BACKGROUND: Inappropriate radiological exam ordering is a large contributor to healthcare waste in the United States. The American College of Radiology’s (ACR) Appropriateness Criteria (AC) are designed to inform radiological exam ordering practices, but many general internists are unfamiliar with it. Nevertheless the ACR AC are respected guidelines that the Centers for Medicare and Medicaid Services deemed as qualified to provide appropriate use criteria to fulfill Protecting Access to Medicare Act requirements. To address the underutilization of this valuable resource and promote evidence-based high-value ordering practices, we developed a curriculum introducing internal medicine residents to the ACR AC and analyzed its impact.
METHODS: Our curriculum has been integrated into the required ambulatory lecture series for internal medicine interns at the University of Chicago in the 2017-2018 academic year. To date, 23 interns have participated. The two-lecture curriculum includes: (1) an introduction to the ACR AC, its website, and mobile app; (2) an assignment to apply the ACR AC to case vignettes through the Radiology-TEACHES online portal (an initiative of the ACR founded by Dr. Marc Willis of Baylor College of Medicine); (3) a group discussion about the vignettes and a radiologist-led session on the principles of high-value radiological exam ordering. We used pre- and post-intervention surveys to assess for change in knowledge (using vignettes from Radiology-TEACHES) and attitudes related to high-value radiological exam ordering and use of the ACR AC. We used McNemar’s test and paired T-test as appropriate to analyze data.
RESULTS: Pre-intervention, 35% of residents were unaware of the ACR AC and only 25% reported it among their top 3 resources guiding ordering decisions; 50% stated that attending physicians rarely if ever mention radiological exam ordering guidelines. Knowledge scores related to appropriate radiological exam ordering improved from a mean of 59% (SD 0.16) correct answers on vignettes pre-intervention to 89% (SD 0.14) post-intervention (p=0.0001). Use of ACR AC during this “open-book” knowledge assessment increased from 17% of residents pre-intervention to 74% post-intervention (p=0.0003). Post-intervention data showed that residents were more likely to agree that they felt comfortable with their knowledge of cost of radiological exams (4% pre vs. 74% post) and with discussing cost with patients (9% vs. 61%), and that they value the ACR AC (65% vs. 96%); p-values were all <0.05. All residents found the curriculum helpful and thought it should be offered yearly; 91% agreed that they plan to change ordering practices as a result of the curriculum.
SIGNIFICANCE: This curriculum was well-received and led to a significant positive shift in knowledge and attitudes towards high-value radiological exam ordering and the ACR AC. A large majority of participants believe the curriculum will change their ordering practices. Future assessments will evaluate the durability of these findings over time through 6-9 month follow-up surveys and will evaluate the impact of curriculum on provider ordering practices through EHR analysis. Expansion to the University of Chicago faculty hospitalist group and the Emergency Medicine Residency Program is underway.
This curriculum is among the few targeting internal medicine residents at a large academic university hospital and is unique as it is multidisciplinary and integrates Radiology-TEACHES software, which won the 2017 American Board of Internal Medicine Creating Value Challenge. This curriculum is also timely as it promotes the use of the ACR AC, which the CMS deemed as qualified to provide appropriate use criteria to fulfill recently implemented Protecting Access to Medicare Act requirements. It was impactful and can be easily disseminated. If resident self-assessment proves accurate, this low cost intervention could have high value impact on ordering practices.
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