title: Provider Feedback about Imaging Appropriateness by Using Scores from Order Entry Decision Support: Raw Rates Misclassify Outliers.
abstract: OBJECTIVE
  To determine the relevant physician- and practice-related factors that jointly affect the rate of low-utility imaging examinations (score of 1-3 out of 9) ordered by means of an order entry system that provides normative appropriateness feedback.
  
  
  METHODS
  This HIPAA-compliant study was approved by the institutional review board under an expedited protocol for analyzing anonymous aggregated administrative data. This is a retrospective study of approximately 250 000 consecutive scheduled outpatient advanced imaging examinations (computed tomography, magnetic resonance imaging, nuclear medicine) ordered by 164 primary care and 379 medical specialty physicians from 2008 to 2012. A hierarchical logistic regression model was used to identify multiple predictors of the probability that an examination received a low utility score. Physician- and practice-specific random effects were estimated to articulate (odds ratio) and quantify (intraclass correlation) interphysician variation.
  
  
  RESULTS
  Fixed effects found to be statistically significant predictors of low-utility imaging included examination type, whether the examination was cancelled, status of the person entering the order, and the total number of examinations ordered by the clinician. Neither patient age nor sex had any effect, and there were no secular trends (year of study). The remaining amount of interphysician variation was moderate (intraclass correlation, 22%), whereas the variation between medical specialties and primary care practices was low (intraclass correlation, 5%). The estimated physician-specific effects had reliability of 70%, which makes them just suitable for identifying outliers.
  
  
  CONCLUSIONS
  The authors found that 22% of the variation in the rate of low-utility examinations is attributable to ordering providers and 5% to their specialty or clinic.
authors.affiliation: From the Physician's Organization (C.L.S., J.B.W., T.G.F.) and Department of Radiology (C.L.S., K.J.D.), Massachusetts General Hospital, Boston, Mass.
authors.forename: Chris L
authors.initials: CL
authors.lastname: Sistrom
authors.forename: Jeffrey B
authors.initials: JB
authors.lastname: Weilburg
authors.forename: Keith J
authors.initials: KJ
authors.lastname: Dreyer
authors.forename: Timothy G
authors.initials: TG
authors.lastname: Ferris
mesh_terms: D000328:Adult; D003952:Diagnostic Imaging / Q000706:statistics & numerical data*; D005246:Feedback; D005260:Female; D006801:Humans; D008297:Male; D050316:Medical Order Entry Systems / Q000706:statistics & numerical data*; D008875:Middle Aged; D010818:Practice Patterns, Physicians'; D012189:Retrospective Studies; D055815:Young Adult