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

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

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.

Keywords: CT brain; Canadian CT head rule; Clinical decision making; Emergency department clinicians; Evidence-based medicine; Malpractice information; Mild head trauma; Patient cost information; Simulation research.

Conflict of interest statement

Ethics approval and consent to participate

This simulation study was approved by the Institutional Review Boards of Clemson University (Clemson, SC), the Greenville Health System (Greenville, SC), and Emory Healthcare (Atlanta, GA)). The National Institutes of Health Office of Human Subjects Research designated this research as exempt from Institutional Review Board review.

This was a web-based simulation study and the informed consent was built into the intervention. It was included in the intervention slides (Additional file 1) just after the welcome. It was an electronic consent document where the participant was required to accept to proceed with the study. If he/she did not consent the system thanked them for their interest but did not let them proceed.

Consent for publication

Not applicable

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Study Flow. Note: Diamonds denote clinician medical imaging decision point

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Source: PubMed

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