title: Journal club: Requiring clinical justification to override repeat imaging decision support: impact on CT use.
abstract: OBJECTIVE
  The purpose of this study was to determine the impact of requiring clinical justification to override decision support alerts on repeat use of CT.
  
  
  METHODS
  This before and after intervention study was conducted at a 793-bed tertiary hospital with computerized physician order entry and clinical decision support systems. When a CT order is placed, decision support alerts the orderer if the patient's same body part has undergone CT within the past 90 days. The study cohort included all 28,420 CT orders triggering a repeat alert in 2010. The intervention required clinical justification, selected from a predetermined menu, to override repeat CT decision support alerts to place a CT order; otherwise the order could not be placed and was dropped. The primary outcome, dropped repeat CT orders, was analyzed using three methods: chi-square tests to compare proportions dropped before and after intervention; multiple logistic regression tests to control for orderer, care setting, and patient factors; and statistical process control for temporal trends.
  
  
  RESULTS
  The repeat CT order drop rate had an absolute increase of 1.4%; 6.1% (682/11,230) before to 7.5% (1290/17,190) after intervention, which was a 23% relative change (7.5 - 6.1)/6.1 × 100 = 23%; p < 0.0001). Orders were dropped more often after intervention (odds ratio, 1.3; 95% CI, 1.1-1.4; p < 0.0001). Statistical control analysis supported the association between the increase in the drop rate with intervention rather than underlying trends.
  
  
  CONCLUSIONS
  Adding a requirement for clinical justification to override alerts modestly but significantly improves the impact of repeat CT decision support (23% relative change), with the overall effect of preventing one in 13 repeat CT orders.
authors.affiliation: 1 Center for Evidence Based Imaging, Brigham and Women's Hospital, Harvard Medical School, 20 Kent St, Second Fl, Brookline, MA 02445.
authors.forename: Stacy D
authors.initials: SD
authors.lastname: O'Connor
authors.forename: Aaron D
authors.initials: AD
authors.lastname: Sodickson
authors.forename: Ivan K
authors.initials: IK
authors.lastname: Ip
authors.forename: Ali S
authors.initials: AS
authors.lastname: Raja
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Healey
authors.forename: Louise I
authors.initials: LI
authors.lastname: Schneider
authors.forename: Ramin
authors.initials: R
authors.lastname: Khorasani
mesh_terms: D020000:Decision Support Systems, Clinical / Q000706:statistics & numerical data*; D006801:Humans; D062527:Meaningful Use / Q000706:statistics & numerical data*; D017410:Practice Guidelines as Topic; D011873:Radiology Information Systems / Q000592:standards*; D014057:Tomography, X-Ray Computed / Q000706:statistics & numerical data*; D014481:United States; D019564:Unnecessary Procedures / Q000706:statistics & numerical data*
keywords: CT; clinical decision support; informatics; repeat testing