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Decreasing inappropriate MRCP with contrast exams: impact of an EMR-Embedded clinical care pathway
Daniella Asch1, Gowthaman Gunabushanam2, Kelsey Cole3
1Yale University, New Haven, USA. daniella.asch@yale.edu.
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.
Insights
Implementing a new clinical pathway significantly reduced unnecessary contrast-enhanced Magnetic Resonance Cholangiopancreatography (MRCP) exams. This initiative decreased contrast use by 22% and improved the appropriateness of MRCP imaging.
Area of Science:
- Radiology
- Medical Informatics
Background:
- Magnetic Resonance Cholangiopancreatography (MRCP) with intravenous contrast is frequently overused in inpatient and emergency settings.
- Clinical decision support (CDS) tools alone may not sufficiently curb unnecessary contrast administration.
Purpose of the Study:
- To decrease the utilization of unnecessary abdominal MRI with intravenous contrast for MRCP exams in emergency department and inpatient populations.
- To improve the clinical appropriateness of MRCP ordering.
Main Methods:
- Removed existing MRCP electronic orders and directed providers to a new clinical care pathway with embedded guidance.
- Reviewed MRCP with contrast orders for appropriateness before and after pathway implementation.
- Manually tracked patient in-room time to compare MRI resource use for contrast vs. non-contrast exams.
Main Results:
- Contrast-enhanced MRCP exams decreased from 71% to 56% (22% relative decrease, p=0.003) after pathway implementation.
- Inappropriate contrast use for MRCP decreased from 54% to 25% (53% relative decrease, p=0.007).
- MRCP exams with contrast required an average of 11.5 minutes longer in the MRI scanner.
Conclusions:
- Redesigning the MRCP ordering process with a dedicated pathway significantly reduced contrast-enhanced MRCP utilization.
- This intervention improved the clinical appropriateness of MRCP exams and reduced unnecessary gadolinium exposure.
- Optimizing MRCP ordering pathways can decrease healthcare costs and enhance MRI scanner efficiency.
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