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Randomized Controlled Trial
. 2017 Apr;18(3):487-495.
doi: 10.5811/westjem.2017.1.33053. Epub 2017 Mar 7.

Impact of Clinical Decision Support on Radiography for Acute Ankle Injuries: A Randomized Trial

Shahein Tajmir  1   2   3   4   1 , Ali S Raja  2   3   5   1 , Ivan K Ip  2   3   6   1 , James Andruchow  2   3   7   1 , Patricia Silveira  2   3   1 , Stacy Smith  3   1 , Ramin Khorasani  2   3   1
Affiliations
Randomized Controlled Trial

Impact of Clinical Decision Support on Radiography for Acute Ankle Injuries: A Randomized Trial

Shahein Tajmir et al. West J Emerg Med. 2017 Apr.

Abstract

Introduction: While only 15-20% of patients with foot and ankle injuries presenting to urgent care centers have clinically significant fractures, most undergo radiography. We examined the impact of electronic point-of-care clinical decision support (CDS) on adherence to the Ottawa Ankle Rules (OAR), as well as use and yield of foot and ankle radiographs in patients with acute ankle injury.

Methods: We obtained institutional review board approval for this randomized controlled study performed April 18, 2012-December 15, 2013. All ordering providers credentialed at an urgent care affiliated with a quaternary care academic hospital were randomized to either receive or not receive CDS, based on the OAR and integrated into the physician order-entry system, with feedback at the time of imaging order. If the patient met OAR low-risk criteria, providers were advised against imaging and could either cancel the order or ignore the alert. We identified patients with foot and ankle complaints via ICD-9 billing codes and electronic health records and radiology reports reviewed for those who were eligible. Chi-square was used to compare adherence to the OAR (primary outcome), radiography utilization rate and radiography yield of foot and ankle imaging (secondary outcomes) between the intervention and control groups.

Results: Of 14,642 patients seen at urgent care during the study period, 613 (4.2%, representing 632 visits) presented with acute ankle injury and were eligible for application of the OAR; 374 (59.2%) of these were seen by control-group providers. In the intervention group, CDS adherence was higher for both ankle (239/258=92.6% vs. 231/374=61.8%, p=0.02) and foot radiography (209/258=81.0% vs. 238/374=63.6%; p<0.01). However, ankle radiography use was higher in the intervention group (166/258=64.3% vs. 183/374=48.9%; p<0.01), while foot radiography use (141/258=54.6% vs. 202/374=54.0%; p=0.95) was not. Radiography yield was also higher in the intervention group (26/307=8.5% vs. 18/385=4.7%; p=0.04).

Conclusion: Clinical decision support, previously demonstrated to improve guideline adherence for high-cost imaging, can also improve guideline adherence for radiography - as demonstrated by increased OAR adherence and increased imaging yield.

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Conflict of interest statement

Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. The authors disclosed none.

Figures

Figure 1A–E
Figure 1A–E
Clinical decision support screens for the Ottawa ankle rule integrated in the computerized physician order-entry system. ED, emergency department
Figure 1A–E
Figure 1A–E
Clinical decision support screens for the Ottawa ankle rule integrated in the computerized physician order-entry system. ED, emergency department
See this image and copyright information in PMC

References

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