Joint Design with Providers of Clinical Decision Support for Value-Based Advanced Shoulder Imaging

Background Provider orders for inappropriate advanced imaging, while rarely altering patient management, contribute enough to the strain on available health care resources, and therefore the United States Congress established the Appropriate Use Criteria Program. Objectives To examine whether co-designing clinical decision support (CDS) with referring providers will reduce barriers to adoption and facilitate more appropriate shoulder ultrasound (US) over magnetic resonance imaging (MRI) in diagnosing Veteran shoulder pain, given similar efficacies and only 5% MRI follow-up rate after shoulder US. Methods We used a theory-driven, convergent parallel mixed-methods approach to prospectively (1) determine medical providers' reasons for selecting MRI over US in diagnosing shoulder pain and identify barriers to ordering US, (2) co-design CDS, informed by provider interviews, to prompt appropriate US use, and (3) assess CDS impact on shoulder imaging use. CDS effectiveness in guiding appropriate shoulder imaging was evaluated through monthly monitoring of ordering data at our quaternary care Veterans Hospital. Key outcome measures were appropriate MRI/US use rates and transition to ordering US by both musculoskeletal specialist and generalist providers. We assessed differences in ordering using a generalized estimating equations logistic regression model. We compared continuous measures using mixed effects analysis of variance with log-transformed data. Results During December 2016 to March 2018, 569 (395 MRI, 174 US) shoulder advanced imaging examinations were ordered by 111 providers. CDS “co-designed” in collaboration with providers increased US from 17% (58/335) to 50% (116/234) of all orders (p < 0.001), with concomitant decrease in MRI. Ordering appropriateness more than doubled from 31% (105/335) to 67% (157/234) following CDS (p < 0.001). Interviews confirmed that generalist providers want help in appropriately ordering advanced imaging. Conclusion Partnering with medical providers to co-design CDS reduced barriers and prompted appropriate transition to US from MRI for shoulder pain diagnosis, promoting evidence-based practice. This approach can inform the development and implementation of other forms of CDS.

A radiographic criteria checklist to determine reasons for errors, resulting in sub-optimal routine shoulder projections

Background: Optimal shoulder images must adhere to specific radiographic criteria before they are sent to the radiologist for reporting. Repeat x-rays of the shoulder may increase radiation exposure to the patient.Aim: The aims of this study were to determine whether images adhered to the required radiographic criteria for routine shoulder imaging and to identify possible reasons for non-adherence.Setting: The study was conducted at an imaging department at a tertiary academic hospital in Bloemfontein, South Africa.Methods: A criteria checklist compiled from literature was used to evaluate 578 routine shoulder images including anteroposterior (AP) with external rotation and lateral-Y (LAT-Y) projections. The checklist determined whether the shoulder images adhered to the criteria with regard to the anatomy included, positioning and technical factors, such as inclusion of the correct anatomical lead marker. Data were analysed using SAS Version 9.2 statistical software.Results: More than 80% of the AP external rotation images included unnecessary anatomical structures owing to incorrect centring. In four out of seven criteria pertaining to positioning for AP external rotation imaging, at least 70% of images were performed incorrectly. Four-sided collimation was not present in more than 50% of both AP external rotation and LAT-Y images because of incorrect centring, while more than 30% of shoulder images presented with anatomical digital markers.Conclusion: The application of criteria required for shoulder imaging must be addressed at the participating imaging department to improve overall patient care. An in-service training session is recommended to enhance the radiographic technique with regard to routine shoulder projections.

Shoulder Arthroplasty Imaging: What’s New

Background:Shoulder arthroplasty, in its different forms (hemiarthroplasty, total shoulder arthroplasty and reverse total shoulder arthroplasty) has transformed the clinical outcomes of shoulder disorders. Improvement of general clinical outcome is the result of stronger adequacy of the treatment to the diagnosis, enhanced surgical techniques, specific implanted materials, and more accurate follow up. Imaging is an important tool in each step of these processes.Method:This article is a review article declining recent imaging processes for shoulder arthroplasty.Results:Shoulder imaging is important for shoulder arthroplasty pre-operative planning but also for post-operative monitoring of the prosthesis and this article has a focus on the validity of plain radiographs for detecting radiolucent line and on new Computed Tomography scan method established to eliminate the prosthesis metallic artefacts that obscure the component fixation visualisation.Conclusion:Number of shoulder arthroplasties implanted have grown up rapidly for the past decade, leading to an increase in the number of complications. In parallel, new imaging system have been established to monitor these complications, especially component loosening