Implementation of a Computerized Decision Support System for Computed Tomography Scan Requests for Nontraumatic Headache in the Emergency Department

Ana Royuela; Cristina Abad; Agustina Vicente; Alfonso Muriel; Rut Romera; Borja M. Fernandez-Felix; Jesus Corres; Patricia Fernandez Bustos; Angelica Ortega; Julio Heras-Mosteiro; Raquel Garcia Latorre; Javier Zamora

doi:10.1016/j.jemermed.2019.08.026

Implementation of a Computerized Decision Support System for Computed Tomography Scan Requests for Nontraumatic Headache in the Emergency Department

Ana Royuela^*, Cristina Abad, Agustina Vicente, Alfonso Muriel, Rut Romera, Borja M. Fernandez-Felix, Jesus Corres, Patricia Fernandez Bustos, Angelica Ortega, Julio Heras-Mosteiro, Raquel Garcia Latorre, Javier Zamora

^*Corresponding author for this work

Metabolism and Systems Research

Research output: Contribution to journal › Article › peer-review

4 Citations (Scopus)

Abstract

Background: Nontraumatic headache is a frequent complaint in the emergency department (ED). Cranial computed tomography (CT) is a widely available test for the diagnostic work-up, despite the risk of exposure to ionizing radiation. Objectives: We sought to develop and evaluate a cranial CT request computerized decision support system (CDSS) for adults with their first presentation of unusual severe nontraumatic headache in the ED. Methods: Electronic database searches identified clinical decision and prediction rules and studies delineating risk factors in nontraumatic headache. A long list of risk factors extracted from these articles was reduced by a 30-member multidisciplinary expert panel (radiologists, emergency physicians, methodologists), using a 90% agreement threshold. This shortlist was used to develop the algorithm for the cranial CT request CDSS, which was implemented in March 2016. Impact evaluation compared CT scan frequency and diagnostic yield of pathologic findings before (March–August 2015) and after (March–August 2016) implementation. Results: From the 10 selected studies, 10 risk factors were shortlisted to activate a request for cranial CT. Before implementation, 377 cranial CTs were ordered (15.3% of 2469 CT scans) compared with 244 after (9.5% of 2561 CT scans; pre–post difference 5.74%; 95% confidence interval [CI] 3.92–7.56%; p < 0.001), corresponding to a 37.6% relative reduction in the test ordering rate (95% CI 25.7–49.5%; p < 0.001). Despite the reduction in cranial CT scans, we did not observe an increase in pathological findings after introducing the decision support system (70 cases before [18.5%] vs. 35 cases after [14.3%]; pre–post difference −4.0% [95% CI −10.0 to 1.6%]; p = 0.170). Conclusion: In nontraumatic headache among adults seen in the ED, CDSS decreased the cranial CT request rate but the diagnostic yield did not improve.

Original language	English
Pages (from-to)	780-790
Number of pages	11
Journal	Journal of Emergency Medicine
Volume	57
Issue number	6
DOIs	https://doi.org/10.1016/j.jemermed.2019.08.026
Publication status	Published - Dec 2019

Bibliographical note

Funding Information:
Supported by research grants PI13/00896 and PI13/01183 (Improving the adequacy of imaging requests with ionizing radiation [CT and Rx] in the Emergency Department, MAPAC-Image Project II) from the Instituto de Salud Carlos III , Ministerio de Ciencia e Innovación , Spain, and the European Regional Development Fund , European Union, “A way to make Europe”.

Funding Information:
Supported by research grants PI13/00896 and PI13/01183 (Improving the adequacy of imaging requests with ionizing radiation [CT and Rx] in the Emergency Department, MAPAC-Image Project II) from the Instituto de Salud Carlos III, Ministerio de Ciencia e Innovaci?n, Spain, and the European Regional Development Fund, European Union, ?A way to make Europe?. Project File Number PI16/00558 that belongs to the State Research Plan Oriented to the Challenges of the Society within the framework of the State Plan for Scientific and Technical Research and Innovation 2013-2016, to ISCIII as a financing entity and co-financed with Feder Funds. MAPAC-Imagen Working Group: Mar?a Eugenia Cobo Reinoso, Mar?a Nieves Plana Farras, In?s Pechorrom?n de las Heras, Olga Mar?a Sanz de Le?n, Santiago Resano Pardo, Javier Bl?zquez S?nchez, Milagros Mart? de Gracia, Inmaculada Pinilla Fern?ndez, A?rea D?ez Tasc?n, Manuel Quintana D?az, Rosa Capilla Pueyo, Angel Aguado Torquero, Joaquin Moran Marsili, Lorena Rodr?guez Gij?n, Diego Garrido Alonso, Alfonso Martin Diaz, Lucia Fern?ndez, Alberto Borobia, Gonzalo Garz?n Moll, Daniel Bernabeu Taboada, Mar?a Jos? Sim?n Merlo, Magdalena Carreras Aja, Rafael Villoria Alonso, Josu Mendiola Arza, Jennifer Barredo Parra, Leire Atilano Santos, Gotzon Iglesias Hidalgo, Ana Rosa Gil Martin, Ver?nica Garc?a de Pereda de Blas, Aitor Garc?a de Vicu?a Mel?ndez, Silvia Carbajo Azabal, Ana Santorcuato Bilbao, Marta Estaella Bellart, Sara de Benito Sobrado, Eunate Arana-Arri.

Publisher Copyright:
© 2019 Elsevier Inc.

Keywords

algorithm
CDSS
cranial CT
emergency department
nontraumatic headache

ASJC Scopus subject areas

Emergency Medicine

Access to Document

10.1016/j.jemermed.2019.08.026

Cite this

Royuela, A., Abad, C., Vicente, A., Muriel, A., Romera, R., Fernandez-Felix, B. M., Corres, J., Fernandez Bustos, P., Ortega, A., Heras-Mosteiro, J., Garcia Latorre, R., & Zamora, J. (2019). Implementation of a Computerized Decision Support System for Computed Tomography Scan Requests for Nontraumatic Headache in the Emergency Department. Journal of Emergency Medicine, 57(6), 780-790. https://doi.org/10.1016/j.jemermed.2019.08.026

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title = "Implementation of a Computerized Decision Support System for Computed Tomography Scan Requests for Nontraumatic Headache in the Emergency Department",

abstract = "Background: Nontraumatic headache is a frequent complaint in the emergency department (ED). Cranial computed tomography (CT) is a widely available test for the diagnostic work-up, despite the risk of exposure to ionizing radiation. Objectives: We sought to develop and evaluate a cranial CT request computerized decision support system (CDSS) for adults with their first presentation of unusual severe nontraumatic headache in the ED. Methods: Electronic database searches identified clinical decision and prediction rules and studies delineating risk factors in nontraumatic headache. A long list of risk factors extracted from these articles was reduced by a 30-member multidisciplinary expert panel (radiologists, emergency physicians, methodologists), using a 90% agreement threshold. This shortlist was used to develop the algorithm for the cranial CT request CDSS, which was implemented in March 2016. Impact evaluation compared CT scan frequency and diagnostic yield of pathologic findings before (March–August 2015) and after (March–August 2016) implementation. Results: From the 10 selected studies, 10 risk factors were shortlisted to activate a request for cranial CT. Before implementation, 377 cranial CTs were ordered (15.3% of 2469 CT scans) compared with 244 after (9.5% of 2561 CT scans; pre–post difference 5.74%; 95% confidence interval [CI] 3.92–7.56%; p < 0.001), corresponding to a 37.6% relative reduction in the test ordering rate (95% CI 25.7–49.5%; p < 0.001). Despite the reduction in cranial CT scans, we did not observe an increase in pathological findings after introducing the decision support system (70 cases before [18.5%] vs. 35 cases after [14.3%]; pre–post difference −4.0% [95% CI −10.0 to 1.6%]; p = 0.170). Conclusion: In nontraumatic headache among adults seen in the ED, CDSS decreased the cranial CT request rate but the diagnostic yield did not improve.",

keywords = "algorithm, CDSS, cranial CT, emergency department, nontraumatic headache",

author = "Ana Royuela and Cristina Abad and Agustina Vicente and Alfonso Muriel and Rut Romera and Fernandez-Felix, {Borja M.} and Jesus Corres and {Fernandez Bustos}, Patricia and Angelica Ortega and Julio Heras-Mosteiro and {Garcia Latorre}, Raquel and Javier Zamora",

note = "Funding Information: Supported by research grants PI13/00896 and PI13/01183 (Improving the adequacy of imaging requests with ionizing radiation [CT and Rx] in the Emergency Department, MAPAC-Image Project II) from the Instituto de Salud Carlos III , Ministerio de Ciencia e Innovaci{\'o}n , Spain, and the European Regional Development Fund , European Union, “A way to make Europe”. Funding Information: Supported by research grants PI13/00896 and PI13/01183 (Improving the adequacy of imaging requests with ionizing radiation [CT and Rx] in the Emergency Department, MAPAC-Image Project II) from the Instituto de Salud Carlos III, Ministerio de Ciencia e Innovaci?n, Spain, and the European Regional Development Fund, European Union, ?A way to make Europe?. Project File Number PI16/00558 that belongs to the State Research Plan Oriented to the Challenges of the Society within the framework of the State Plan for Scientific and Technical Research and Innovation 2013-2016, to ISCIII as a financing entity and co-financed with Feder Funds. MAPAC-Imagen Working Group: Mar?a Eugenia Cobo Reinoso, Mar?a Nieves Plana Farras, In?s Pechorrom?n de las Heras, Olga Mar?a Sanz de Le?n, Santiago Resano Pardo, Javier Bl?zquez S?nchez, Milagros Mart? de Gracia, Inmaculada Pinilla Fern?ndez, A?rea D?ez Tasc?n, Manuel Quintana D?az, Rosa Capilla Pueyo, Angel Aguado Torquero, Joaquin Moran Marsili, Lorena Rodr?guez Gij?n, Diego Garrido Alonso, Alfonso Martin Diaz, Lucia Fern?ndez, Alberto Borobia, Gonzalo Garz?n Moll, Daniel Bernabeu Taboada, Mar?a Jos? Sim?n Merlo, Magdalena Carreras Aja, Rafael Villoria Alonso, Josu Mendiola Arza, Jennifer Barredo Parra, Leire Atilano Santos, Gotzon Iglesias Hidalgo, Ana Rosa Gil Martin, Ver?nica Garc?a de Pereda de Blas, Aitor Garc?a de Vicu?a Mel?ndez, Silvia Carbajo Azabal, Ana Santorcuato Bilbao, Marta Estaella Bellart, Sara de Benito Sobrado, Eunate Arana-Arri. Publisher Copyright: {\textcopyright} 2019 Elsevier Inc.",

year = "2019",

month = dec,

doi = "10.1016/j.jemermed.2019.08.026",

language = "English",

volume = "57",

pages = "780--790",

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Royuela, A, Abad, C, Vicente, A, Muriel, A, Romera, R, Fernandez-Felix, BM, Corres, J, Fernandez Bustos, P, Ortega, A, Heras-Mosteiro, J, Garcia Latorre, R & Zamora, J 2019, 'Implementation of a Computerized Decision Support System for Computed Tomography Scan Requests for Nontraumatic Headache in the Emergency Department', Journal of Emergency Medicine, vol. 57, no. 6, pp. 780-790. https://doi.org/10.1016/j.jemermed.2019.08.026

TY - JOUR

T1 - Implementation of a Computerized Decision Support System for Computed Tomography Scan Requests for Nontraumatic Headache in the Emergency Department

AU - Royuela, Ana

AU - Abad, Cristina

AU - Vicente, Agustina

AU - Muriel, Alfonso

AU - Romera, Rut

AU - Fernandez-Felix, Borja M.

AU - Corres, Jesus

AU - Fernandez Bustos, Patricia

AU - Ortega, Angelica

AU - Heras-Mosteiro, Julio

AU - Garcia Latorre, Raquel

AU - Zamora, Javier

N1 - Funding Information: Supported by research grants PI13/00896 and PI13/01183 (Improving the adequacy of imaging requests with ionizing radiation [CT and Rx] in the Emergency Department, MAPAC-Image Project II) from the Instituto de Salud Carlos III , Ministerio de Ciencia e Innovación , Spain, and the European Regional Development Fund , European Union, “A way to make Europe”. Funding Information: Supported by research grants PI13/00896 and PI13/01183 (Improving the adequacy of imaging requests with ionizing radiation [CT and Rx] in the Emergency Department, MAPAC-Image Project II) from the Instituto de Salud Carlos III, Ministerio de Ciencia e Innovaci?n, Spain, and the European Regional Development Fund, European Union, ?A way to make Europe?. Project File Number PI16/00558 that belongs to the State Research Plan Oriented to the Challenges of the Society within the framework of the State Plan for Scientific and Technical Research and Innovation 2013-2016, to ISCIII as a financing entity and co-financed with Feder Funds. MAPAC-Imagen Working Group: Mar?a Eugenia Cobo Reinoso, Mar?a Nieves Plana Farras, In?s Pechorrom?n de las Heras, Olga Mar?a Sanz de Le?n, Santiago Resano Pardo, Javier Bl?zquez S?nchez, Milagros Mart? de Gracia, Inmaculada Pinilla Fern?ndez, A?rea D?ez Tasc?n, Manuel Quintana D?az, Rosa Capilla Pueyo, Angel Aguado Torquero, Joaquin Moran Marsili, Lorena Rodr?guez Gij?n, Diego Garrido Alonso, Alfonso Martin Diaz, Lucia Fern?ndez, Alberto Borobia, Gonzalo Garz?n Moll, Daniel Bernabeu Taboada, Mar?a Jos? Sim?n Merlo, Magdalena Carreras Aja, Rafael Villoria Alonso, Josu Mendiola Arza, Jennifer Barredo Parra, Leire Atilano Santos, Gotzon Iglesias Hidalgo, Ana Rosa Gil Martin, Ver?nica Garc?a de Pereda de Blas, Aitor Garc?a de Vicu?a Mel?ndez, Silvia Carbajo Azabal, Ana Santorcuato Bilbao, Marta Estaella Bellart, Sara de Benito Sobrado, Eunate Arana-Arri. Publisher Copyright: © 2019 Elsevier Inc.

PY - 2019/12

Y1 - 2019/12

N2 - Background: Nontraumatic headache is a frequent complaint in the emergency department (ED). Cranial computed tomography (CT) is a widely available test for the diagnostic work-up, despite the risk of exposure to ionizing radiation. Objectives: We sought to develop and evaluate a cranial CT request computerized decision support system (CDSS) for adults with their first presentation of unusual severe nontraumatic headache in the ED. Methods: Electronic database searches identified clinical decision and prediction rules and studies delineating risk factors in nontraumatic headache. A long list of risk factors extracted from these articles was reduced by a 30-member multidisciplinary expert panel (radiologists, emergency physicians, methodologists), using a 90% agreement threshold. This shortlist was used to develop the algorithm for the cranial CT request CDSS, which was implemented in March 2016. Impact evaluation compared CT scan frequency and diagnostic yield of pathologic findings before (March–August 2015) and after (March–August 2016) implementation. Results: From the 10 selected studies, 10 risk factors were shortlisted to activate a request for cranial CT. Before implementation, 377 cranial CTs were ordered (15.3% of 2469 CT scans) compared with 244 after (9.5% of 2561 CT scans; pre–post difference 5.74%; 95% confidence interval [CI] 3.92–7.56%; p < 0.001), corresponding to a 37.6% relative reduction in the test ordering rate (95% CI 25.7–49.5%; p < 0.001). Despite the reduction in cranial CT scans, we did not observe an increase in pathological findings after introducing the decision support system (70 cases before [18.5%] vs. 35 cases after [14.3%]; pre–post difference −4.0% [95% CI −10.0 to 1.6%]; p = 0.170). Conclusion: In nontraumatic headache among adults seen in the ED, CDSS decreased the cranial CT request rate but the diagnostic yield did not improve.

AB - Background: Nontraumatic headache is a frequent complaint in the emergency department (ED). Cranial computed tomography (CT) is a widely available test for the diagnostic work-up, despite the risk of exposure to ionizing radiation. Objectives: We sought to develop and evaluate a cranial CT request computerized decision support system (CDSS) for adults with their first presentation of unusual severe nontraumatic headache in the ED. Methods: Electronic database searches identified clinical decision and prediction rules and studies delineating risk factors in nontraumatic headache. A long list of risk factors extracted from these articles was reduced by a 30-member multidisciplinary expert panel (radiologists, emergency physicians, methodologists), using a 90% agreement threshold. This shortlist was used to develop the algorithm for the cranial CT request CDSS, which was implemented in March 2016. Impact evaluation compared CT scan frequency and diagnostic yield of pathologic findings before (March–August 2015) and after (March–August 2016) implementation. Results: From the 10 selected studies, 10 risk factors were shortlisted to activate a request for cranial CT. Before implementation, 377 cranial CTs were ordered (15.3% of 2469 CT scans) compared with 244 after (9.5% of 2561 CT scans; pre–post difference 5.74%; 95% confidence interval [CI] 3.92–7.56%; p < 0.001), corresponding to a 37.6% relative reduction in the test ordering rate (95% CI 25.7–49.5%; p < 0.001). Despite the reduction in cranial CT scans, we did not observe an increase in pathological findings after introducing the decision support system (70 cases before [18.5%] vs. 35 cases after [14.3%]; pre–post difference −4.0% [95% CI −10.0 to 1.6%]; p = 0.170). Conclusion: In nontraumatic headache among adults seen in the ED, CDSS decreased the cranial CT request rate but the diagnostic yield did not improve.

KW - algorithm

KW - CDSS

KW - cranial CT

KW - emergency department

KW - nontraumatic headache

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U2 - 10.1016/j.jemermed.2019.08.026

DO - 10.1016/j.jemermed.2019.08.026

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AN - SCOPUS:85072792895

SN - 0736-4679

VL - 57

SP - 780

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JO - Journal of Emergency Medicine

JF - Journal of Emergency Medicine

IS - 6

ER -

Implementation of a Computerized Decision Support System for Computed Tomography Scan Requests for Nontraumatic Headache in the Emergency Department

Abstract

Bibliographical note

Keywords

ASJC Scopus subject areas

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