Similarly, some organizations place CT scanners in emergency departments to determine whether a patient with abdominal pain is suffering from appendicitis. "It is a good example of how a normal scan—with no abnormalities in the abdomen—is effective to keep them from exploratory surgery," says Weilburg. "Finding nothing in that case is effective or finding something is effective."
MGH added a decision support component to its ROE system, which is connected to its electronic medical record, in 2004. Since then, the growth rate of the utilization of CT scanning declined, he says. The big difference between MGH's ROE system and an RBM model is that the decision to order a test remains in the hands of the physician who is managing the patient's condition. The physician may have to answer some additional questions about why the test is warranted, but ultimately it is their call. They don’t have to keep appealing a decision made by an RBM to get approval for the test, which can be a time-consuming and cumbersome process.
Currently, MGH is evaluating how effective decision support is on the use of CT scans for patients with sinusitis. "The initial supposition was in no case should primary care physicians order CT scans of the face that only specialists should," Weilburg says. But the results are not as clear cut. In a high proportion of primary care physician cases patients met the criteria and the test was appropriate, he says.
The ultimate guide to effectiveness may rest in data on how individual physicians order tests. MGH has been conducting appropriate-variation analysis to show primary-care physicians how they vary in their use of imaging—taking into account the acuity of their patients. For example, if one physician tends to order more CTs of the head than another physician, it may be due to training, patient differences, and concerns about liability. If organizations can factor that out, they may be able to reduce some preferences that are deemed ineffective, explains Weilburg.
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