Advertisement

A Clinical Reminder Order Check Intervention to Improve Guideline-concordant Imaging Practices for Men With Prostate Cancer: A Pilot Study

      Abstract

      Objective

      To understand how to potentially improve inappropriate prostate cancer imaging rates we used National Comprehensive Cancer Network's guidelines to design and implement a Clinical Reminder Order Check (CROC) that alerts ordering providers of potentially inappropriate imaging orders in real-time based on patient features of men diagnosed with low-risk prostate cancer.

      Methods

      We implemented the CROC at VA New York Harbor Healthcare System from April 2, 2015 to November 15, 2017. We then used VA administrative claims from the VA's Corporate Data Warehouse to analyze imaging rates among men with low-risk prostate cancer at VA New York Harbor Healthcare System before and after CROC implementation. We also collected and cataloged provider responses in response to overriding the CROC in qualitative analysis.

      Results Fifty seven percent

      (117/205) of Veterans before CROC installation and 73% (61/83) of Veterans post-intervention with low-risk prostate cancer received guideline-concordant care.

      Conclusion

      While the decrease in inappropriate imaging during our study window was almost certainly due to many factors, a Computerized Patient Record System-based CROC intervention is likely associated with at least moderate improvement in guideline-concordant imaging practices for Veterans with low-risk prostate cancer.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Urology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Makarov DV
        • Hu E
        • Walter D
        • et al.
        Appropriateness of prostate cancer imaging among veterans in a delivery system without incentives for overutilization.
        Health Serv Res. 2015; 51: 1021-1051
        • Han M
        • Partin AW
        • Pound CR
        • Epstein JI
        • Walsh PC
        Long-term biochemical disease-free and cancer-specific survival following anatomic radical retropubic prostatectomy. The 15-year Johns Hopkins experience.
        Urol Clin North Am. 2001; 28: 555-565
        • Cooperberg MR
        • Lubeck DP
        • Meng MV
        • Mehta SS
        • Carroll PR
        The changing face of low-risk prostate cancer: trends in clinical presentation and primary management.
        J Clin Oncol. 2004; 22: 2141-2149
      1. Prostate Cancer. 2015; NCCN Clinical Practice Guidelines in Oncology.http://www.nccn.org/professionals/physician_gls/pdf/prostate.pdf. Accessed Nov 14, 2018.

        • Schnipper LE
        • Smith TJ
        • Raghavan D
        • et al.
        American Society of Clinical Oncology identifies five key opportunities to improve care and reduce costs: the top five list for oncology.
        J Clin Oncol. 2012; 30: 1715-1724
      2. American Board of Internal Medicine Foundation: the choosing wisely campaign five things physicians and patients should question. 2012; Available at: http://choosingwisely.org/wp-content/uploads/2011/12/about_choosingwisely.pdf. Accessed May 5, 2012.

        • Cassel CK
        • Guest JA
        Choosing wisely: helping physicians and patients make smart decisions about their care.
        JAMA. 2012; 307: 1801-1802
        • Makarov DV
        • Sharma R
        • Yu JB
        • et al.
        The population level prevalence and correlates of appropriate and inappropriate imaging to stage incident prostate cancer in the medicare population.
        J Urol. 2012; 187: 97-102
        • Drangsholt S
        • Walter D
        • Ciprut S
        • et al.
        Quantifying downstream impact of inappropriate staging imaging in a cohort of veterans with low- and intermediate-risk incident prostate cancer.
        Urol Oncol. 2019; 37: 145-149
        • Makarov DV
        • Sedlander E
        • Braithwaite RS
        • et al.
        A qualitative study to understand guideline-discordant use of imaging to stage incident prostate cancer.
        Implemen Scie. 2016; 11: 118
        • Goldzweig CL
        • Orshansky G
        • Paige NM
        • et al.
        VA evidence-based synthesis program reports.
        Electronic Health Record-Based Interventions for Reducing Inappropriate Imaging in the Clinical Setting: A Systematic Review of the Evidence. Department of Veterans Affairs (US), Washington, DC2015
        • Curry L
        • Reed MH
        Electronic decision support for diagnostic imaging in a primary care setting.
        J Am Med Inform Assoc. 2011; 18: 267-270
        • Goldzweig CL
        • Orshansky G
        • Paige NM
        • et al.
        Electronic health record-based interventions for improving appropriate diagnostic imaging: a systematic review and meta-analysis.
        Ann Intern Med. 2015; 162: 557-565
        • Gupta A
        • Ip IK
        • Raja AS
        • Andruchow JE
        • Sodickson A
        • Khorasani R
        Effect of clinical decision support on documented guideline adherence for head CT in emergency department patients with mild traumatic brain injury.
        J Am Med Inform Assoc. 2014; 21: e347-e351
        • Raja AS
        • Gupta A
        • Ip IK
        • Mills AM
        • Khorasani R
        The use of decision support to measure documented adherence to a national imaging quality measure.
        Acad Radiol. 2014; 21: 378-383
        • Hoo GW
        • Wu CC
        • Vazirani S
        • Li Z
        • Barack BM
        Does a clinical decision rule using D-dimer level improve the yield of pulmonary CT angiography?.
        AJR Am J Roentgenol. 2011; 196: 1059-1064
        • Day F
        • Hoang LP
        • Ouk S
        • Nagda S
        • Schriger DL
        The impact of a guideline-driven computer charting system on the emergency care of patients with acute low back pain.
        in: Proceedings Symposium on Computer Applications in Medical Care. 1995: 576-580
        • Shelton JB
        • Ochotorena L
        • Bennett C
        • et al.
        Reducing PSA-Based prostate cancer screening in men aged 75 years and older with the use of highly specific computerized clinical decision support.
        J Gen Intern Med. 2015; 38: 1133-1139
      3. ACR appropriateness criteria prostate cancer - pretreatment detection, staging, and surveillance.
        J Am Coll Radiol. 2013; 10: 83-92
      4. Association AU. PSA Testing for the Pretreatment Staging and Posttreatment Management of Prostate Cancer. 2013.

        • Heidenreich A
        • Bastian PJ
        • Bellmunt J
        • et al.
        EAU guidelines on prostate cancer. part 1: screening, diagnosis, and local treatment with curative intent-update 2013.
        Eur Urol. 2014; 65: 124-137
        • Creswell JW
        • Plano Clark VL
        Designing and conducting mixed methods research. Third Edition. 2018;
        • O'Connor SD
        • Sodickson AD
        • Ip IK
        • et al.
        Journal club: Requiring clinical justification to override repeat imaging decision support: impact on CT use.
        AJR Am J Roentgenol. 2014; 203: W482-W490
        • Lin ND
        • Martins SB
        • Chan AS
        • et al.
        Identifying barriers to hypertension guideline adherence using clinician feedback at the point of care.
        in: AMIA Annual Symposium proceedings AMIA Symposium. 2006: 494-498
        • Nanji KC
        • Slight SP
        • Seger DL
        • et al.
        Overrides of medication-related clinical decision support alerts in outpatients.
        J Am Med Inform Assoc. 2014; 21: 487-491
        • Bradley EH
        • Curry LA
        • Devers KJ
        Qualitative data analysis for health services research: developing taxonomy, themes, and theory.
        Health Serv Res. 2007; 42: 1758-1772
        • Hsieh HF
        • Shannon SE
        Three approaches to qualitative content analysis.
        Qual Health Res. 2005; 15: 1277-1288
        • Mayring P
        Qualitative content anaylsis.
        A Companion to Qualitative Research. 2004; 1: 159-176
        • Litvin CB
        • Ornstein SM
        • Wessell AM
        • Nemeth LS
        • Nietert PJ
        Use of an electronic health record clinical decision support tool to improve antibiotic prescribing for acute respiratory infections: the ABX-TRIP study.
        J Gen Intern Med. 2013; 28: 810-816
        • Jani YH
        • Barber N
        • Wong IC
        Characteristics of clinical decision support alert overrides in an electronic prescribing system at a tertiary care paediatric hospital.
        Int J Pharm Pract. 2011; 19: 363-366
        • Ciprut S
        • Sedlander E
        • Watts KL
        • et al.
        Designing a theory-based intervention to improve the guideline-concordant use of imaging to stage incident prostate cancer.
        Urol Oncol. 2018; 36: 246-251