Studies have shown the American College of Radiology’s (ACR) evidence-based Appropriateness Criteria (ACR-AC) have had trouble gaining traction among resident trainees and attending physicians, despite being available for more than a decade. The latest such study, a survey of thoracic imaging practices sent to resident trainees and pulmonary and critical medicine fellows, once again shows lacking awareness of the ACR-AC, according to the results published in the May issue of Academic Radiology.

“In academic institutions, residents and fellows are responsible for the bulk of imaging decisions, and therefore, improving their awareness and application of the criteria is imperative,” wrote authors Allan B. Chiunda, MPH, of Case Western Reserve University, and Tan-Lucien H. Mohammed, MD, of the Cleveland Clinic Foundation’s Imaging Institute.

To evaluate the knowledge of the ACR-AC, specifically the guidelines on appropriate thoracic imaging, Chiunda and Mohammed surveyed trainees and fellows at the Cleveland Clinic Foundation during July and August 2010. The survey featured 20 multiple-choice questions based on hypothetical clinical scenarios, administered online, and invitations were sent to resident trainees in radiology, medicine and surgery, as well as pulmonary and critical medicine fellows.

A total of 69 trainees completed the survey, with an overall 65 percent correct response rate. Radiology residents performed the best, with a median score of 15 correct responses out of 20. Median scores for trainees in medicine, surgery and pulmonary and critical medicine were 10, nine and 13, respectively.

Certain scenarios presented by the survey had particularly low correct response rates. For example, just 9 percent correctly identified that a chest radiograph should be ordered to evaluate chronic cardiopulmonary disease in a patient over 70 years old with a previous radiograph from the last six months available. The most common incorrect response to that scenario was “no imaging needed.” Another scenario featuring a solitary pulmonary nodule less than 1 cm in size only had 19 percent give the correct response of a chest CT without contrast.

The authors suggested that awareness of the criteria could be increased by wider dissemination of the ACR-AC in journals and online. Computerized physician order entry systems and inclusion of the criteria into resident and trainee didactic sessions as required elements of discussion also could increase knowledge of the recommendations.

“Ultimately, the application of these criteria will eliminate unnecessary imaging, thereby improving the quality of patient care by increasing safety and decreasing diagnostic delay as well as lowering costs,” wrote Chiunda and Mohammed.

The publication of this study comes on the heels of the American Board of Internal Medicine Foundation’s Choosing Wisely campaign event last week in which nine physician specialty societies released lists of tests or procedures that are commonly ordered despite not always being medically necessary. The ACR was one of the societies, and their list, as well as the lists of the other eight societies, can be found at www.ChoosingWisely.org.