title: Effects of Performance Feedback Reports on Adherence to Evidence-Based Guidelines in Use of CT for Evaluation of Pulmonary Embolism in the Emergency Department: A Randomized Trial.
abstract: OBJECTIVE
  The purpose of this study was to assess whether implementing emergency department (ED) physician performance feedback reports improves adherence to evidence-based guidelines for use of CT for evaluation of pulmonary embolism (PE) beyond that achieved with clinical decision support (CDS) alone.
  
  
  METHODS
  This prospective randomized controlled trial was conducted from January 1, 2012, to December 31, 2013, at an urban level 1 adult trauma center ED. Attending physicians were stratified into quartiles by use of CT for evaluation of PE in 2012 and were randomized to receive quarterly feedback reporting or not, beginning January 2013. Reports consisted of individual and anonymized group data on guideline adherence (using the Wells criteria), use of CT for PE (number of CT examinations for PE per 1000 patients), and yield (percentage of CT examinations for PE with positive findings). We compared guideline adherence (primary outcome) and use and yield (secondary outcomes) of CT for PE between the control and intervention groups in 2013 and with historical imaging data from 2012.
  
  
  RESULTS
  Of 109,793 ED patients during the control and intervention periods, 2167 (2.0%) underwent CT for evaluation of PE. In the control group, guideline adherence remained unchanged between 2012 (78.8% [476/604]) and 2013 (77.2% [421/545]) (p = 0.5); in the intervention group, guideline adherence increased 8.8% after feedback report implementation, from 78.3% (426/544) to 85.2% (404/474) (p < 0.05). Use and yield were unchanged in both groups.
  
  
  CONCLUSIONS
  Implementation of quarterly feedback reporting resulted in a modest but significant increase in adherence to evidence-based guidelines for use of CT for evaluation of PE in ED patients, enhancing the impact of CDS alone. These results suggest potentially synergistic effects of traditional performance improvement tools with CDS to improve guideline adherence.
authors.affiliation: 1 Center for Evidence-Based Imaging, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115.|2 Department of Radiology, Brigham and Women's Hospital, Boston, MA.|3 Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA.|4 Harvard Medical School, Boston, MA.
authors.forename: Ali S
authors.initials: AS
authors.lastname: Raja
authors.affiliation: 1 Center for Evidence-Based Imaging, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115.|2 Department of Radiology, Brigham and Women's Hospital, Boston, MA.|4 Harvard Medical School, Boston, MA.|5 Department of Medicine, Brigham and Women's Hospital, Boston, MA.
authors.forename: Ivan K
authors.initials: IK
authors.lastname: Ip
authors.affiliation: 1 Center for Evidence-Based Imaging, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115.|2 Department of Radiology, Brigham and Women's Hospital, Boston, MA.|4 Harvard Medical School, Boston, MA.
authors.forename: Ruth M
authors.initials: RM
authors.lastname: Dunne
authors.affiliation: 1 Center for Evidence-Based Imaging, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115.|3 Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA.|4 Harvard Medical School, Boston, MA.
authors.forename: Jeremiah D
authors.initials: JD
authors.lastname: Schuur
authors.affiliation: 6 Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
authors.forename: Angela M
authors.initials: AM
authors.lastname: Mills
authors.affiliation: 1 Center for Evidence-Based Imaging, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115.|2 Department of Radiology, Brigham and Women's Hospital, Boston, MA.|4 Harvard Medical School, Boston, MA.
authors.forename: Ramin
authors.initials: R
authors.lastname: Khorasani
mesh_terms: D000328:Adult; D020000:Decision Support Systems, Clinical; D019317:Evidence-Based Medicine; D005246:Feedback; D005260:Female; D019983:Guideline Adherence; D006786:Hospitals, Urban; D006801:Humans; D008297:Male; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011446:Prospective Studies; D011655:Pulmonary Embolism / Q000000981:diagnostic imaging*; D058996:Quality Improvement; D014057:Tomography, X-Ray Computed / Q000706:statistics & numerical data*; D014193:Trauma Centers / Q000592:standards*
keywords: imaging overuse; performance improvement; physician feedback; pulmonary embolism; randomized controlled trial