Does an AUC Decision Support Tool Improve Appropriate Use of Imaging Tests?

Use of a multimodality appropriate use criteria decision support tool (AUC-DST) at the point of care not only enabled rapid determination of test appropriateness, but was also associated with decreased testing for inappropriate indications, according to results from a new study published in the Journal of the American College of Cardiology.

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The multicenter study evaluated use of an AUC-DST by 100 physicians ordering myocardial perfusion scintigraphy (MPS), stress echocardiography (STE) or coronary computed tomographic angiography (CCTA) for 472 patients insured by one large private payer. Each site was granted exemption from the health plan's prior authorization requirements by radiology benefit managers (RBMs) during the eight-month study period.

Overall, use of an AUC-DST was associated with increases in appropriate testing and decreases in inappropriate testing over the study period. For tests ordered in the first two months compared to the last two months, appropriate tests increased from 49 percent to 61 percent (p=0.02), while inappropriate tests decreased from 22 percent to 6 percent (p<0.001). During this period, intended changes in medical therapy increased from 11 percent to 32 percent (p = 0.001), possibly as a result of the decreasing number of inappropriate studies over the course of the intervention.

In addition to changes in appropriate and inappropriate testing, the AUC-DST was also found to be a quick and immediate source of feedback, with users reporting the tool took an average of approximately 2 minutes to determine the category of appropriateness based on AUC ratings developed by the American College of Cardiology.

"Given the immediacy of feedback, the AUC-DST offered an educational component as well, which may have been associated with the observed trends towards increased intended changes in medical therapy changes without affecting intended rates of downstream testing," the authors said. "To our knowledge, this study is the first to evaluate the use of an AUC-DST to describe behavior of physician-preferred over policy-based testing, as well as the first to relate levels of appropriateness across multiple CAD imaging modalities to test results and future intended treatment plans.

The authors point out that their study results differ from prior studies in that "patient- and scenario-specific educational feedback was provided necessarily as a function of using the AUC-DST in a manner that promoted learning and quality improvement through 'hands-on' usage rather than formal didactics; continuously as opposed to sporadically; from a multimodality rather than single modality perspective; and as a method for avoidance time-consuming RBM processes." In addition, the AUC-DST was used at the time of test ordering vs. later in the CAD evaluation process. However, they also acknowledge that the current study does not directly compare AUC-DST performance to RBMs in terms of test appropriateness rates, costs and clinical outcomes – a comparison they suggest now appears warranted.

In the meantime, the authors point out that the study results may prove relevant to policymakers seeking to reduce unnecessary health care costs. "The results of our study suggest that a computerized point-of-order decision support system can reliably track physician behavior and that favorable changes can occur, even in the absence of RBM prior authorization requirements," the authors said. "Our results engender promise of the value of such an AUC-DST for improving appropriate testing, enhancing transparency, and reducing administrative burden."

Keywords: Myocardial Perfusion Imaging, Quality Improvement, Echocardiography, Stress, Health Care Costs, Feedback, United States

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