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Over the past decade, technological advances have provided new tools for radiologists. However, the effect of these technological advances on radiologist workload and detecting pathologies needs to be assessed.The purpose of this study is to assess the workload, including non-interpretative tasks, associated with Computed Tomography Angiogram (CTA) of Aorta exams performed in the Emergency Department (ED) over a 10-year period and their relationship to detection of aortic pathology.This is a retrospective analysis of CTAs of Aorta performed on adults with suspected acute aortic pathology within the ED at an academic level I quaternary care hospital from January 1, 2005, through December 31, 2015. Data assessed included (1) Interpretive tasks: total number of images, number of reformat series, number of radiology reports with positive aortic pathologies; and (2) Non-interpretative tasks: recommendations and documentation of verbal communication with requesting providers. Statistical analyses were performed to assess temporal trends of variables. P values less than 0.05 are considered significant.A total of 4368 examinations (mean age: 69.8, M/F: 56.8%/43.2%) were performed. Studies per year increased significantly from 2005 (n = 278) to 2007 (n = 445), but not significantly after. The number of images and reformat series per scan increased from 487 to 2819 and 6.4 to 13.7, respectively (both P-value0.01). The proportion of exams with aortic findings did not significantly change (28.1% in 2005 and 24.9% in 2015). However, The proportions of exams with verbal communication increased from 9.3% to 24.6% and with recommendations from 1.8% to 28.9% (both P-value0.01).During a 10-year period, CTAs performed in the ED for suspected aortic pathology were associated with a significant increase in images created, reformat series generated, recommendations, and verbal communications with ordering providers without a concomitant increase in the rate of aortic pathologies. To completely capture the complexities of CTA workloads, non-interpretive tasks such as radiologist recommendations and verbal communications should also be included.

Background Missed appointments can have an adverse impact on health outcomes by delaying appropriate imaging, which can be critical in influencing treatment decisions. Objective To assess for socioeconomic and imaging exam factors associated with missed appointments among children scheduled for diagnostic imaging. Materials and methods We retrospectively analyzed children (21 days (OR=3.7; 95% CI=2.9–4.8). The use of radiation, intravenous contrast agent or sedation was not associated with increased likelihood of missed appointments. Conclusion Expanding our knowledge of how different socioeconomic and imaging-related factors influence missed appointments among children can serve as a foundational step to better understand existing and emerging disparities and inform strategies to advance health equity efforts in radiology.

Oncologic imaging in the emergency department (ED) is frequently encountered, including non-acute scans known as "metastatic workups" or "staging" (referred to as "cancer staging computed tomography (CT) exams"). This study examines the impact of oncologic staging CT exams on ED imaging turnaround time (TAT), defined as the time from the end of the CT exam to a final signed radiologist report, as well as order to scan completion time.A retrospective review was conducted of all adult patients presenting to an urban, quaternary academic medical center ED from February 2016 to September 2017, who had CT imaging ordered, performed, and interpreted in the ED imaging department. CT exams containing institution-specific cancer descriptors were included. After excluding all acute exams, cancer staging CT exams were compared to a matched cohort of non-oncologic ED CT exams to evaluate median TAT and order to scan completion time using a log transformed multivariable linear regression.Adjusting for age and CT body part, cancer staging CT exams were associated with an independently statistically significant increased median log TAT compared to non-oncologic ED CT exams (114.5 min [IQR 112] versus 69 min [IQR 67], respectively, p .0001) and an independently statistically significant increased median log initial order to scan completion time (166 min [IQR: 89] vs 119 min [IQR: 93], p .0001).Oncology patients receiving non-acute metastatic workup scans in the ED have a significantly longer TAT compared to non-oncologic ED CT exams as well as longer order to scan completion times.

To assess temporal trends and utilization patterns of diagnostic imaging performed for substance use disorder (SUD)-related indications in an academic radiology emergency department (ED).Retrospective analyses of ED imaging examinations acquired from 2005 to 2015 were performed. Imaging examinations performed for suspected SUD-related indications, based on the order history, were compared with those without a SUD-related indication. Unadjusted analyses comparing demographic and imaging characteristics between SUD-related versus non-SUD-related indications used Wilcoxon and Pearson's χAmong 938,245 examinations, 0.17% had an SUD-related indication. Patients with SUD-related indications were younger (mean 37.2 ± 11.1 versus 53.5 ± 22.4, P.001) and more commonly male (65% versus 52%, P.001). The proportions of MR (17%), spine (17%), and extremities (33%) studies performed for SUD-related indications were larger among SUD than non-SUD indications (6%, 8%, 26%, respectively, all P.001). Regression analysis demonstrated the odds of acquiring an ED imaging examination with an SUD-related indication significantly increased over time (P.001, adjusted odds ratio [aOR] = 1.06), which was most pronounced among MR (P.001, aOR = 1.23). For all regression models, younger age, male gender, and body part being imaged were identified as independent predictors of an SUD-related indication for ED imaging.Imaging performed for an SUD-related indication represented a small but increasing subset of overall ED imaging. Utilization of MR for SUD-related indications significantly outpaced growth of MR without SUD-related indications.

The aim of this study was to assess the differences in timeliness to MRI appointments and missed MRI appointment rates before and after the implementation of a rideshare program.Retrospective analysis of a rideshare program was performed 9 months after implementation to compare the effects before and after implementation. Variables obtained included demographics, MRI appointment variables, and data related to rideshare use. Descriptive statistics and linear and logistic regression analyses were used to compare demographic characteristics among patients using the rideshare program with (1) those who did not use the rideshare program after implementation and (2) patients before rideshare implementation. Rates of missed appointments derived from patient-related, same-day appointment cancellations were analyzed using logistic regression analyses. Timeliness was analyzed using linear regression analyses. All analyses were adjusted for potential confounders.Of 7,707 patients scheduled for MRI appointments during the postintervention period, 151 patients used the rideshare service (1.95%). There were no statistically significant differences in missed appointment rates after rideshare implementation (adjusted odds ratio, 1.09; 95% confidence interval, 0.93-1.27; P = .275). Patients using the rideshare service were more likely to be on time (adjusted coefficient = 13.0; 95% confidence interval, 5.4-20.5; P = .001). Older patients (P = .001), unemployed patients (P.001), and patients without commercial insurance (P.001) were more likely to use the rideshare service.Implementation of a rideshare program did not significantly decrease missed appointment rates, but it significantly improved timeliness to MRI appointments while assisting at-risk patient populations reporting transportation barriers.

Purpose Traditional radiology productivity metrics do not account for noninterpretive tasks (NITs). This study aimed to systematically quantify NITs and their impact on report turn-around time (RTAT) during solo academic neuroradiology overnight coverage in the emergency department. Methods Retrospective analysis of 1 week of data, including phone call quantity and duration, clinician identification badge access to the reading room ("badge swipes"), suspected acute strokes, imaging examination volume, and emergency department patient volume, was performed. Univariate analyses were employed to quantify NITs. Multivariate linear regression was used to determine if NITs within an hour are predictive of RTAT of studies completed within that hour. Results Sixty-three hours of overnight neuroradiology coverage were analyzed. The mean number of phone calls per hour was 8.7 (SD: 5.7), and mean duration of phone calls per hour was 12 min (SD: 9.6 min, range 1-46). The mean number of badge swipes per hour was 2.1 (SD 1.6). The mean number of examinations (CT and MRI) performed per hour was 2.2 (SD: 1.7). Regression analyses found total duration of phone calls in an hour as the strongest independent predictor of RTAT (unstandardized β = 4.25, P P R 2 = 0.596; adjusted R 2 = 0.578). Conclusions For every 1-min increase in total duration of calls in an hour, mean RTAT increased by 4.25 min. Standardizing capture of NITs may aid development of strategies that address productivity, communication, and value in radiology.

Current guidelines do not address the disposition of patients with mild traumatic brain injury (TBI) and resultant intracranial hemorrhage (ICH). Emergency medicine clinicians working in hospitals without neurosurgery coverage typically transfer patients with both to a trauma center with neurosurgery capability. Evidence is accruing which demonstrates that the risk of neurologic decompensation depends on the type of ICH and as a result, not every patient may need to be transferred. The purpose of this study was to identify risk factors for admission among patients with mild TBI and ICH who were transferred from a community hospital to the emergency department (ED) of a Level 1 trauma center.Study subjects were patients ≥18years of age who were transferred from a community hospital to the ED of an urban, academic Level 1 trauma center between April 1, 2015 and March 31, 2016, and with an isolated traumatic ICH. Patients who had an epidural hematoma, were deemed to require a trauma center's level of service, were found to have non-traumatic ICHs, or had a Glasgow Coma Scale of13 were excluded. Using a multivariable logistic regression model, we sought to determine patient factors and Computed Tomography (CT) findings which were associated with admission (to the floor, intensive care unit, or operating room with neurosurgery) of the Level 1 trauma center.644 transferred patients were identified; 205 remained eligible after exclusion criteria. Presence of warfarin (odds ratio [OR] 4.09, 95% Confidence Interval [CI] 1.64, 10.25, p=0.0026) and a subdural hematoma (SDH) ≥1 cm (OR 6.28, 95% CI 1.24, 31.71, p=0.0263) were independently statistically significant factors predicting admission. Age, sex, GCS, presence of neurologic deficit, aspirin use, clopidogrel use, SDH1 cm, IPH, and SAH were each independently not significant predictive factors of an admission.After controlling for factors, transferred patients with mild TBI with a SDH ≥1 cm or on warfarin have a higher odds ratio of requiring inpatient admission to a Level 1 trauma center. While these patients may require admission, there may be opportunities to develop and study a low risk traumatic intracranial hemorrhage protocol, which keeps a subgroup of patients with a mild TBI and resultant ICH at community hospitals with access to a nearby Level 1 trauma center.

Introduction Emergency Department Observation Units (EDOUs) are a valuable alternative to inpatient admissions for Emergency Department (ED) patients needing extended care. However, while the use of advanced imaging is becoming more common in the ED, there are no studies characterizing the use of magnetic resonance imaging (MRI) examinations in the EDOU. Methods This Institutional Review Board-approved, retrospective study was performed at a 999-bed quaternary care academic Level 1 adult and pediatric trauma center, with approximately 114,000 ED visits annually and a 32-bed adult EDOU. The EDOU patient database was retrospectively reviewed for all MRI examinations done from October 1st, 2013 to September 30th, 2015. We sought to describe the most frequent uses for MRI during EDOU admissions and reviewed EDOU length of stay (LOS) to determine whether the use of MRI was associated with any change in LOS. Results 22,840 EDOU admissions were recorded during the two-year study period, and 4,437 (19%) of these patients had a least one MRI examination during their stay. 2,730 (62%) of these studies were of the brain, head, or neck and an additional 1,392 (31%) were of the spine. There was no significant difference between the median LOS of admissions in which an MRI study was performed (17.5 hours) and the median LOS (17.7 hours) of admissions in which an MRI study was not performed [p=0.33]. Conclusion Neuroimaging makes up the clear majority of MRI examinations from our EDOU, and the use of MRI does not appear to prolong EDOU LOS. Future work should focus on the appropriateness of these MRI examinations to determine potential resource and cost savings.

Purpose To characterize the management, outcomes, and emergency department (ED) length of stay (LOS) following iodinated contrast media extravasation events in the ED. Methods All ED patients who developed iodinated contrast media extravasation following contrast-enhanced CT (CECT) from October 2007–December 2016 were retrospectively identified. Medical records were reviewed and management, complications, frequency of surgical consultation, and ED LOS were quantified using descriptive statistics. The Wilcoxon rank sum test was used to compare ED LOS in patients who did and did not receive surgical consultation. Results A total of 199 contrast extravasation episodes occurred in ED patients during the 9-year study period. Of these, 42 patients underwent surgical consultation to evaluate the contrast extravasation event. No patient developed progressive symptoms, compartment syndrome, or tissue necrosis, and none received treatment beyond supportive care (warm/cold packs, elevation, compression). Median ED LOS for patients who did and did not receive surgical consultation was 11.3 h versus 9.0 h, respectively (p Conclusion Close observation and supportive care are sufficient for contrast extravasation events in the ED without concerning symptoms (progressive pain/swelling, altered tissue perfusion, sensory changes, or blistering/ulceration). Routine surgical consultation is likely unnecessary in the absence of these symptoms – concordant with the current American College of Radiology guidelines – and may be associated with longer ED LOS without impacting management.

Millions of women undergo mammography screening each year, presenting an opportunity for radiologists to identify women eligible for lung cancer screening (LCS) with low-dose chest CT and smoking cessation counseling. The purpose of our study was to estimate the proportion of women eligible for LCS and tobacco cessation counseling among women reporting mammography screening within the previous 2 years using nationally representative cross-sectional survey data.Women between the ages of 55 and 74 years in the 2015 National Health Interview Survey without history of lung or breast cancer who reported mammography use in the previous 2 years were included. The primary outcome was the weighted proportion of women eligible for LCS. Secondary outcomes included self-reported receipt of LCS and current smoking. Bivariate and multiple variable logistic regression analyses were performed to evaluate the association between primary and secondary outcomes and sociodemographics, accounting for complex survey design elements.Among 3,806 women meeting inclusion criteria, 7.1% were eligible for LCS and 9.8% were current smokers. Multivariable analyses demonstrated that LCS-eligible women were more likely to be white, younger, and non-college-educated and have lower household incomes (all P.001). Among all LCS-eligible women, 58% reported undergoing mammography screening within the previous 2 years. Among LCS-eligible women who underwent screening mammography, 7.9% reported undergoing LCS.The majority of LCS-eligible women received mammography screening but did not receive LCS. Mammography encounters may represent prime opportunities to increase LCS participation among patients already receiving imaging-based screening services.

Objective: The aim of this study was to determine the association between the presence of chronic medical disease and mammography screening adherence. Materials and Methods: We performed a...

Regular contact with a primary care physician (PCP) is associated with increased participation in screening mammography. Older studies suggested that PCP interaction may have a smaller effect on screening mammography uptake among racial and ethnic minorities compared with whites, but there is limited contemporary evidence about the effect of PCP interaction on screening mammography uptake across different racial and ethnic groups. The purpose of this study was to evaluate the association between PCP contact and longitudinal adherence with screening mammography guidelines over a 10-year period across different racial/ethnic groups.This HIPAA-compliant and institutional review board-approved retrospective single-institution study included women between the ages of 50 and 64 years who underwent screening mammography in the calendar year of 2005. The primary outcome of interest was adherence to recommended screening mammography guidelines (yes or no) at each 2-year interval from their index screening mammographic examination in 2005 until 2015. Patients were defined as having a high level of PCP interaction if their PCPs were listed in the electronic medical record within the top three providers with whom the patients had the most visits during the study period. Generalized estimating equation models were used to estimate the effect of high PCP interaction on screening mammography adherence while adjusting for correlated observations and patient characteristics.Patients in the high PCP interaction group had increased longitudinal adherence to recommended screening mammography (adjusted odds ratio [OR], 1.51; 95% confidence interval [CI], 1.42-1.73; P.001). This was observed in stratified analyses for all self-reported racial groups, including white (adjusted OR, 1.51; 95% CI, 1.36-1.68; P.001), black (adjusted OR, 1.93; 95% CI, 1.31-2.86; P = .001), Hispanic (adjusted OR, 1.92; 95% CI, 1.27-2.87; P = .002), Asian (adjusted OR, 1.55; 95% CI, 1.01-2.39; P = .045), and other (adjusted OR, 2.18; 95% CI, 1.32-3.56; P = .002), with no evidence of effect modification by race/ethnicity (P = .342). Medicaid (adjusted OR, 0.41; 95% CI, 0.31-0.53) and self-pay or other (adjusted OR, 0.39; 95% CI, 0.27-0.56) insurance categories were associated with decreased longitudinal adherence to recommended screening mammography (P.001 for both).High levels of PCP interaction result in similar improvements in longitudinal screening mammography adherence for all racial/ethnic minority groups. Future efforts will require targeted outreach to assist Medicaid and uninsured patient populations overcome barriers to screening mammography adherence.

Author(s): Glover, McKinley; Gottumukkala, Ravi; Sanchez, Yadiel; Yun, Brian J.; Benzer, Theodore I.; White, Benjamin A.; Prabhakar, Anand M.; Raja, Ali S. | Abstract: Introduction: Emergency departments (ED) and hospitals face increasing challenges related to capacity, throughput, and stewardship of limited resources while maintaining high quality. Appropriate utilization of extremity magnetic resonance imaging (MRI) examinations within the emergency setting is not well known. Therefore, this study aimed to determine indications for and appropriateness of MRI of the extremities for musculoskeletal conditions in the ED observation unit (EDOU).Methods: We conducted this institutional review board-approved, retrospective study in a large, quaternary care academic center and Level I trauma center. An institutional database was queried retrospectively to identify all adult patients undergoing an extremity MRI while in the EDOU during the two-year study period from October 2013 through September 2015. We compared clinical history with the American College of Radiology (ACR) Appropriateness Criteria® for musculoskeletal indications. The primary outcome was appropriateness of musculoskeletal MRI exams of the extremities; examinations with an ACR Criteria score of seven or higher were deemed appropriate. Secondary measures included MRI utilization and imaging findings. Results: During the study period, 22,713 patients were evaluated in the EDOU. Of those patients, 4,409 had at least one MRI performed, and 88 MRIs met inclusion criteria as musculoskeletal extremity examinations (2% of all patients undergoing an MRI exam in the EDOU during the study period). The most common exams were foot (27, 31%); knee (26, 30%); leg/femur (10, 11%); and shoulder (10, 11%). The most common indications were suspected infection (42, 48%) and acute trauma (23, 26%). Fifty-six percent of exams were performed with intravenous contrast; and 83% (73) of all MRIs were deemed appropriate based on ACR Criteria. The most common reason for inappropriate imaging was lack of performance of radiographs prior to MRI. Conclusion: The majority of musculoskeletal extremity MRI examinations performed in the EDOU were appropriate based on ACR Appropriateness Criteria. However, the optimal timing and most-appropriate site for performance of many clinically appropriate musculoskeletal extremity MRIs performed in the EDOU remains unclear. Potential deferral to the outpatient setting may be a preferred population health management strategy.

An increasing number of hospitals and health systems utilize social media to allow users to provide feedback and ratings. The correlation between ratings on social media and more conventional hospital quality metrics remains largely unclear, raising concern that healthcare consumers may make decisions on inaccurate or inappropriate information regarding quality. The purpose of this study was to examine the extent to which hospitals utilize social media and whether user-generated metrics on Facebook® correlate with a Hospital Compare® metric, specifically 30-day all cause unplanned hospital readmission rates. This was a retrospective cross-sectional study conducted among all U.S. hospitals performing outside the confidence interval for the national average on 30-day hospital readmission rates as reported on Hospital Compare. Participants were 315 hospitals performing better than U.S. national rate on 30-day readmissions and 364 hospitals performing worse than the U.S. national rate. The study analyzed ratings of hospitals on Facebook’s five-star rating scale, 30-day readmission rates, and hospital characteristics including beds, teaching status, urban vs. rural location, and ownership type. Hospitals performing better than the national average on 30-day readmissions were more likely to use Facebook than lower-performing hospitals (93.3 % vs. 83.5 %; p < 0.01). The average rating for hospitals with low readmission rates (4.15 ± 0.31) was higher than that for hospitals with higher readmission rates (4.05 ± 0.41, p < 0.01). Major teaching hospitals were 14.3 times more likely to be in the high readmission rate group. A one-star increase in Facebook rating was associated with increased odds of the hospital belonging to the low readmission rate group by a factor of 5.0 (CI: 2.6–10.3, p < 0.01), when controlling for hospital characteristics and Facebook-related variables. Hospitals with lower rates of 30-day hospital-wide unplanned readmissions have higher ratings on Facebook than hospitals with higher readmission rates. These findings add strength to the concept that aggregate measures of patient satisfaction on social media correlate with more traditionally accepted measures of hospital quality.

Purpose The aim of this study was to investigate the impact of wait days (WDs) on missed outpatient MRI appointments across different demographic and socioeconomic factors. Methods An institutional review board–approved retrospective study was conducted among adult patients scheduled for outpatient MRI during a 12-month period. Scheduling data and demographic information were obtained. Imaging missed appointments were defined as missed scheduled imaging encounters. WDs were defined as the number of days from study order to appointment. Multivariate logistic regression was applied to assess the contribution of race and socioeconomic factors to missed appointments. Linear regression was performed to assess the relationship between missed appointment rates and WDs stratified by race, income, and patient insurance groups with analysis of covariance statistics. Results A total of 42,727 patients met the inclusion criteria. Mean WDs were 7.95 days. Multivariate regression showed increased odds ratio for missed appointments for patients with increased WDs (7-21 days: odds ratio [OR], 1.39; >21 days: OR, 1.77), African American patients (OR, 1.71), Hispanic patients (OR, 1.30), patients with noncommercial insurance (OR, 2.00-2.55), and those with imaging performed at the main hospital campus (OR, 1.51). Missed appointment rate linearly increased with WDs, with analysis of covariance revealing underrepresented minorities and Medicaid insurance as significant effect modifiers. Conclusions Increased WDs for advanced imaging significantly increases the likelihood of missed appointments. This effect is most pronounced among underrepresented minorities and patients with lower socioeconomic status. Efforts to reduce WDs may improve equity in access to and utilization of advanced diagnostic imaging for all patients.

GH excess is a serious complication of McCune-Albright syndrome (MAS) and has been associated with craniofacial morbidity.The aim of the study was to determine whether early diagnosis and treatment of MAS-associated GH excess prevents optic neuropathy and hearing impairment, the major morbidities associated with GH excess.A retrospective cross-sectional analysis was conducted at a clinical research center.Twenty-two subjects with MAS-associated GH excess and 21 control MAS subjects without GH excess were included in the study.Biochemical testing included random GH, nadir GH after glucose load, nadir GH on frequent sampling, and IGF-I Z-score. Subjects underwent imaging, ophthalmological, audiological, and otolaryngological assessment. Treatment included octreotide, pegvisomant, transphenoidal surgery, and/or radiotherapy as indicated.Association of optic neuropathy and hearing impairment to age at GH excess diagnosis/treatment was measured.Of 129 MAS subjects, 26 (20%) were diagnosed with GH excess based on elevation of two measures of GH function. Of these, 22 subjects were candidates for pharmacological intervention. Optic neuropathy was significantly correlated with intervention status, with no cases in the early intervention group (diagnosed/treated before age 18) or the control group, and four of seven (57%) in the late intervention group (diagnosed/treated after age 18) (Fisher's exact test; odds ratio, 0.027; P = 0.0058). Early diagnosis/intervention was not associated with reduction in hearing deficits (odds ratio, 1.25; P = 1.00). Mean head circumference SD score was significantly higher in the late (6.08; range, 2.70 to 22.56) than the early intervention (2.67; range, -0.65 to 6.72) or control groups (2.13; range, -2.06 to 7.79) (P = 0.003).Early diagnosis/treatment of GH excess in MAS is important to prevent optic neuropathy and craniofacial expansion. The relationship between hearing deficits and GH excess remains less clear and requires further study.

Background: Lung cancer is the leading cause of cancer-related deaths in the United States. Despite mandated insurance coverage for eligible patients, lung cancer screening rates remain low. Digital platforms, including social media, provide a potentially valuable tool to enhance health promotion and patient engagement related to lung cancer screening (LCS). Objective: The aim was to assess the effectiveness of LCS digital awareness campaigns on utilization of low-dose computed tomography (LDCT) and visits to institutional online educational content. Methods: A pay-per-click campaign utilizing Google and Facebook targeted adults aged 55 years and older and caregivers aged 18 years and older (eg, spouses, adult children) with LCS content during a 20-week intervention period from May to September 2016. A concurrent pay-per-click campaign using LinkedIn and Twitter targeted health care providers with LCS content. Geographic target radius was within 60 miles of an academic medical center. Social media data included aggregate demographics and click-through rates (CTRs). Primary outcome measures were visits to institutional Web pages and scheduled LDCT exams. Study period was 20 weeks before, during, and after the digital awareness campaigns. Results: Weekly visits to the institutional LCS Web pages were significantly higher during the digital awareness campaigns compared to the 20-week period prior to implementation (mean 823.9, SD 905.8 vs mean 51, SD 22.3, P=.001). The patient digital awareness campaign surpassed industry standard CTRs on Google (5.85%, 1108/18,955 vs 1.8%) and Facebook (2.59%, 47,750/1,846,070 vs 0.8%). The provider digital awareness campaign surpassed industry standard CTR on LinkedIn (1.1%, 630/57,079 vs 0.3%) but not Twitter (0.19%, 1139/587,133 vs 0.25%). Mean scheduled LDCT exam volumes per week before, during, and after the digital awareness campaigns were 17.4 (SD 7.5), 20.4 (SD 5.4), and 26.2 (SD 6.4), respectively, with the difference between the mean number of scheduled exams after the digital awareness campaigns and the number of exams scheduled before and after the digital awareness campaigns being statistically significant (P