title: Impact of clinical decision support on head computed tomography use in patients with mild traumatic brain injury in the ED.
abstract: BACKGROUND
  Reduction of unnecessary head computed tomographies (CTs) in patients with mild traumatic brain injury (MTBI) was recently endorsed by American College of Emergency Physicians (ACEP) in the "Choosing Wisely" campaign. We examined the impact of computerized clinical decision support (CDS) on head CT utilization in MTBI emergency department (ED) visits.
  
  
  METHODS
  We conducted a 2-year cohort study at a level 1 trauma center and compared our results with the National Hospital Ambulatory Medical Care Survey from 2009 to 2010. All adult patients discharged from the ED with MTBI-associated diagnoses were included. After a baseline observation period at our institution, real-time CDS was implemented. Based upon the clinical history entered, low utility orders triggered an alert to clinicians, suggesting imaging studies might not adhere to evidence-based guidelines. Clinicians could cancel the order or ignore the alert. Primary outcome was intensity of head CT use in MTBI ED visits. Secondary outcomes included rates of delayed imaging and delays in diagnosing radiologically significant findings. χ(2), logistic regression, and process control chart assessed preintervention and postintervention differences.
  
  
  RESULTS
  In study patients, 58.1% of MTBI-related visits resulted in head CT preintervention vs 50.3% postintervention (13.4% relative decrease, P = .005), a change not detected in controls (73.3% vs 76.9%, P = .272). Study cohort patients not receiving a head CT during their index visit were neither more nor less likely to receive one in the subsequent 7 days (6.7% preintervention vs 9.4% postintervention, P = .231). Rates of delayed diagnosis of radiologically significant findings were unchanged (0% vs 0%).
  
  
  CONCLUSIONS
  Evidence-based CDS can reduce low utility imaging for MTBI.
authors.affiliation: Center for Evidence-Based Imaging, Harvard Medical School, Boston, MA; Department of Radiology, Harvard Medical School, Boston, MA; Department of Medicine, Harvard Medical School, Boston, MA; Brigham and Women's Hospital, Harvard Medical School, Boston, MA. Electronic address: iip@partners.org.
authors.forename: Ivan K
authors.initials: IK
authors.lastname: Ip
authors.affiliation: Center for Evidence-Based Imaging, Harvard Medical School, Boston, MA; Department of Radiology, Harvard Medical School, Boston, MA; Department of Emergency Medicine, Harvard Medical School, Boston, MA; Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
authors.forename: Ali S
authors.initials: AS
authors.lastname: Raja
authors.affiliation: Center for Evidence-Based Imaging, Harvard Medical School, Boston, MA; Department of Radiology, Harvard Medical School, Boston, MA; Department of Emergency Medicine, Harvard Medical School, Boston, MA; Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
authors.forename: Anurag
authors.initials: A
authors.lastname: Gupta
authors.affiliation: Center for Evidence-Based Imaging, Harvard Medical School, Boston, MA; Department of Radiology, Harvard Medical School, Boston, MA; Department of Emergency Medicine, Harvard Medical School, Boston, MA; Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
authors.forename: James
authors.initials: J
authors.lastname: Andruchow
authors.affiliation: Center for Evidence-Based Imaging, Harvard Medical School, Boston, MA; Department of Radiology, Harvard Medical School, Boston, MA; Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
authors.forename: Aaron
authors.initials: A
authors.lastname: Sodickson
authors.affiliation: Center for Evidence-Based Imaging, Harvard Medical School, Boston, MA; Department of Radiology, Harvard Medical School, Boston, MA; Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
authors.forename: Ramin
authors.initials: R
authors.lastname: Khorasani
mesh_terms: D000328:Adult; D000368:Aged; D001921:Brain / Q000000981:diagnostic imaging*; D001930:Brain Injuries / Q000000981:diagnostic imaging*; D015331:Cohort Studies; D003658:Decision Making, Computer-Assisted; D020000:Decision Support Systems, Clinical; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D014057:Tomography, X-Ray Computed / Q000706:statistics & numerical data*; D055815:Young Adult