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Review Article

Reducing Unnecessary Imaging and Pathology Tests: A Systematic Review

Harriet Hiscock, Rachel Jane Neely, Hayley Warren, Jason Soon and Andrew Georgiou
Pediatrics February 2018, 141 (2) e20172862; DOI: https://doi.org/10.1542/peds.2017-2862
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Abstract

CONTEXT: Unnecessary imaging and pathology procedures represent low-value care and can harm children and the health care system.

OBJECTIVE: To perform a systematic review of interventions designed to reduce unnecessary pediatric imaging and pathology testing.

DATA SOURCES: We searched Medline, Embase, Cinahl, PubMed, Cochrane Library, and gray literature.

STUDY SELECTION: Studies we included were: reports of interventions to reduce unnecessary imaging and pathology testing in pediatric populations; from developed countries; written in the English language; and published between January 1, 1996, and April 29, 2017.

DATA EXTRACTION: Two researchers independently extracted data and assessed study quality using a Cochrane group risk of bias tool. Level of evidence was graded using the Oxford Centre for Evidence-Based Medicine grading system.

RESULTS: We found 64 articles including 44 before-after, 14 interrupted time series, and 1 randomized controlled trial. More effective interventions were (1) multifaceted, with 3 components (mean relative reduction = 45.0%; SD = 28.3%) as opposed to 2 components (32.0% [30.3%]); or 1 component (28.6%, [34.9%]); (2) targeted toward families and clinicians compared with clinicians only (61.9% [34.3%] vs 30.0% [32.0%], respectively); and (3) targeted toward imaging (41.8% [38.4%]) or pathology testing only (48.8% [20.9%]), compared with both simultaneously (21.6% [29.2%]).

LIMITATIONS: The studies we included were limited to the English language.

CONCLUSIONS: Promising interventions include audit and feedback, system-based changes, and education. Future researchers should move beyond before-after designs to rigorously evaluate interventions. A relatively novel approach will be to include both clinicians and the families they manage in such interventions.

  • Abbreviations:
    AR —
    absolute reduction
    CT —
    computed tomography
    ED —
    emergency department
    EMR —
    electronic medical record
    LVC —
    low-value care
    NICE —
    National Institute for Health and Care Excellence
    RBUS —
    renal bladder ultrasound
    RCT —
    randomized controlled trial
    RR —
    relative reduction
    UTI —
    urinary tract infection
    VCUG —
    voiding cystourethrogram

    • Low-value care (LVC) is care that provides little or no benefit, may cause patients harm, or yields marginal benefits at a disproportionately high cost.1 This problem of LVC, or unnecessary care, is gaining wider recognition through professionally led initiatives such as Choosing Wisely.2 These initiatives strive to achieve clinician consensus on what constitutes LVC, with the hope that identifying LVC procedures will catalyze efforts to reduce such care. Doing so is crucial to a sustainable health care system, given that LVC is thought to constitute up to one-third of health care costs,3 at least in adult care in the United States. LVC practices commonly include unnecessary imaging and pathology procedures.

    To reduce LVC, we need to know how to change clinician practices. Attempts to reduce LVC practices identified by Choosing Wisely have so far yielded only small magnitude changes.4 However, when delivered across populations, even small changes can represent clinically meaningful change and reduce costs. Although systematic reviews of the evidence on interventions to reduce LVC have been published,5,6 they are focused almost exclusively on adults and do not differentiate pediatric populations. Effective interventions to reduce LVC in children may differ from those in adults because of additional factors driving LVC in children, such as increased parental demand and decreased clinician confidence in treating children compared with adults.

    In this systematic review, we aim to summarize evidence from the literature regarding interventions to reduce unnecessary imaging and pathology tests in pediatric populations (mean age ≤18 years) as 2 common, high-volume exemplars of LVC. To identify potentially sustainable solutions, we limited our review to studies that included a follow-up period of >6 months.

    Methods

    This systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.7 A protocol was registered with the International Prospective Register of Systematic Reviews on September 19, 2016 (registration number CRD42016047960).

    A systematic search of the Medline, Embase, Cinahl, PubMed, and Cochrane Library databases was conducted by using Medical Subject Headings and keywords adapted for each database. Four broad categories were included: (1) unnecessary procedures; (2) imaging and pathology tests; (3) intervention, trials, or reviews; and (4) children and adolescents (Supplemental Information). The search was limited to literature published in developed countries between January 1, 1996, and April 29, 2017. A gray literature search was employed via a keyword structure that paralleled that of the main search (Supplemental Information). This included searches of Google Scholar, Choosing Wisely publications (United States, Canada, Australia), EVOLVE (ie, the Royal Australasian College of Physicians “do-not-do” lists) publications, and gray literature databases.

    Studies were included if they contained reports on 1 or more intervention(s) to reduce unnecessary imaging or pathology tests among pediatric patients. We selected studies that were aimed at reducing unnecessary or LVC as per established guidelines (for example, “do-not-do” procedures [ie, National Institute for Health and Care Excellence (NICE) Guidelines8]); tests repeated routinely, or without clinical indication to do so (Choosing Wisely2). Studies were required to use a control group; however, to allow for a comprehensive review, we were liberal in defining this (eg, usual practice, other active intervention, nonexposed control group, or pre-intervention comparison). We expected interventions to include 1 or more of the following attributes on the basis of the adult literature9: education (eg, lectures or guidelines distribution), audit and feedback (eg, clinician or organization performance is compared with peers), system and/or process based (eg, electronic clinical decision support, computer order entry changes, or institutional guideline), incentive or penalty schemes (eg, reward or punishment for certain ordering practices), or guideline publication (eg, an external body published a guideline, with no specific adaptation for the institution studied). We considered studies to be relevant to a pediatric population if the total patient sample had a mean age ≤18 years. Literature in any language other than English was excluded during the screening process because of limits on available resources to conduct translation. Studies with a follow-up period of ≤6 months were excluded so that the interventions reported here reflect medium- to longer-term results.

    Studies were screened for eligibility via a 2-stage process, first by screening title and abstract, followed by full-text review. For studies without sufficient information to assess eligibility, first authors were contacted for missing information. Data including study design, sample characteristics, intervention components, and outcomes were extracted by 2 coauthors using a standardized data extraction form within the EPPI-Reviewer software.10 The same 2 authors independently assessed risk of bias (at the outcome level) for all included papers by using the “Cochrane Effective Practice and Organization of Care (EPOC) guidelines for assessing risk of bias in studies with a separate control group,"11 and discrepancies were resolved via joint article review and discussion. Additionally, the level of evidence for each study was graded from 1 to 5 according to a modified version of the Oxford Centre for Evidence-Based Medicine levels of evidence system, in which 1 = a properly powered and conducted randomized controlled trial (RCT) or systematic review with meta-analysis and 5 = opinion of respected authorities or case reports.12

    Where not directly reported, we calculated a relative reduction (RR) in testing for each study and an absolute reduction (AR) in testing for studies in which reported data made this possible. ARs were calculated as the percentage of patients who received the test in the pre-intervention (for before-after studies) or comparator group minus the percentage of patients who received the test in the post-intervention or intervention group. RRs were calculated as the number of tests conducted in the pre-intervention or comparator group minus the number of tests conducted in the post-intervention or intervention group, divided by the number of tests conducted in the pre-intervention or comparator group. Both ARs and RRs were conducted with the unit of analysis as the type of test, with some studies containing reports of effects of the intervention on multiple tests (eg, computed tomography [CT] and ultrasound, or multiple laboratory tests). We did not quantitatively pool study results because there was a large degree of heterogeneity in study design and reporting of outcomes. As such, we present a narrative summary of ARs and RRs using means and SDs to summarize effects. We present these results stratified by interventions targeting imaging only, pathology only, and imaging and pathology, followed by a summary of the overall effects. All analyses were performed by using Stata version 14.0 (StataCorp, College Station, TX).

    Results

    Search Results

    Database searches generated 10 554 results, of which 2423 were duplicates (Fig 1). After screening on title and abstract, 155 full-text articles were reviewed for eligibility. The gray literature search produced 3104 studies, from which only 1 nonduplicated paper was eligible for inclusion. In addition, 1 article13 was identified via discussion with colleagues at The Royal Children’s Hospital (from where this review was conducted). A total of 64 studies were included in the final review.

    FIGURE 1
    FIGURE 1

    Preferred Reporting Items for Systematic Reviews and Meta-Analyses flowchart of included and excluded studies.

    Interventions Targeting Imaging Only

    Thirty-two studies contained reports of interventions to reduce unnecessary imaging, with sample sizes ranging from 61 to 160 000 (see Table 1). Of these, 23 were from the United States and 4 were from Australia. The majority (n = 16) were conducted in the emergency department (ED), with 5 conducted in inpatient populations, 4 conducted in outpatient populations, and 4 conducted across multiple settings. Most (n = 21) were conducted in pediatric hospitals, 8 in general hospitals, and 1 across a mix of sites.14 Twenty-four studies were conducted at single sites. Nearly all studies (n = 27) targeted clinicians, and only 2 studies targeted a combination of patients and/or families and clinicians.15,16 Three studies (in a series on reducing imaging in irritable bowel syndrome17–19) targeted patients and their families only. Follow-up periods ranged from 10 months to 7 years, and most studies were before-after (n = 23) or interrupted time series designs (n = 5), with only 1 RCT.20 Regarding intervention complexity, the majority of interventions (n = 18) comprised only a single component, of which most (n = 11) were a system- and/or process-based change, though 4 studies13,21–23 contained reports of the effects of an external guideline publication on imaging rates. Of the 14 multifaceted interventions, nearly all (n = 13) were a system- and/or process-based change alongside an education component, with or without an audit and feedback component. Absolute changes in imaging ranged from a 92% reduction to a 21% increase, and relative changes ranged from a 100% reduction to an 81% increase.

    View this table:
    TABLE 1

    Included Studies Targeting Imaging (Only): Study Detail and Intervention Characteristics

    Interventions Targeting Pathology Only

    Ten studies contained reports on interventions to reduce unnecessary pathology testing, with sample sizes ranging from 61 to 3523 (see Table 2). Of these, 9 were from the United States and 1 from the United Kingdom. Most were in ICU patients (n = 8), and the majority (n = 7) were conducted in pediatric hospitals. All studies were single site. All except 1 study45 targeted clinicians only, and none targeted patients only. Follow-up periods ranged from 8 months to 2.5 years, and nearly all (n = 8) were before-after designs, with 2 interrupted time series.46,47 Regarding intervention complexity, all interventions included a system- and/or process-based change component. In addition to this component, 2 studies included education,45,48 1 study included audit and feedback,49 and 4 studies included both education and audit and feedback components alongside a system- and/or process-based change.46,47,50,51 Three studies contained examinations of only a system- and/or process-based change.52–54

    View this table:
    TABLE 2

    Included Studies Targeting Pathology (Only): Study Detail and Intervention Characteristics

    All interventions that exclusively targeted pathology revealed some reduction in testing or no change, and no studies contained reports of an increase in testing. One study51 contained a report of ARs in unnecessary testing of 12% for repeat testing and 9% for basic metabolic panels and complete blood counts. RRs across all pathology studies ranged from a 100% reduction to no change (0% reduction). Studies revealed a greater reduction in testing when baseline levels were higher.

    Interventions Targeting Imaging and Pathology

    Twenty-two studies contained reports on interventions to reduce both unnecessary pathology testing and imaging, with sample sizes ranging from 51 to 120 539 (Table 3). All except 1 study were from the United States (n = 21). The majority of studies were conducted in inpatient settings (n = 10) or EDs (n = 7), or both inpatient settings and EDs55–57 (n = 3). Again, studies were mostly conducted in pediatric hospitals (n = 19) and at a single site (n = 17). All except 1 study58 were targeted at clinicians alone, and none was targeted at patients alone. Follow-up periods ranged from 9 months to 5.5 years, and most studies were before-after (n = 13) or interrupted time series (n = 7). Regarding intervention complexity, approximately half (n = 13) comprised a single component, usually a system- and/or process-based change (n = 10). Three studies55,59,60 contained reports on effects after an external guideline publication. Multifaceted interventions (n = 9) largely comprised a system- and/or process-based component alongside education (n = 6). For studies in which imaging and pathology were targeted simultaneously, ARs ranged from a 46% reduction to a 22% increase, and RRs ranged from a 100% reduction to a 92% increase.

    View this table:
    TABLE 3

    Included Studies Targeting Imaging and Pathology: Study Detail and Intervention Characteristics

    Overall Effects

    Overall, there is evidence to suggest that intervention complexity was related to reduced testing (Fig 2), with a combination of 3 components (system- and/or process-based, education, and audit and feedback) appearing more effective (mean RR = 45.0%; SD = 28.3%) than 1 (mean RR = 28.6%; SD = 34.9%) or 2 components (mean RR = 32.0%; SD = 30.3%). Of the single component interventions, the most effective type was education alone (mean RR = 57.9%; SD = 13.6%); however, this mean is calculated from only 3 studies. Studies contained reports of varying effectiveness of system- and/or process-based interventions (mean RR = 35.0%; SD = 33.3%) and guideline publication (mean RR = 15.8%; SD = 34.7%).

    FIGURE 2
    FIGURE 2

    Box plots of relative changes in testing stratified by combinations of intervention components. Negative values represent a reduction in testing; positive values represent an increase in testing. There were no other combinations of intervention components. System- and/or process-based (n = 24); education (n = 3); guideline publication (n = 7); audit and feedback plus system- and/or process-based (n = 3); education plus system- and/or process-based (n = 14); audit and feedback plus system- and/or process-based plus education (n = 13).

    Interventions were more effective if they targeted only imaging (mean RR = 41.8%; SD = 38.4) or only pathology testing (mean RR = 48.8%; SD = 20.9) rather than both simultaneously (mean RR = 21.6%; SD = 29.2). Interventions in which both clinicians and patients were targeted appeared more effective (mean RR = 61.9%; SD = 34.3) than those in which clinicians alone were targeted (mean RR = 30.0%; SD = 32.0). The only studies in which patients alone were targeted was a series of 3 studies on irritable bowel syndrome in adolescents,17–19 in which a mean RR of 57.9% (SD = 13.6) was reported.

    The type of test was also associated with differences in reductions, with greater RR seen in routine follow-up imaging (mean RR = 76.1%; SD = 12.1%) and invasive voiding cystourethrogram (VCUG) tests (mean RR = 69.3%; SD = 20.0%) compared with respiratory syncytial virus testing (mean RR = 11.5%; SD = 52.8%). In studies aimed at reducing CT scans for appendicitis, CT scan use decreased but abdominal ultrasound use increased (mean increase = 15.0%; SD 23.5%).

    Setting of care was also associated with varying reductions in unnecessary testing. Consistent reductions were observed in the ICU (mean RR = 47.6%; SD = 21.0%) and ED (mean RR = 32.3%; SD = 25.5%), with no studies containing reports of an increase in testing in these settings. In contrast, 5 studies contained reports of an increase in testing in inpatient and outpatient settings. Two of these studies20,28 involved multiple sites where each site implemented the suite of interventions separately. Some sites had reductions, whereas others had an increase in LVC.28 Two studies23,59 contained reports on the effect of publication of external guidelines with no individual site modification and/or implementation. Differences in site characteristics and/or how the interventions were implemented may account for the different outcomes. Reductions in testing were smaller and more variable for inpatient (mean RR = 25.7%; SD = 34.1%) and multiple setting studies (mean RR = 26.7%; SD = 48.7%). Greater reductions were observed for single-site (mean RR = 35.6%; SD = 31.4%) versus multisite interventions (mean RR = 24.6%; SD = 35.6%) and for general hospitals (mean RR = 41.7%; SD = 38.9%) versus pediatric hospitals (mean RR = 31.5%; SD = 30.6%).

    Secondary Outcomes

    Most studies contained reports on at least 1 balancing measure (ie, secondary effects of the intervention such as length of stay in hospital or ED, admission rates, mortality, or cost). All authors reported either no change or an improvement in these outcomes after the intervention. Eighteen studies contained reports of a reduction in length of stay, and an additional 17 studies contained reports of no change. Seven contained reports of a reduced rate of admission to hospital, whereas 11 studies contained reports of no change. Only 1 study62 contained a report of a reduction in readmissions, and 14 contained reports of no change. Of the 21 studies that contained reports on the effect of the intervention on hospital or patient costs, all contained reports of a cost saving as a result of conducting fewer tests. However, no authors conducted a cost-effectiveness analysis for the intervention as a whole. Two studies67,74 contained reports of lower mortality in the postintervention period, and 9 contained reports of no change.

    Quality of Included Studies

    Overall quality of included studies was poor. The κ interrater reliability for the study risk of bias ratings was 0.82, with all discrepancies subsequently resolved through discussion. Similarity in risk of bias ratings across the studies was largely because of the study design; the majority of studies were before-after design or interrupted-time series designs and were graded fairly equally. Only 1 RCT was conducted, and it was rated as a low risk of bias. All other studies were rated as high risk of bias on at least 2 of the 9 Cochrane Effective Practice and Organization of Care domains, although approximately one-third (n = 20) of studies were rated high risk on 3 or more domains. The majority of studies did not contain enough information to provide a clear assessment, and many domains were rated as unclear risk. Study level of evidence based on Oxford Centre for Evidence-Based Medicine ratings is presented for each study alongside intervention details in Tables 1–3.

    Discussion

    The majority of studies designed to evaluate interventions to reduce LVC in pediatric imaging and pathology reveal positive effects ranging from small to large. Characteristics of more effective interventions include multifaceted as opposed to single-component interventions, interventions that target imaging or pathology only (and not both), and interventions that include both families and their treating clinicians. Greater reductions were seen in general compared with pediatric hospitals, likely because general hospitals usually had higher baseline levels of testing than pediatric hospitals. No studies contained reports on our secondary outcome of cost-effectiveness; however, studies generally contained reports of an improvement (or no adverse effect) on balancing measures such as length of stay, admissions, and hospital or patient costs.

    The authors of 4 studies15,16,45,58 implemented an intervention targeting both clinicians and families. The authors of 1 of these studies45 aimed to reduce blood testing after surgical closure of atrial septal defects in a single general hospital. A clinical pathway for postoperative care was introduced, and patients and families were educated on what care to expect and were informed of significant variations from the clinical pathway. They found promising reductions in unnecessary blood testing (RR range: 13.7%–69.2%) that were sustained up to 2.5 years post–initial intervention. Even more effective were the 2 studies15,16 in which unnecessary imaging was targeted and clinicians and patients were included in the intervention; 1 of these studies16 contained a report of a 100% reduction in VCUG testing after a normal renal bladder ultrasound (RBUS) in suspected urinary tract infection (UTI) in inpatient care. The researchers achieved this at a single pediatric hospital through the use of a multifaceted intervention including education for staff and families, lectures, electronic medical record (EMR) order set changes, and audit and feedback. Further comparative studies are needed to determine if family involvement increases efficacy and sustainability of interventions. Communicating risks of LVC practices to families (eg, radiation doses in abdominal radiographs, increased length of stay, and exposure to nosocomial infections after false-positive blood test results) may be a powerful tool in prompting families to refuse or at least question clinician-driven, LVC practices.

    Effective methods to reduce unnecessary imaging depended on the condition. For example, common to effective methods to reduce abdominal CTs in children with suspected appendicitis was an early surgical consult. The authors of 1 study15 reported a comparatively high (92.4%) RR in use of chest radiographs in asthma versus 29.1% and 35.4% reported in the other 2 studies31,33 that contained reports on this. The more effective of the 3 studies15 included patient asthma education sessions and assigned patients to a primary care provider who was trained in national asthma guidelines.

    Similarly, the authors of 4 studies67,69,74,75 examined changes in resource use after a staffing and/or structural change (eg, a dedicated pediatric ED or staffing changes), although the authors of 1 study67 saw greater reductions than was reported in other studies, and they implemented a staffing and/or structure change with supporting education. The authors opened a dedicated “small baby unit” separate from the NICU, with processes promoting continuity of care and education for staff. Education comprised ongoing training and talks (ie, 16 hours of baseline education followed by quarterly 3-hour case discussions, informal talks twice per week, and weekly pharmacy and nutrition rounds). This study achieved a 63% reduction in laboratory testing and 51% decrease in abdominal and chest radiographs over a 4-year follow-up period.

    Overall, the quality of the studies was poor. The majority of studies were quality improvement studies, which are difficult to assess with traditional evidence grading scales yet may still offer ideas as to how best to reduce LVC. Only 1 RCT was conducted,20 and this had a low risk of bias. RCTs can be difficult to conduct in complex health care systems. Recent evidence suggests that ITS designs may offer results similar to those arising from RCTs but at a fraction of the cost and time.77 Although several before-after studies revealed positive effects in reducing unnecessary imaging and pathology testing, results are likely to be overinflated because they do not account for secular trends in care patterns or potential confounders of the effect of the intervention on the LVC practice. Replication of these effects should be demonstrated in ITS or RCTs before claims of effectiveness can be confirmed. In this respect, the pediatric literature contrasts with the adult literature in which more RCTs have been conducted.9,78 In Kobewka et al’s9 systematic review of interventions to reduce unnecessary pathology testing, 14 of 109 studies were RCTs. However, similar to our review, Kobewka et al9 found that interventions were more effective if they were multicomponent and their conductors targeted fewer rather than more tests. Sustainability was also an issue in adult studies; only 15 of 109 studies contained reports of outcomes beyond 12 months. Unlike the pediatric literature, no authors targeted clinicians and patients in their interventions.

    Our review has a number of strengths. We conducted a comprehensive search across published and gray literature and only included studies with a follow-up period of >6 months to assess sustainability. We rigorously assessed study risk of bias and had high interrater reliability in doing so. We note some limitations. First, the overall risk of bias was high because of poor study quality. Second, we limited our screening to English language papers and so excluded ∼6 papers published in another language. However, we scanned over 10 000 texts and included 64 studies and believe it is unlikely that inclusion of a handful of non-English language studies would have changed our conclusions in any meaningful way. We were unable to pool results because of the heterogeneous nature of the interventions. We thus attempted to estimate, when data permitted, relative and absolute changes in LVC, pre- and post-interventions. Finally, most studies were conducted in single sites, predominantly in US hospitals, possibly because of the availability of large health data sets to analyze, together with incentives (eg, hospital rankings) to reduce wasteful care. This reduces the external validity of the findings given that health systems and practices vary widely between countries and between hospitals.

    Conclusions

    There is no single solution to reducing LVC. Our systematic review suggests that future researchers should rigorously evaluate interventions that are multifaceted, include audit and feedback, system-based changes and education, and target 1 low-value practice at a time. Aligning with key recommendations from the 2017 National Quality Forum report79 on improving diagnostic quality, interventions to reduce LVC should be codesigned with patients and clinicians (a relatively novel approach in the LVC literature), tailored to the needs of their environment, and take advantage of electronic health records to report on outcomes. Evaluations should report on both effectiveness and cost-effectiveness outcomes, ensure long-term follow-up to assess sustainability of the intervention(s), and ideally be conducted across multiple sites to provide evidence of generalizability.

    Footnotes

      • Accepted November 16, 2017.
    • Address correspondence to Harriet Hiscock, PhD, Centre for Community Child Health, Royal Children’s Hospital, 50 Flemington Rd, Parkville, VIC 3052, Australia. E-mail: harriet.hiscock{at}rch.org.au

    • This trial has been registered with the PROSPERO international prospective register of systematic reviews (identifier CRD42016047960).

    • FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

    • FUNDING: The Health Services Research Unit of The Royal Children’s Hospital is funded by a Royal Children’s Hospital Foundation grant (2015-521). Dr Hiscock is supported by a National Health and Medical Research Council Career Development Fellowship (1068947). Mr Soon is supported by the Policy and Advocacy Department of the Royal Australasian College of Physicians. The Murdoch Children’s Research Institute is supported by the Victorian Government’s Operational Infrastructure Program. The funding organizations had no role in the design and conduct of the study; collection, management, analysis, or interpretation of the data; preparation, review, or approval of the manuscript; or the decision to submit the manuscript for publication.

    • POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

    • COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2017-3859.

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    Vol. 141, Issue 2
    1 Feb 2018
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    Reducing Unnecessary Imaging and Pathology Tests: A Systematic Review
    Harriet Hiscock, Rachel Jane Neely, Hayley Warren, Jason Soon, Andrew Georgiou
    Pediatrics Feb 2018, 141 (2) e20172862; DOI: 10.1542/peds.2017-2862
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