Imaging Appropriate Use Criteria for the Pediatric Population
Background
Evidence-based Appropriate Use Criteria (AUC) for complex imaging examinations have been developed by the American College of Radiology (ACR) since the early 1990s. In 2012, the ACR and National Decision Support Company (NDSC) began to collaborate on ACR Select™ by translating the ACR’s Appropriateness Criteria® into a digitally consumable set of content that could be easily integrated into the Electronic Medical Record (EMR). This collaborative effort was recently extended to the development of evidence-based pediatric imaging AUC, delivered through NDSC’s CareSelect™ Clinical Decision Support Platform.
Pediatric AUC
The ACR and the Society for Pediatric Radiology (SPR) invited a team of pediatric radiology subspecialty experts to collaborate with NDSC on a clinical decision support tool supported by evidence-based criteria that applied to pediatric clinical scenarios. The resulting Pediatric Rapid Response Committee, chaired by Marta Hernanz-Schulman, MD, FAAP, FACR, Professor of Radiology and Pediatrics and Chief of Diagnostic Imaging at Monroe Carell Jr. Children’s Hospital at Vanderbilt, consists of more than 30 SPR experts. The committee includes experts in pediatric musculoskeletal, thoracic, gastrointestinal, genitourinary and cardiac imaging.
The collaboration between the ACR and NDSC has resulted in the most comprehensive set of evidence- based imaging AUC available today. NDSC’s CareSelect Platform continues to expand to new clinical areas, including additional imaging opportunities that include complete coverage for Pediatrics.
The adage that “children are not little adults” takes on a special meaning when one realizes the complexity of pediatric imaging, which applies not to one, but to many populations. “A premature baby, a newborn baby at term, a 6-month-old, a 5-year-old, a 10-year-old and a 16-year-old are different; when certain symptoms, such as pain and vomiting occur in a patient, the likely diagnosis, and the appropriate imaging exam to accomplish that diagnosis, will differ respectively,” said Dr. Hernanz-Schulman.
“Our work with the ACR was foundational to the development of our skill in transposing and delivering complex clinical guidelines into EMR workflows,” explained Robert Cooke, Vice-President of Marketing, NDSC. “We author, curate and deliver ACR Select™, together with a range of evidence-based guidelines covering multiple domains, within our CareSelect Platform.”
In addition to the diagnostic efficacy of the examination, other considerations factor into the AUC. These include the safety of the examination: the use and amount of radiation that the specific examination entail; the need for sedation; the need for use of contrast material and the potential side effects within the specific population. Utilizing specific pediatric AUC can streamline the diagnostic evaluation of the patient – minimizing radiation and invasive maneuvers such as sedation while reducing the total number of studies performed.
“It is really about doing the right test – at the right time – for the right reasons,” said Becky Haines, Senior Director, American College of Radiology Press.”
Child-Centered Clinical Decision Support
The Pediatric AUC will further benefit by what NDSC has learned from the development and roll-out of CareSelect Imaging™, the company’s Clinical Decision Support solution for adult patients.
“One of the areas where we have made tremendous improvement is in our ability to refine and present indications and criteria based on both patient and provider context,” explained Cooke. “This allows us to tune the EMR presentation of guidelines to a provider’s scope of practice and the patient age to ensure efficient access to relevant clinical information.”
Dr. Hernanz-Schulman likewise believes that easy access is critical to the successful application of AUC in pediatrics. “You want to make things as easy as possible for everyone, so that providers can spend time thinking about and with their patients, rather than interacting with the computer.”
“We have made a giant step forward in use of imaging in children and that is why I am personally excited. This simply has not existed for children before.”
-Dr. Michael Bettmann, MD, Co-Chair of the ACR Task Force Appropriateness Criteria Oversight Committee
Adopting Clinical Decision Support Within Institutions
NDSC delivers the pediatric criteria together with ACR Select as part of the CareSelect Imaging Platform. All users of the ACR Select criteria can now access this content as part of their next content upgrade.
One facility currently employing the CareSelect Platform to manage imaging is Tampa General Hospital. From the start, the health system’s radiologists took an active role in the success of the project.
“Radiologists train for years to learn all of the ways imaging modalities and techniques can be appropriately applied to answer complex clinical questions,” explained Rajendra Kedar, MD, Radiology Associates of Florida. “Expecting non-radiologists to request the right test in nearly all cases without tools to support them in that decision-making is unrealistic. This is especially true for the pediatric patient population where there is an additional layer of complexity regarding age appropriateness, sedation and dose reduction.”
Dr. Kedar presented at the 2017 Children’s Hospital Association (CHA) meeting on his group’s experience with CareSelect. When Tampa General began using CareSelect, nearly 96 percent of all orders deemed “Inappropriate” (scores of 1-3 out of 9) were proceeded upon (Fig. 1). With continued use of the system, the number of proceeded “Inappropriate” examinations dropped by almost 30% with most of the changed orders being cancelled outright (Fig. 2).
“The real benefit of Clinical Decision Support is that it enables institutions to understand their imaging utilization. For hospitals moving toward more value-based care and striving for the best possible outcomes for patients, understanding clinical variation and when that variation is warranted, and when it is not, is important,” explained Dr. Kedar. “These same tools, when coupled with the pediatric AUC set will give us a new perspective and opportunity to assess variations and gaps in care in an important patient population.”
Data analytics in CareSelect Reporting allow institutions to see both global and individual provider practice patterns and identify outliers. If physicians are almost always overruling the CDS recommendations, it would indicate that either physician practice patterns or the CDS tool itself needs to be adjusted or localized. In this way, the system is always learning and improving.
More Than Just Appropriate Use Criteria
The assessment of pediatric head trauma using algorithm’s such as PECARN is a key component of JACHO certification. The CareSelect™ Platform also delivers these assessment tools through the combination of EMR data and patient assessment questions to ensure when imaging is warranted.
In addition, NDSC has integrated Radiology dose tracking data to inform AUC consultation for pediatrics.
Summary
CareSelect Imaging reduces unwarranted variation in care and helps ensure every child receives the most appropriate imaging regardless of where they were first treated. It helps organizations that have taken the Image Gently™ and Image Wisely™ pledge to reduce pediatric patients’ exposure to ionizing radiation achieve these laudable goals and helps provide greater insight into individual provider practice patterns. Furthermore, it supports the vision of Imaging 3.0 of radiology being a more engaged and collaborative specialty that can work with requesting physicians and patients alike on shared decision making.
“As we seek continued impact of our solutions we are now turning our attention to the opportunity to reducing cost and complexity associated with the authorization of services,” Cooke added. “Children represent the largest Medicaid population, and CDS can streamline these processes and ensure utilization is safely and responsibly managed. Reducing the burden of long wait times for services for patients and their families, both in terms of improving quality of care and creating value, the expansion of CDS criteria to now cover nearly 3,000 clinical end points for pediatric imaging is truly exciting.”