CDS can mean fewer tests, but has limits
A new study from RAND Corporation shows that decision support technology can lead to a reduction in inappropriate advanced imaging studies. But practical challenges remain when it comes to putting the tools to work in clinical settings.
Overuse of imaging tests as MRI and CT is a big cause of rising healthcare costs. Starting in 2017, the Centers for Medicare & Medicaid Services will require the use of clinical decision support to inform the ordering of any advanced diagnostic imaging study paid for by Medicare.
The CDS tools in this study, which match a patient's characteristics against treatment criteria and recommend options, translated into a higher percentage of tests for Medicare fee-for-service patients rated as appropriate, according RAND's findings, which were published today in the Journal of the American Medical Association. Still, there were some significant limitations.
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Sponsored by the CMS, the Medicare Imaging Demonstration enlisted RAND to determine whether offering physicians guidelines for the appropriateness of advanced imaging would reduce or eliminate unneeded tests.
To develop appropriateness criteria, several medical specialty societies reviewed evidence and completed a structured rating process. Those criteria were then loaded into the clinical decision support tools for all participating clinicians.
Over the course of the two-year study, 3,340 clinicians placed 117,348 orders for advanced diagnostic imaging procedures.
The bad news? Most orders were unable to be matched by the clinical decision support system to appropriateness criteria because no appropriateness criteria were available for a particular test, or because the tool itself was unable to find matching criteria, RAND researchers found.
The good news? There was a small increase in the percentage of orders rated appropriate between the baseline and intervention period – pointing to a successful intervention because fewer patients were exposed to expensive, clinically inappropriate, potentially harmful tests.
"The increase in orders rated as appropriate is promising, but the number of tests that were not rated indicates there is room for further improvement of these tools," said Peter S. Hussey, senior policy researcher at RAND and lead author of the JAMA article, in a press statement.
"In response to these findings, we recommend that clinical decision support efforts should focus on tools that help clinicians perform their work more efficiently and effectively," said the study's principal investigator, Katherine Kahn, MD, senior natural scientist at RAND and professor of medicine at the David Geffen School of Medicine at UCLA, in a statement.
"We need a more-comprehensive set of evidence-based guidelines that cover a greater proportion of advanced imaging orders for Medicare patients, and provide better methods for communicating feedback to clinicians," she added.
The study was notable for the scale and the diversity of its clinical settings, according to RAND. Participating organizations were located in eight states and included three academic medical centers, two integrated delivery systems, one group of independent practices in a single geographic area and one group of independent practices recruited by a radiology benefits management organization.
RAND is delivering a report to Congress on the findings, in which "we've outlined a series of improvements to the decision support tools that we expect can lead to greater reductions in unnecessary tests," according to Hussey.