriate head CT use in patients with MTBI and automated data capture needed for unambiguous guideline adherence metrics. Implementation of the CDS was associated with a 56% relative increase in documented adherence to evidence-based guidelines for imaging in ED patients with MTBI.

Journal of the American College of Radiology, 2012

Purpose: Physician Quality Reporting System (PQRS) measure 10 assesses the percentage of radiolog... more Purpose: Physician Quality Reporting System (PQRS) measure 10 assesses the percentage of radiology reports for possible stroke that document the presence or absence of hemorrhage, mass, and acute infarction. Although it is an important report quality metric, determining adherence to this measure is often laborious, limiting its practical use. The aim of this study was to assess adherence to PQRS measure 10 using an automated approach to facilitate continuous measurement. A secondary goal was to identify explanatory variables that may affect adherence.