title: Changes in Physician Decision Making after CT: A Prospective Multicenter Study in Primary Care Settings.
abstract: Purpose To determine the effect of computed tomography (CT) results on physician decision making in three common clinical scenarios in primary care. Materials and Methods This research was approved by the institutional review board (IRB) and was HIPAA compliant. All physicians consented to participate with an opt-in or opt-out mechanism; patient consent was waived with IRB approval. In this prospective multicenter observational study, outpatients referred by primary care providers (PCPs) for CT evaluation of abdominal pain, hematuria, or weight loss were identified. Prior to CT, PCPs were surveyed to elicit their leading diagnosis, confidence in that diagnosis (confidence range, 0%-100%), a rule-out diagnosis, and a management plan if CT were not available. Surveys were repeated after CT. Study measures were the proportion of patients in whom leading diagnoses and management changed (PCP management vs specialist referral vs emergency department transfer), median changes in diagnostic confidence, and the proportion of patients in whom CT addressed rule-out diagnoses. Regression analyses were used to identify associations between study measures and site and participant characteristics. Specifically, logistic regression analysis was used for binary study measures (change in leading diagnosis, change in management), and linear regression analysis was used for the continuous study measure (change in diagnostic confidence). Accrual began on September 5, 2012, and ended on June 28, 2014. Results In total, 91 PCPs completed pre- and post-CT surveys in 373 patients. In patients with abdominal pain, hematuria, or weight loss, leading diagnoses changed after CT in 53% (131 of 246), 49% (36 of 73), and 57% (27 of 47) of patients, respectively. Management changed in 35% (86 of 248), 27% (20 of 74), and 54% (26 of 48) of patients, respectively. Median absolute changes in diagnostic confidence were substantial and significant (+20%, +20%, and +19%, respectively; P ≤ .001 for all); median confidence after CT was high (90%, 88%, and 80%, respectively). PCPs reported CT was helpful in confirming or excluding rule-out diagnoses in 98% (184 of 187), 97% (59 of 61), and 97% (33 of 34) of patients, respectively. Significant associations between primary measures and site and participant characteristics were not identified. Conclusion Changes in PCP leading diagnoses and management after CT were common, and diagnostic confidence increased substantially.©RSNA, 2016 Online supplemental material is available for this article.
authors.affiliation: From the Department of Radiology (P.V.P., E.F.H., G.S.G.), Institute for Technology Assessment (P.V.P., M.S.H., A.C.T., E.C.D., J.D.E., E.F.H., G.S.G.), Department of Medicine, Division of Internal Medicine (C.I.A.), and Department of Medicine, Mongan Institute for Health Policy (K.D.), Massachusetts General Hospital, 101 Merrimac St, 10th Floor, Boston, MA 02114; Department of Radiology, Virginia Mason Medical Center, Seattle, Wash (D.L.C.); Departments of Radiology (A.Z.) and Medicine (B.H.A.), Johns Hopkins Medical Institutions, Baltimore, Md; Department of Radiology, Duke University Medical Center, Durham, NC (C.M.M.); and Department of Medicine, Yale School of Medicine, New Haven, Conn (J.D.E.).
authors.forename: Pari V
authors.initials: PV
authors.lastname: Pandharipande
authors.affiliation: From the Department of Radiology (P.V.P., E.F.H., G.S.G.), Institute for Technology Assessment (P.V.P., M.S.H., A.C.T., E.C.D., J.D.E., E.F.H., G.S.G.), Department of Medicine, Division of Internal Medicine (C.I.A.), and Department of Medicine, Mongan Institute for Health Policy (K.D.), Massachusetts General Hospital, 101 Merrimac St, 10th Floor, Boston, MA 02114; Department of Radiology, Virginia Mason Medical Center, Seattle, Wash (D.L.C.); Departments of Radiology (A.Z.) and Medicine (B.H.A.), Johns Hopkins Medical Institutions, Baltimore, Md; Department of Radiology, Duke University Medical Center, Durham, NC (C.M.M.); and Department of Medicine, Yale School of Medicine, New Haven, Conn (J.D.E.).
authors.forename: Claude I
authors.initials: CI
authors.lastname: Alabre
authors.affiliation: From the Department of Radiology (P.V.P., E.F.H., G.S.G.), Institute for Technology Assessment (P.V.P., M.S.H., A.C.T., E.C.D., J.D.E., E.F.H., G.S.G.), Department of Medicine, Division of Internal Medicine (C.I.A.), and Department of Medicine, Mongan Institute for Health Policy (K.D.), Massachusetts General Hospital, 101 Merrimac St, 10th Floor, Boston, MA 02114; Department of Radiology, Virginia Mason Medical Center, Seattle, Wash (D.L.C.); Departments of Radiology (A.Z.) and Medicine (B.H.A.), Johns Hopkins Medical Institutions, Baltimore, Md; Department of Radiology, Duke University Medical Center, Durham, NC (C.M.M.); and Department of Medicine, Yale School of Medicine, New Haven, Conn (J.D.E.).
authors.forename: David L
authors.initials: DL
authors.lastname: Coy
authors.affiliation: From the Department of Radiology (P.V.P., E.F.H., G.S.G.), Institute for Technology Assessment (P.V.P., M.S.H., A.C.T., E.C.D., J.D.E., E.F.H., G.S.G.), Department of Medicine, Division of Internal Medicine (C.I.A.), and Department of Medicine, Mongan Institute for Health Policy (K.D.), Massachusetts General Hospital, 101 Merrimac St, 10th Floor, Boston, MA 02114; Department of Radiology, Virginia Mason Medical Center, Seattle, Wash (D.L.C.); Departments of Radiology (A.Z.) and Medicine (B.H.A.), Johns Hopkins Medical Institutions, Baltimore, Md; Department of Radiology, Duke University Medical Center, Durham, NC (C.M.M.); and Department of Medicine, Yale School of Medicine, New Haven, Conn (J.D.E.).
authors.forename: Atif
authors.initials: A
authors.lastname: Zaheer
authors.affiliation: From the Department of Radiology (P.V.P., E.F.H., G.S.G.), Institute for Technology Assessment (P.V.P., M.S.H., A.C.T., E.C.D., J.D.E., E.F.H., G.S.G.), Department of Medicine, Division of Internal Medicine (C.I.A.), and Department of Medicine, Mongan Institute for Health Policy (K.D.), Massachusetts General Hospital, 101 Merrimac St, 10th Floor, Boston, MA 02114; Department of Radiology, Virginia Mason Medical Center, Seattle, Wash (D.L.C.); Departments of Radiology (A.Z.) and Medicine (B.H.A.), Johns Hopkins Medical Institutions, Baltimore, Md; Department of Radiology, Duke University Medical Center, Durham, NC (C.M.M.); and Department of Medicine, Yale School of Medicine, New Haven, Conn (J.D.E.).
authors.forename: Chad M
authors.initials: CM
authors.lastname: Miller
authors.affiliation: From the Department of Radiology (P.V.P., E.F.H., G.S.G.), Institute for Technology Assessment (P.V.P., M.S.H., A.C.T., E.C.D., J.D.E., E.F.H., G.S.G.), Department of Medicine, Division of Internal Medicine (C.I.A.), and Department of Medicine, Mongan Institute for Health Policy (K.D.), Massachusetts General Hospital, 101 Merrimac St, 10th Floor, Boston, MA 02114; Department of Radiology, Virginia Mason Medical Center, Seattle, Wash (D.L.C.); Departments of Radiology (A.Z.) and Medicine (B.H.A.), Johns Hopkins Medical Institutions, Baltimore, Md; Department of Radiology, Duke University Medical Center, Durham, NC (C.M.M.); and Department of Medicine, Yale School of Medicine, New Haven, Conn (J.D.E.).
authors.forename: Maurice S
authors.initials: MS
authors.lastname: Herring
authors.affiliation: From the Department of Radiology (P.V.P., E.F.H., G.S.G.), Institute for Technology Assessment (P.V.P., M.S.H., A.C.T., E.C.D., J.D.E., E.F.H., G.S.G.), Department of Medicine, Division of Internal Medicine (C.I.A.), and Department of Medicine, Mongan Institute for Health Policy (K.D.), Massachusetts General Hospital, 101 Merrimac St, 10th Floor, Boston, MA 02114; Department of Radiology, Virginia Mason Medical Center, Seattle, Wash (D.L.C.); Departments of Radiology (A.Z.) and Medicine (B.H.A.), Johns Hopkins Medical Institutions, Baltimore, Md; Department of Radiology, Duke University Medical Center, Durham, NC (C.M.M.); and Department of Medicine, Yale School of Medicine, New Haven, Conn (J.D.E.).
authors.forename: Angela C
authors.initials: AC
authors.lastname: Tramontano
authors.affiliation: From the Department of Radiology (P.V.P., E.F.H., G.S.G.), Institute for Technology Assessment (P.V.P., M.S.H., A.C.T., E.C.D., J.D.E., E.F.H., G.S.G.), Department of Medicine, Division of Internal Medicine (C.I.A.), and Department of Medicine, Mongan Institute for Health Policy (K.D.), Massachusetts General Hospital, 101 Merrimac St, 10th Floor, Boston, MA 02114; Department of Radiology, Virginia Mason Medical Center, Seattle, Wash (D.L.C.); Departments of Radiology (A.Z.) and Medicine (B.H.A.), Johns Hopkins Medical Institutions, Baltimore, Md; Department of Radiology, Duke University Medical Center, Durham, NC (C.M.M.); and Department of Medicine, Yale School of Medicine, New Haven, Conn (J.D.E.).
authors.forename: Emily C
authors.initials: EC
authors.lastname: Dowling
authors.affiliation: From the Department of Radiology (P.V.P., E.F.H., G.S.G.), Institute for Technology Assessment (P.V.P., M.S.H., A.C.T., E.C.D., J.D.E., E.F.H., G.S.G.), Department of Medicine, Division of Internal Medicine (C.I.A.), and Department of Medicine, Mongan Institute for Health Policy (K.D.), Massachusetts General Hospital, 101 Merrimac St, 10th Floor, Boston, MA 02114; Department of Radiology, Virginia Mason Medical Center, Seattle, Wash (D.L.C.); Departments of Radiology (A.Z.) and Medicine (B.H.A.), Johns Hopkins Medical Institutions, Baltimore, Md; Department of Radiology, Duke University Medical Center, Durham, NC (C.M.M.); and Department of Medicine, Yale School of Medicine, New Haven, Conn (J.D.E.).
authors.forename: Jonathan D
authors.initials: JD
authors.lastname: Eisenberg
authors.affiliation: From the Department of Radiology (P.V.P., E.F.H., G.S.G.), Institute for Technology Assessment (P.V.P., M.S.H., A.C.T., E.C.D., J.D.E., E.F.H., G.S.G.), Department of Medicine, Division of Internal Medicine (C.I.A.), and Department of Medicine, Mongan Institute for Health Policy (K.D.), Massachusetts General Hospital, 101 Merrimac St, 10th Floor, Boston, MA 02114; Department of Radiology, Virginia Mason Medical Center, Seattle, Wash (D.L.C.); Departments of Radiology (A.Z.) and Medicine (B.H.A.), Johns Hopkins Medical Institutions, Baltimore, Md; Department of Radiology, Duke University Medical Center, Durham, NC (C.M.M.); and Department of Medicine, Yale School of Medicine, New Haven, Conn (J.D.E.).
authors.forename: Bimal H
authors.initials: BH
authors.lastname: Ashar
authors.affiliation: From the Department of Radiology (P.V.P., E.F.H., G.S.G.), Institute for Technology Assessment (P.V.P., M.S.H., A.C.T., E.C.D., J.D.E., E.F.H., G.S.G.), Department of Medicine, Division of Internal Medicine (C.I.A.), and Department of Medicine, Mongan Institute for Health Policy (K.D.), Massachusetts General Hospital, 101 Merrimac St, 10th Floor, Boston, MA 02114; Department of Radiology, Virginia Mason Medical Center, Seattle, Wash (D.L.C.); Departments of Radiology (A.Z.) and Medicine (B.H.A.), Johns Hopkins Medical Institutions, Baltimore, Md; Department of Radiology, Duke University Medical Center, Durham, NC (C.M.M.); and Department of Medicine, Yale School of Medicine, New Haven, Conn (J.D.E.).
authors.forename: Elkan F
authors.initials: EF
authors.lastname: Halpern
authors.affiliation: From the Department of Radiology (P.V.P., E.F.H., G.S.G.), Institute for Technology Assessment (P.V.P., M.S.H., A.C.T., E.C.D., J.D.E., E.F.H., G.S.G.), Department of Medicine, Division of Internal Medicine (C.I.A.), and Department of Medicine, Mongan Institute for Health Policy (K.D.), Massachusetts General Hospital, 101 Merrimac St, 10th Floor, Boston, MA 02114; Department of Radiology, Virginia Mason Medical Center, Seattle, Wash (D.L.C.); Departments of Radiology (A.Z.) and Medicine (B.H.A.), Johns Hopkins Medical Institutions, Baltimore, Md; Department of Radiology, Duke University Medical Center, Durham, NC (C.M.M.); and Department of Medicine, Yale School of Medicine, New Haven, Conn (J.D.E.).
authors.forename: Karen
authors.initials: K
authors.lastname: Donelan
authors.affiliation: From the Department of Radiology (P.V.P., E.F.H., G.S.G.), Institute for Technology Assessment (P.V.P., M.S.H., A.C.T., E.C.D., J.D.E., E.F.H., G.S.G.), Department of Medicine, Division of Internal Medicine (C.I.A.), and Department of Medicine, Mongan Institute for Health Policy (K.D.), Massachusetts General Hospital, 101 Merrimac St, 10th Floor, Boston, MA 02114; Department of Radiology, Virginia Mason Medical Center, Seattle, Wash (D.L.C.); Departments of Radiology (A.Z.) and Medicine (B.H.A.), Johns Hopkins Medical Institutions, Baltimore, Md; Department of Radiology, Duke University Medical Center, Durham, NC (C.M.M.); and Department of Medicine, Yale School of Medicine, New Haven, Conn (J.D.E.).
authors.forename: G Scott
authors.initials: GS
authors.lastname: Gazelle
mesh_terms: D015746:Abdominal Pain / Q000000981:diagnostic imaging*; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002983:Clinical Competence / Q000592:standards; D000066491:Clinical Decision-Making; D004635:Emergency Medicine / Q000592:standards; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D058007:Physicians, Primary Care / Q000592:standards*; D010865:Pilot Projects; D011446:Prospective Studies; D012017:Referral and Consultation / Q000706:statistics & numerical data; D014057:Tomography, X-Ray Computed; D055815:Young Adult