Decreasing inappropriate MRCP with contrast exams: impact of an EMR-Embedded clinical care pathway

Abstract

Purpose: Decrease unnecessary abdominal MRI with intravenous contrast with MRCP exams for emergency department and inpatients.

Methods: Our institution's two MRCP orders were removed from the electronic medical record (one with intravenous (IV) contrast and the other without), with all providers directed to a new MRCP clinical care pathway containing clinical guidance and links to the appropriate orders based on indication and patient characteristics. Before and after deployment, a random set of MRCP with contrast orders were reviewed for clinical appropriateness of needing IV contrast. A manual tracking of "patient in room" time was performed to compare MRI resource use for MRCP exams with contrast vs. non-contrast. A commercial clinical decision support (CDS) tool was active throughout the study period. Statistical significance was assessed with Chi-square test.

Results: At baseline, 71% (142/200) of MRCP exams were completed with contrast and 29% (58/200) without contrast. After two plan-do-study-act (PDSA) cycles, percentage of MRCPs performed with contrast decreased to 56% (p = 0.003), a 22% relative decrease, and MRCPs performed without contrast increased to 44%, a 53% relative increase. At baseline, contrast use was deemed inappropriate in 54% (29/54) of MRCP studies. Reassessment after PDSA cycle 1 showed a decrease in inappropriate MRCP with contrast orders to 25% (9/36), a 53% relative decrease (p = 0.007). Mean "in room" time was 11.5 min longer for MRCP with contrast exams.

Conclusion: Despite CDS, MRCP with contrast orders were deemed inappropriate 54% of the time at baseline. Redesigning the MRCP ordering process via creation of a pathway with embedded clinical guidance significantly decreased the proportion of contrast-enhanced MRCP exams by 22% and improved relative clinical appropriateness of MRCP with contrast exams by 62%. Properly directing ordering providers to non-contrast MRCP orders can help reduce healthcare costs, reduce unnecessary gadolinium exposure, and improve MR scanner efficiency.

Keywords: Clinical pathway; Contrast; MRCP; Order entry; Quality improvement.