Equity in Diagnostic Imaging Trial

Investigators at our institution (Hwang & Richardson)* documented a racial disparity in the
use of CT scans to diagnose subarachnoid hemorrhage, (SAH) a life-threatening form of
stroke. Subsequent analyses found a similar finding in NHAMCS, a national ED Visit
database*. The investigators will compare the effectiveness of 1) an audit-feedback
intervention that provides data on race-specific CT rates and 2) a clinical decision support
(CDS) message in the electronic "headache" charting template in eliminating the previously
observed Black-White disparity in CT rates to rule out SAH.

Study Setting: The adult section of the Mount Sinai Emergency Department, an urban academic
department with an annual volume of over 70,000 adult visits and a patient population
representing a diverse cross-section of race and socioeconomic groups. The adult patients
are cared for by a staff that includes: attending physicians, physician assistants,
emergency medicine resident physicians, and rotating resident physicians from other
specialties. The department has a dedicated CT scanner that is readily available around the
clock. Epic Production is used for all physician and nurse documentation and for all order
entry (including CT scans).

Over a 24-month period the investigators will compare the intervention and control groups'
rates of testing for SAH across races, controlling for patient acuity, age and
co-morbidities. Because the close working relationships among the attending and resident
physicians in our department may lead to knowledge diffusion, the intervention may change
the behavior of the control group as well as the intervention group, thus leading to an
underestimation of the intervention effect as measured by the between- groups difference.
The investigators will use a time series design to allow us to evaluate this effect. 10
months after the implementation of the first intervention, the clinical decision support
message will be implemented. The impact of each intervention will be evaluated using a
repeated measures design using a mixed linear model.

Inclusion Criteria:

Attending Physicians, Emergency Room Resident Physicians, and PA's will be included if:

- they provide care to adult patients in the emergency department of Mount Sinai
Hospital.

Patients will be enrolled for medical record review if

- they present with a complaint of headache and charted on the headache template in the
period between four years pre-intervention and the end of the study period.

Exclusion Criteria:

- anyone who does not meet the inclusion criteria will be excluded from the study