BACKGROUND: One driver of increasing health care costs is the use of radiologic imaging procedures. More appropriate use could improve quality and reduce costs.
PURPOSE: To review interventions that use the computerized clinical decision-support (CCDS) capabilities of electronic health records to improve appropriate use of diagnostic radiologic test ordering.
DATA SOURCES: English-language articles in PubMed from 1995 to September 2014 and searches in Web of Science and PubMed of citations related to key articles.
STUDY SELECTION: 23 studies, including 3 randomized trials, 7 time-series studies, and 13 pre-post studies that assessed the effect of CCDS on diagnostic radiologic test ordering in adults.
DATA EXTRACTION: 2 independent reviewers extracted data on functionality, study outcomes, and context and assessed the quality of included studies.
DATA SYNTHESIS: Thirteen studies provided moderate-level evidence that CCDS improves appropriateness (effect size, -0.49 [95% CI, -0.71 to -0.26]) and reduces use (effect size, -0.13 [CI, -0.23 to -0.04]). Interventions with a "hard stop" that prevents a clinician from overriding the CCDS without outside consultation, as well as interventions in integrated care delivery systems, may be more effective. Harms have rarely been assessed but include decreased ordering of appropriate tests and physician dissatisfaction.
LIMITATION: Potential for publication bias, insufficient reporting of harms, and poor description of context and implementation.
CONCLUSION: Computerized clinical decision support integrated with the electronic health record can improve appropriate use of diagnostic radiology by a moderate amount and decrease use by a small amount. Before widespread adoption can be recommended, more data are needed on potential harms.
PRIMARY FUNDING SOURCE: U.S. Department of Veterans Affairs. (PROSPERO registration number: CRD42014007469).
Abstract Laboratory and radiographic tests are often ordered unnecessarily. This excess testing has financial costs and is a burden on patients. We performed a systematic review to determine the effectiveness interventions to reduce test utilization by physicians. The MEDLINE and EMBASE databases were searched for the years 1946 through to September 2013 for English articles that had themes of test utilization and cost containment or optimization. Bibliographies of included papers were scanned to identify other potentially relevant studies. Our search resulted in 3236 articles of which 109 met the inclusion criteria of having an intervention aimed at reducing test utilization with results that could be expressed as a percent reduction in test use relative to the comparator. Each intervention was categorized into one or more non-exclusive category of education, audit and feedback, system based, or incentive or penalty. A rating of study quality was also performed. The percent reductions in test use ranged from a 99.7% reduction to a 27.7% increase in test use. Each category of intervention was effective in reducing test utilization. Heterogeneity between interventions, poor study quality, and limited time horizons makes generalizations difficult and calls into question the validity of results. Very few studies measure any patient safety or quality of care outcomes affected by reduced test use. There are numerous studies that use low investment strategies to reduce test utilization with one time changes in the ordering system. These low investment strategies are the most promising for achievable and durable reductions in inappropriate test use.
BACKGROUND: While studies have been published in the last 30 years that examine the effect of charge display during physician decision-making, no analysis or synthesis of these studies has been conducted.
OBJECTIVE: We aimed to determine the type and quality of charge display studies that have been published; to synthesize this information in the form of a literature review.
METHODS: English-language articles published between 1982 and 2013 were identified using MEDLINE, Web of Knowledge, ABI-Inform, and Academic Search Premier. Article titles, abstracts, and text were reviewed for relevancy by two authors. Data were then extracted and subsequently synthesized and analyzed.
RESULTS: Seventeen articles were identified that fell into two topic categories: the effect of charge display on radiology and laboratory test ordering versus on medication choice. Seven articles were randomized controlled trials, eight were pre-intervention vs. post-intervention studies, and two interventions had a concurrent control and intervention groups, but were not randomized. Twelve studies were conducted in a clinical environment, whereas five were survey studies. Of the nine clinically based interventions that examined test ordering, seven had statistically significant reductions in cost and/or the number of tests ordered. Two of the three clinical studies looking at medication expenditures found significant reductions in cost. In the survey studies, physicians consistently chose fewer tests or lower cost options in the theoretical scenarios presented.
CONCLUSIONS: In the majority of studies, charge information changed ordering and prescribing behavior.
PURPOSE: Computerised physician order entry (CPOE) systems hold the promise of significant improvements to health care delivery and patient care. The implementation of such systems is costly and complex. The purpose of this paper is to review current evidence of the impact of CPOE on hospital pathology services. METHODS: This paper presents a review of the literature (1990-August 2004) about CPOE systems and identifies indicators for measuring the impact of CPOE on pathology services. RESULTS: Nineteen studies which contained some form of 'control' group, were identified. They featured a variety of designs including randomised controlled trials, quasi-experimental and before and after studies. We categorised these into three groups: studies comparing pathology CPOE systems (with no decision support) to paper systems; pathology CPOE systems (with decision support) to paper systems; and pathology CPOE systems with specific pathology features compared to systems without those features. We identified 10 areas of impact assessment and 39 indicators used to measure the impact of CPOE on different stages of the pathology test ordering and reporting process. CONCLUSION: We conclude that while some data suggest that CPOE systems are beneficial for clinical and laboratory work processes, these data are limited, and further research is needed. Few data are available regarding the impact of CPOE on patient outcomes.
BACKGROUND: Experts consider health information technology key to improving efficiency and quality of health care. PURPOSE: To systematically review evidence on the effect of health information technology on quality, efficiency, and costs of health care. DATA SOURCES: The authors systematically searched the English-language literature indexed in MEDLINE (1995 to January 2004), the Cochrane Central Register of Controlled Trials, the Cochrane Database of Abstracts of Reviews of Effects, and the Periodical Abstracts Database. We also added studies identified by experts up to April 2005. STUDY SELECTION: Descriptive and comparative studies and systematic reviews of health information technology. DATA EXTRACTION: Two reviewers independently extracted information on system capabilities, design, effects on quality, system acquisition, implementation context, and costs. DATA SYNTHESIS: 257 studies met the inclusion criteria. Most studies addressed decision support systems or electronic health records. Approximately 25% of the studies were from 4 academic institutions that implemented internally developed systems; only 9 studies evaluated multifunctional, commercially developed systems. Three major benefits on quality were demonstrated: increased adherence to guideline-based care, enhanced surveillance and monitoring, and decreased medication errors. The primary domain of improvement was preventive health. The major efficiency benefit shown was decreased utilization of care. Data on another efficiency measure, time utilization, were mixed. Empirical cost data were limited. LIMITATIONS: Available quantitative research was limited and was done by a small number of institutions. Systems were heterogeneous and sometimes incompletely described. Available financial and contextual data were limited. CONCLUSIONS: Four benchmark institutions have demonstrated the efficacy of health information technologies in improving quality and efficiency. Whether and how other institutions can achieve similar benefits, and at what costs, are unclear.
OBJECTIVES: To appraise findings from studies examining the impact of computers on primary care consultations. DESIGN: Systematic review of world literature from 1980 to 1997. DATA SOURCES: 5475 references were identified from electronic databases (Medline, Science Citation Index, Social Sciences Citation Index, Index of Scientific and Technical Proceedings, Embase, OCLC FirstSearch Proceedings), bibliographies, books, identified articles, and by authors active in the field. 1892 eligible abstracts were independently rated, and 89 studies met the inclusion criteria. MAIN OUTCOME MEASURES: Effect on doctors' performance and patient outcomes; attitudes towards computerisation. RESULTS: 61 studies examined effects of computers on practitioners' performance, 17 evaluated their impact on patient outcome, and 20 studied practitioners' or patients' attitudes. Computer use during consultations lengthened the consultation. Reminder systems for preventive tasks and disease management improved process rates, although some returned to pre-intervention levels when reminders were stopped. Use of computers for issuing prescriptions increased prescribing of generic drugs, and use of computers for test ordering led to cost savings and fewer unnecessary tests. There were no negative effects on those patient outcomes evaluated. Doctors and patients were generally positive about use of computers, but issues of concern included their impact on privacy, the doctor-patient relationship, cost, time, and training needs. CONCLUSIONS: Primary care computing systems can improve practitioner performance, particularly for health promotion interventions. This may be at the expense of patient initiated activities, making many practitioners suspicious of the negative impact on relationships with patients. There remains a dearth of evidence evaluating effects on patient outcomes.
OBJECTIVES: To review the published literature on interventions aimed at improving physicians' testing practices and propose methodologic standards for these studies and to review selected studies using the PRECEDE framework, a behavioral model that helps categorize interventions based on which behavioral factors are being affected. DATA SOURCES: MEDLINE, EMBASE, and HEALTHStar databases were searched for the years 1966 to January 1, 1998, for English-language articles pertaining to diagnostic testing behavior; bibliographies were scanned to identify articles of potential interest; and researchers in health services, health behavior, and behavior modification were contacted for proprietary and other unpublished articles. STUDY SELECTION: A total of 102 articles were identified that described the results of interventions aimed at changing physicians' testing practices. We included the 49 studies that compared diagnostic testing practices in intervention and control groups. DATA EXTRACTION: Two investigators independently reviewed each article in a blinded fashion using a standard data collection form to obtain a methodologic score and to abstract the key elements of each intervention. DATA SYNTHESIS: On a 38-point methodologic criteria scale, the mean +/- SD score was 13+/-4.4. The desired behavior change was reported in the intervention group in 37 (76%) of 49 studies. Twenty-four (86%) of 28 interventions targeted at many behavioral factors were successful, while 13 (62%) of 21 studies aimed at a single behavioral factor were successful (P=.12). CONCLUSIONS: A majority of interventions to improve physicians' testing practices reported in the literature claimed success, with interventions based on multiple behavioral factors trending toward being more successful. While methodologic flaws hamper drawing strong conclusions from this literature, application of a behavioral framework appears to be useful in explaining interventions that are successful and can facilitate interpretation of intervention results.
Objectives.— To review the published literature on interventions aimed at improving physicians' testing practices and propose methodologic standards for these studies and to review selected studies using the PRECEDE framework, a behavioral model that helps categorize interventions based on which behavioral factors are being affected. Data Sources.— MEDLINE, EMBASE, and HEALTHStar databases were searched for the years 1966 to January 1, 1998, for English-language articles pertaining to diagnostic testing behavior; bibliographies were scanned to identify articles of potential interest; and researchers in health services, health behavior, and behavior modification were contacted for proprietary and other unpublished articles. Study Selection.— A total of 102 articles were identified that described the results of interventions aimed at changing physicians' testing practices. We included the 49 studies that compared diagnostic testing practices in intervention and control groups. Data Extraction.— Two investigators independently reviewed each article in a blinded fashion using a standard data collection form to obtain a methodologic score and to abstract the key elements of each intervention. Data Synthesis.— On a 38-point methodologic criteria scale, the mean±SD score was 13 ± 4.4. The desired behavior change was reported in the intervention group in 37 (76%) of 49 studies. Twenty-four (86%) of 28 interventions targeted at many behavioral factors were successful, while 13 (62%) of 21 studies aimed at a single behavioral factor were successful (P=.12). Conclusions.— A majority of interventions to improve physicians' testing practices reported in the literature claimed success, with interventions based on multiple behavioral factors trending toward being more successful. While methodologic flaws hamper drawing strong conclusions from this literature, application of a behavioral framework appears to be useful in explaining interventions that are successful and can facilitate interpretation of intervention results. DIAGNOSTIC TESTING and imaging are essential tools for disease screening, diagnosis, and monitoring. These aspects of medical care represent an enormous expenditure1 and studies suggest wide variation in test ordering behavior for seemingly similar indications.2- 4 Several factors that may explain this variation include physicians' inability to estimate test performance characteristics, inaccurate interpretation of diagnostic test results,5- 12 and rapid advances in diagnostic technology that make it difficult for clinicians to stay abreast of the most effective testing strategies. Improving the appropriateness of testing behavior is a major focus of quality improvement, and many interventions have targeted laboratory and radiographic test ordering. Intervention strategies have included educational programs, guideline development and implementation, utilization audits, and economic incentives. Studies of interventions to modify physicians' test ordering behavior suggest that behavior change rarely can be accomplished solely through education, feedback of laboratory utilization data has inconsistent effects, rewarding physicians for improved ordering practices may result in short-term behavior change only, and testing guidelines have a variable effect depending on the implementation of the guidelines.13- 17 Nearly every strategy has had both success and failure, providing limited guidance for designing new or more effective strategies. Past reviews of this subject14- 18 have not discriminated among tests used for screening, diagnosis, or monitoring—clinical situations that profoundly impact physicians' motivation and willingness to tolerate uncertainty and their test ordering behavior. Interventions aimed at screening generally have used accepted algorithms and attempt to enhance test usage, quite a different challenge than tests used for diagnosis, which are generally overused. No standardized evaluation of the methodology used in these interventions has been applied. Finally, and perhaps most importantly, the literature provides no evidence that the interventions utilized known behavioral theory. The PRECEDE model of behavior change18 is a standardized framework that has been used to design successful, large-scale health interventions.19,20 PRECEDE incorporates 3 types of factors that precipitate or inhibit behavior change—predisposing, enabling, and reinforcing—and can be described through a clinical example. A 45-year-old man complains of chronic lower back pain and sciatica. His physician believes that this patient is at risk for metastatic cancer, leading him to order an imaging study. This physician's perception of his patient's risk for cancer exemplifies a predisposing factor, which includes other cognitive attributes such as attitudes or knowledge, underlying testing behavior. Enabling factors are skills, resources, or structural barriers that facilitate or prevent behavior. Extending the above example, if the physician had access to a specialist in his practice whom he could consult, he might learn that sciatica rarely represents metastatic cancer in patients younger than 50 years.21 Hence, proximity to an expert opinion might enable the physician to take a "wait and see" approach instead of ordering imaging. Reinforcing factors reward a specific behavior through feedback. In this example, on follow-up the patient's back and leg pain remits, reinforcing the importance of examining for sciatica and that a wait and see approach is often appropriate in lower back pain. Predisposing, enabling, and reinforcing factors can facilitate or hinder behaviors. They are not mutually exclusive nor are their effects the same in all settings. For instance, a diagnostic guideline outlining indications for imaging studies printed on a radiology ordering form may guide physicians who do not know current recommendations, thus changing attitudes or predisposing factors, but reinforce the ordering practices of others who are more knowledgeable. These guidelines may also act as a memory aid for other clinicians who have heard about the recommendations, but do not remember them. Thus, the guideline-based order form can act to enable appropriate ordering. Analysis of behavior change in terms of predisposing, reinforcing, and enabling factors has proven robust in behavior change planning for a variety of behaviors at many levels, including individual, institutional, and community.18 These groupings of variables encapsulate much of what has been learned empirically in the fields of psychology, sociology, and planned change. Because most behaviors are determined by multiple factors, it follows that interventions that address several key factors are more likely to be successful than unidimensional interventions. This observation was made by Oxman et al,22 who have developed a typology of interventions to change physician behavior. We elected to use the PRECEDE framework to categorize studies in our review since we believe it has greater explanatory power. We reviewed the literature on interventions to modify physician testing behavior for methodologic rigor and whether known and effective behavioral principles were utilized. We hypothesized that multidimensional interventions that target more than 1 behavioral factor would be most effective.
Displaying order prices to physicians is 1 potential strategy to reduce unnecessary health expenditures, but its impact on patterns of care is unclear.
OBJECTIVE:
To review characteristics of previous price display interventions, impact on order costs and volume, effects on patient safety, acceptability to physicians, and the quality of this evidence.
DESIGN:
Systematic review of studies that showed numeric prices of laboratory tests, imaging studies, or medications to providers in real time during the ordering process and evaluated the impact on provider ordering. Two investigators independently extracted data for each study and evaluated study quality using a modified Downs and Black checklist.
RESULTS:
Of 1494 studies reviewed, 19 met inclusion criteria, including 5 randomized trials, 13 pre-post intervention studies, and 1 time series analysis. Studies were published between 1983 and 2014. Of 15 studies reporting the quantitative impact of price display on aggregate order costs or volume, 10 demonstrated a statistically significant decrease in the intervention group. Price display was found to decrease aggregate order costs (9 of 13 studies) more frequently than order volume (3 of 8 studies). Patient safety was evaluated in 5 studies and was unaffected by price display. Provider acceptability tended to be positive, although evidence was limited. Study quality was mixed, with checklist scores ranging from 5/21 to 20/21.
