1
|
Lopez-Rippe J, Schwartz ES, Davis JC, Dennis RA, Francavilla ML, Jalloul M, Kaplan SL. Imaging Stewardship: Triage for Neuroradiology MR During Limited-Resource Hours. J Am Coll Radiol 2024; 21:70-80. [PMID: 37863151 DOI: 10.1016/j.jacr.2023.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 10/14/2023] [Accepted: 10/16/2023] [Indexed: 10/22/2023]
Abstract
OBJECTIVES To decrease call burden on pediatric neuroradiologists, we developed guidelines for appropriate use of MR overnight. These guidelines were implemented using triage by in-house generalist pediatric radiologists. Process measures and balancing measures were assessed during implementation. METHODS For this improvement project, interdepartmental consensus guidelines were developed using exploratory mixed-methods design. Implementation of triage used plan-do-study-act cycles. Process measures included reduction in the number of telephone calls, frequency of calls, triage decisions, and number and type of examinations ordered. Balancing measures included burden of time and effort to the generalist radiologists. Differences in examination orders between implementation intervals was assessed using Kruskal-Wallis, with significance at P < .05. RESULTS Consensus defined MR requests as "do," "defer," or "divert" (to CT). Guidelines decreased neuroradiologist calls 74% while adding minimal burden to the generalist radiologists. Most nights had zero or one triage request and the most common triage decision was "do," and the most common examination was routine brain MR. Number of MR ordered and completed overnight did not significantly change with triage. DISCUSSION Multidisciplinary consensus for use of pediatric neurological MR during limited resource hours overnight is an example of imaging stewardship that decreased the burden of calls and burnout for neuroradiologists while maintaining a comparable level of service to the ordering clinicians.
Collapse
Affiliation(s)
- Julian Lopez-Rippe
- Research Scholar, Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Erin S Schwartz
- Division Chief Neuroradiology and Associate Chair for Diversity, Equity, and Inclusion, Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Professor of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - J Christopher Davis
- Section Director for Emergency Radiology, Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and Assistant Professor of Clinical Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rebecca A Dennis
- Director of Fellowship, Residency and Observership Program, Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and Assistant Professor of Clinical Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael L Francavilla
- Associate Professor and Chief Medical Information Officer for Radiology, Department of Radiology, University of South Alabama, Mobile, Alabama
| | - Mohammad Jalloul
- Research Scholar, Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Summer L Kaplan
- Associate Chair for Quality and Medical Director of Point-of-Care Ultrasound, Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and Assistant Professor of Clinical Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
| |
Collapse
|
2
|
Dijk SW, Kroencke T, Wollny C, Barkhausen J, Jansen O, Halfmann MC, Rizopoulos D, Hunink MGM. Medical Imaging Decision And Support (MIDAS): Study protocol for a multi-centre cluster randomized trial evaluating the ESR iGuide. Contemp Clin Trials 2023; 135:107384. [PMID: 37949165 DOI: 10.1016/j.cct.2023.107384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 10/20/2023] [Accepted: 11/03/2023] [Indexed: 11/12/2023]
Abstract
OBJECTIVES Medical imaging plays an essential role in healthcare. As a diagnostic test, imaging is prone to substantial overuse and potential overdiagnosis, with dire consequences to patient outcomes and health care costs. Clinical decision support systems (CDSSs) were developed to guide referring physicians in making appropriate imaging decisions. This study will evaluate the effect of implementing a CDSS (ESR iGuide) with versus without active decision support in a physician order entry on the appropriate use of imaging tests and ordering behaviour. METHODS A protocol for a multi-center cluster-randomized trial with departments acting as clusters, combined with a before-after-revert design. Four university hospitals with eight participating departments each for a total of thirty-two clusters will be included in the study. All departments start in control condition with structured data entry of the clinical indication and tracking of the imaging exams requested. Initially, the CDSS is implemented and all physicians remain blinded to appropriateness scores based on the ESR imaging referral guidelines. After randomization, half of the clusters switch to the active intervention of decision support. Physicians in the active condition are made aware of the categorization of their requests as appropriate, under certain conditions appropriate, or inappropriate, and appropriate exams are suggested. Physicians may change their requests in response to feedback. In the revert condition, active decision support is removed to study the educational effect. RESULTS/CONCLUSIONS The main outcome is the proportion of inappropriate diagnostic imaging exams requested per cluster. Secondary outcomes are the absolute number of imaging exams, radiation from diagnostic imaging, and medical costs. TRIAL REGISTRATION NUMBER Approval from the Medical Ethics Review Committee was obtained under protocol numbers 20-069 (Augsburg), B 238/21 (Kiel), 20-318 (Lübeck) and 2020-15,125 (Mainz). The trial is registered in the ClinicalTrials.gov register under registration number NCT05490290.
Collapse
Affiliation(s)
- Stijntje W Dijk
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Epidemiology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Thomas Kroencke
- Department of Diagnostic and Interventional Radiology, University Hospital Augsburg, Augsburg, Germany
| | - Claudia Wollny
- Department of Diagnostic and Interventional Radiology, University Hospital Augsburg, Augsburg, Germany
| | - Joerg Barkhausen
- Department of Radiology and Nuclear Medicine, University of Lübeck, Lübeck, Germany
| | - Olav Jansen
- Department of Radiology and Neuroradiology, University Medical Center Schleswig-Holstein (UKSH), Kiel, Germany
| | - Moritz C Halfmann
- Department of Diagnostic and Interventional Radiology, University Medical Center Mainz, Mainz, Germany
| | - Dimitris Rizopoulos
- Department of Biostatistics, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - M G Myriam Hunink
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Epidemiology, Erasmus MC University Medical Center, Rotterdam, the Netherlands; Centre for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, United States of America.
| |
Collapse
|
3
|
Thind GS, Hussein A, Mishra V, Ramachandran V, Lohia M, Ennala S, Guduguntla N, Dugar S, Martin C, Moghekar A, Sadana DS, Krishnan S. Characteristics of Cumulative Annual Radiation Exposure in Young Intensive Care Unit Survivors. J Patient Saf 2022; 18:e985-e991. [PMID: 35617610 DOI: 10.1097/pts.0000000000001041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Patients admitted to the intensive care unit (ICU) are at high risk for hazardous medical radiation exposure. However, the cumulative annual radiation exposure in ICU survivors remains unknown. METHODS This was a single-center retrospective study of all critically ill adult patients admitted to the 64-bed adult medical ICU at a quaternary medical center. The study included patients aged 18 to 39 years admitted through the year 2013 (January 1, 2013-December 31, 2013) who survived their respective ICU admission. RESULTS A total of 353 patients were included in the study. The median cumulative effective dose (CED) for the calendar year was 9.14 mSv (interquartile range, 1.74-27 mSv). In 11.6% of the patients (n = 41), CED was more than 50 mSv, while 5.1% of the patients (n = 18) exceeded annual CED of 100 mSv. Overall, radiation exposure from ICU-related imaging studies was lower than those from other medical settings (mean difference, -9.2 ± 83.6; P < 0.05). However, there was no statistically significant difference in exposure (ICU versus non-ICU) when restricting the analysis to patients with a CED of greater than 50 and greater than 100 mSv. Eighty-seven percent of the original cohort was alive at the end of the year. CONCLUSIONS Young ICU survivors are at risk for high annual radiation exposure from both ICU and non-ICU sources. A subset is exposed to hazardous annual radiation exposure in excess of 100 mSv.
Collapse
Affiliation(s)
| | - Ahmed Hussein
- From the Department of Critical Care Medicine, Cleveland Clinic, Cleveland, Ohio
| | | | | | - Mehul Lohia
- From the Department of Critical Care Medicine, Cleveland Clinic, Cleveland, Ohio
| | | | | | - Siddharth Dugar
- From the Department of Critical Care Medicine, Cleveland Clinic, Cleveland, Ohio
| | | | - Ajit Moghekar
- From the Department of Critical Care Medicine, Cleveland Clinic, Cleveland, Ohio
| | | | - Sudhir Krishnan
- From the Department of Critical Care Medicine, Cleveland Clinic, Cleveland, Ohio
| |
Collapse
|
4
|
Al Badarin FJ. Extra-cardiac findings in the age of hybrid cardiac imaging: Incidental or essential? J Nucl Cardiol 2022; 29:1823-1825. [PMID: 33948887 DOI: 10.1007/s12350-021-02629-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 03/22/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Firas J Al Badarin
- Heart and Vascular Institute (Swing Wing C08-260), Cleveland Clinic Abu Dhabi, Al Maryah Island, PO Box 112412, Abu Dhabi, United Arab Emirates.
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA.
| |
Collapse
|
5
|
Tummalapalli SL, Zech JR, Cho HJ, Goetz C. Risk stratification for hydronephrosis in the evaluation of acute kidney injury: a cross-sectional analysis. BMJ Open 2021; 11:e046761. [PMID: 34389565 PMCID: PMC8365791 DOI: 10.1136/bmjopen-2020-046761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To validate an existing clinical decision support tool to risk-stratify patients with acute kidney injury (AKI) for hydronephrosis and compare the risk stratification framework with nephrology consultant recommendations. SETTING Cross-sectional study of hospitalised adults with AKI who had a renal ultrasound (RUS) ordered at a large, tertiary, academic medical centre. PARTICIPANTS Two hundred and eighty-one patients were included in the study cohort. Based on the risk stratification framework, 111 (40%), 76 (27%) and 94 (33%) patients were in the high-risk, medium-risk and low-risk groups for hydronephrosis, respectively. OUTCOMES Outcomes were the presence of unilateral or bilateral hydronephrosis on RUS. RESULTS Thirty-five patients (12%) were found to have hydronephrosis. The high-risk group had 86% sensitivity and 67% specificity for identifying hydronephrosis. A nephrology consult was involved in 168 (60%) patients and RUS was recommended by the nephrology service in 95 (57%) cases. Among patients with a nephrology consultation, 9 (56%) of the 16 total patients with hydronephrosis were recommended to obtain an RUS. CONCLUSIONS We further externally validated a risk stratification framework for hydronephrosis. Clinical decision support systems may be useful to supplement clinical judgement in the evaluation of AKI.
Collapse
Affiliation(s)
- Sri Lekha Tummalapalli
- Division of Healthcare Delivery Science and Innovation, Department of Population Health Sciences, Weill Cornell Medicine, New York, New York, USA
| | - John R Zech
- Department of Radiology, New York Presbyterian Hospital-Columbia University Irving Medical Center, New York, New York, USA
| | - Hyung J Cho
- Chief Value Officer, New York City Health and Hospitals, New York, NY, USA
- Senior Fellow, Lown Institute, Brookline, MA, USA
| | - Celine Goetz
- Director of Education, Division of Hospital Medicine, Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA
| |
Collapse
|
6
|
Sharp AL, Baecker A, Nassery N, Park S, Hassoon A, Lee MS, Peterson S, Pitts S, Wang Z, Zhu Y, Newman-Toker DE. Missed acute myocardial infarction in the emergency department-standardizing measurement of misdiagnosis-related harms using the SPADE method. Diagnosis (Berl) 2021; 8:177-186. [PMID: 32701479 DOI: 10.1515/dx-2020-0049] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 06/03/2020] [Indexed: 12/02/2023]
Abstract
OBJECTIVES Diagnostic error is a serious public health problem. Measuring diagnostic performance remains elusive. We sought to measure misdiagnosis-related harms following missed acute myocardial infarctions (AMI) in the emergency department (ED) using the symptom-disease pair analysis of diagnostic error (SPADE) method. METHODS Retrospective administrative data analysis (2009-2017) from a single, integrated health system using International Classification of Diseases (ICD) coded discharge diagnoses. We looked back 30 days from AMI hospitalizations for antecedent ED treat-and-release visits to identify symptoms linked to probable missed AMI (observed > expected). We then looked forward from these ED discharge diagnoses to identify symptom-disease pair misdiagnosis-related harms (AMI hospitalizations within 30-days, representing diagnostic adverse events). RESULTS A total of 44,473 AMI hospitalizations were associated with 2,874 treat-and-release ED visits in the prior 30 days. The top plausibly-related ED discharge diagnoses were "chest pain" and "dyspnea" with excess treat-and-release visit rates of 9.8% (95% CI 8.5-11.2%) and 3.4% (95% CI 2.7-4.2%), respectively. These represented 574 probable missed AMIs resulting in hospitalization (adverse event rate per AMI 1.3%, 95% CI 1.2-1.4%). Looking forward, 325,088 chest pain or dyspnea ED discharges were followed by 508 AMI hospitalizations (adverse event rate per symptom discharge 0.2%, 95% CI 0.1-0.2%). CONCLUSIONS The SPADE method precisely quantifies misdiagnosis-related harms from missed AMIs using administrative data. This approach could facilitate future assessment of diagnostic performance across health systems. These results correspond to ∼10,000 potentially-preventable harms annually in the US. However, relatively low error and adverse event rates may pose challenges to reducing harms for this ED symptom-disease pair.
Collapse
Affiliation(s)
- Adam L Sharp
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
- Department of Health System Science, Kaiser Permanente School of Medicine, Pasadena, CA, United States
| | - Aileen Baecker
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
| | - Najlla Nassery
- Department of Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Stacy Park
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
| | - Ahmed Hassoon
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Ming-Sum Lee
- Kaiser Permanente Southern California, Los Angeles Medical Center, Division of Cardiology, Los Angeles, CA, United States
| | - Susan Peterson
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Samantha Pitts
- Department of Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Zheyu Wang
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Yuxin Zhu
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - David E Newman-Toker
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| |
Collapse
|
7
|
Georgieva MV, Wheeler SB, Erim D, Smith-Bindman R, Loo R, Ng C, Garg T, Raynor M, Nielsen ME. Comparison of the Harms, Advantages, and Costs Associated With Alternative Guidelines for the Evaluation of Hematuria. JAMA Intern Med 2019; 179:1352-1362. [PMID: 31355874 PMCID: PMC6664383 DOI: 10.1001/jamainternmed.2019.2280] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
IMPORTANCE Existing recommendations for the diagnostic testing of hematuria range from uniform evaluation of varying intensity to patient-level risk stratification. Concerns have been raised about not only the costs and advantages of computed tomography (CT) scans but also the potential harms of CT radiation exposure. OBJECTIVE To compare the advantages, harms, and costs associated with 5 guidelines for hematuria evaluation. DESIGN, SETTING, AND PARTICIPANTS A microsimulation model was developed to assess each of the following guidelines (listed in order of increasing intensity) for initial evaluation of hematuria: Dutch, Canadian Urological Association (CUA), Kaiser Permanente (KP), Hematuria Risk Index (HRI), and American Urological Association (AUA). Participants comprised a hypothetical cohort of patients (n = 100 000) with hematuria aged 35 years or older. This study was conducted from August 2017 through November 2018. EXPOSURES Under the Dutch and CUA guidelines, patients received cystoscopy and ultrasonography if they were 50 years or older (Dutch) or 40 years or older (CUA). Under the KP and HRI guidelines, patients received different combinations of cystoscopy, ultrasonography, and CT urography or no evaluation on the basis of risk factors. Under the AUA guidelines, all patients 35 years or older received cystoscopy and CT urography. MAIN OUTCOMES AND MEASURES Urinary tract cancer detection rates, radiation-induced secondary cancers (from CT radiation exposure), procedural complications, false-positive rates per 100 000 patients, and incremental cost per additional urinary tract cancer detected. RESULTS The simulated cohort included 100 000 patients with hematuria, aged 35 years or older. A total of 3514 patients had urinary tract cancers (estimated prevalence, 3.5%; 95% CI, 3.0%-4.0%). The AUA guidelines missed detection for the fewest number of cancers (82 [2.3%]) compared with the detection rate of the HRI (116 [3.3%]) and KP (130 [3.7%]) guidelines. However, the simulation model projected 108 (95% CI, 34-201) radiation-induced cancers under the KP guidelines, 136 (95% CI, 62-229) under the HRI guidelines, and 575 (95% CI, 184-1069) under the AUA guidelines per 100 000 patients. The CUA and Dutch guidelines missed detection for a larger number of cancers (172 [4.9%] and 251 [7.1%]) but had 0 radiation-induced secondary cancers. The AUA guidelines cost approximately double the other 4 guidelines ($939/person vs $443/person for Dutch guidelines), with an incremental cost of $1 034 374 per urinary tract cancer detected compared with that of the HRI guidelines. CONCLUSIONS AND RELEVANCE In this simulation study, uniform CT imaging for patients with hematuria was associated with increased costs and harms of secondary cancers, procedural complications, and false positives, with only a marginal increase in cancer detection. Risk stratification may optimize the balance of advantages, harms, and costs of CT.
Collapse
Affiliation(s)
- Mihaela V Georgieva
- Department of Health Policy and Management, University of North Carolina Gillings School of Global Public Health, Chapel Hill
| | - Stephanie B Wheeler
- Department of Health Policy and Management, University of North Carolina Gillings School of Global Public Health, Chapel Hill.,University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill
| | - Daniel Erim
- Division of eHealth, Quality and Analytics, Social Policy, Health and Economics Research Unit, RTI International, Research Triangle Park, North Carolina
| | - Rebecca Smith-Bindman
- Departments of Radiology, Epidemiology and Biostatistics, University of California at San Francisco, San, Francisco
| | - Ronald Loo
- Department of Urology, Kaiser Permanente Southern California, Los Angeles, California
| | - Casey Ng
- Department of Urology, Kaiser Permanente Southern California, Los Angeles, California
| | - Tullika Garg
- Department of Urology, Geisinger Health, Danville, Pennsylvania
| | - Mathew Raynor
- Department of Urology, University of North Carolina School of Medicine, Chapel Hill
| | - Matthew E Nielsen
- Department of Health Policy and Management, University of North Carolina Gillings School of Global Public Health, Chapel Hill.,University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill.,Department of Urology, University of North Carolina School of Medicine, Chapel Hill.,Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill.,Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| |
Collapse
|
8
|
Radiation Dose Reduction in Children With Hydrocephalus Using Ultrafast Brain MRI. J Am Coll Radiol 2019; 16:1173-1176. [DOI: 10.1016/j.jacr.2019.02.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 02/14/2019] [Accepted: 02/16/2019] [Indexed: 11/20/2022]
|
9
|
American Urological Association, American College of Emergency Physicians and American College of Radiology Quality Improvement Summit 2017: Challenges and Opportunities for Stewardship of Urological Imaging. UROLOGY PRACTICE 2019. [DOI: 10.1097/upj.0000000000000030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
10
|
Abstract
PURPOSE OF REVIEW Radionuclide myocardial perfusion imaging (MPI) continues to be the most reliable modality for diagnosis of hemodynamically significant coronary artery disease (CAD). The application of radionuclide MPI using single photon emission computed tomography (SEPCT) and positron emission tomography (PET) for CAD is reviewed, with emphasis on diagnosis and risk stratification. RECENT FINDINGS Contemporary studies have reported the diagnostic and prognostic value of novel imaging protocols, employing stress-first or stress-only approach. In addition, the superior diagnostic value of PET has been established with a role of assessment of myocardial blood flow to improve risk stratification. The utility of MPI in special populations, such as the elderly, women, and diabetic patients has also been recently evaluated. Furthermore, multicenter studies have reported a similar diagnostic and prognostic value of radionuclide MPI compared with other functional and anatomical techniques for CAD. Radionuclide MPI with SPECT and PET are efficacious for diagnosis and prognosis of CAD. Its universal application in varied patient populations highlights its excellent clinical effectiveness.
Collapse
|
11
|
|
12
|
Kadom N, Zafar HM, Cook TS, Greene A, Durand DJ. Engaging Patients: Models for Patient- and Family-centered Care in Radiology. Radiographics 2018; 38:1866-1871. [DOI: 10.1148/rg.2018180018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
13
|
Conway SJ, Himmelrich S, Feeser SA, Flynn JA, Kravet SJ, Bailey J, Hebert LC, Donovan SH, Kachur SG, Brown PM, Baumgartner WA, Berkowitz SA. Strategic Review Process for an Accountable Care Organization and Emerging Accountable Care Best Practices. Popul Health Manag 2018; 21:357-365. [DOI: 10.1089/pop.2017.0149] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | | | | | - John A. Flynn
- Johns Hopkins School of Medicine, Baltimore, Maryland
| | | | | | | | - Susan H. Donovan
- Primary Care Coalition of Montgomery County Maryland, Silver Spring, Maryland
| | | | | | | | | |
Collapse
|
14
|
Liao JM, Basu A, Lee CI. The Value of Outpatient Imaging-Based Cancer Screening Episodes. J Gen Intern Med 2018; 33:1571-1573. [PMID: 30022411 PMCID: PMC6109007 DOI: 10.1007/s11606-018-4571-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 05/30/2018] [Accepted: 07/02/2018] [Indexed: 10/28/2022]
Abstract
In order to shift US health care towards greater value, the Centers for Medicare & Medicaid Services (CMS) is exploring outpatient episode-based cost measures under the new Quality Payment Program and planning a bundled payment program that will introduce the first ever outpatient episodes of care. One novel approach to capitalize on this paradigm shift and extend bundled payment policies is to engage primary care physicians and specialists by bundling outpatient imaging studies and associated procedures-central tools in disease screening and diagnosis, but also tools that are expensive and susceptible to increasing health care costs and patient harm. For example, both breast and lung cancer screening represent target areas ripe for bundled payment given high associated costs and variation in management strategies and suboptimal care coordination between responsible clinicians. Benefits to imaging-based screening episodes include stronger alignment between providers (primary care physicians, radiologists, and other clinicians), reduction in unwarranted variation, creation of appropriateness standards, and ability to overcome barriers to cancer screening adherence. Implementation considerations include safeguarding against providers inappropriately withholding care as well as ensuring that accountability and financial risk are distributed appropriately among responsible clinicians.
Collapse
Affiliation(s)
- Joshua M Liao
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA.
- Leonard Davis Institute of Health Economics, Wharton School, University of Pennsylvania, Philadelphia, PA, USA.
- UW Medicine Value and Systems Science Lab, Seattle, WA, USA.
| | - Anirban Basu
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, School of Pharmacy, University of Washington School of Medicine, Seattle, WA, USA
| | - Christoph I Lee
- Department of Radiology, University of Washington School of Medicine, Seattle, WA, USA
- Fred Hutchinson Cancer Research Center, Hutchinson Institute for Cancer Outcomes Research, Seattle, WA, USA
| |
Collapse
|
15
|
Diagnostic Stewardship for Healthcare-Associated Infections: Opportunities and Challenges to Safely Reduce Test Use. Infect Control Hosp Epidemiol 2018; 39:214-218. [PMID: 29331159 PMCID: PMC7053094 DOI: 10.1017/ice.2017.278] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
|
16
|
Armao D, Hartman TS, Shea CM, Katz L, Thurnes T, Smith JK. Maximizing Benefit and Minimizing Risk in Medical Imaging Use: An Educational Primer for Health Care Professions Students. JOURNAL OF MEDICAL EDUCATION AND CURRICULAR DEVELOPMENT 2018; 5:2382120518798812. [PMID: 30211315 PMCID: PMC6131289 DOI: 10.1177/2382120518798812] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 08/13/2018] [Indexed: 06/08/2023]
Abstract
"I am not young enough to know everything."Oscar Wilde. BACKGROUND There is insufficient knowledge among providers and patients/caregivers of ionizing radiation exposure from medical imaging examinations. This study used a brief, interactive educational intervention targeting the topics of best imaging practices and radiation safety early in health professions students' training. The authors hypothesized that public health, medical, and physician assistant students who receive early education for imaging appropriateness and radiation safety will undergo a change in attitude and have increased awareness and knowledge of these topics. MATERIALS AND METHODS The authors conducted a 1.5-hour interactive educational intervention focusing on medical imaging utilization and radiation safety. Students were presented with a pre/postquestionnaire and data were analyzed using t tests and multivariate analysis of variance. RESULTS A total of 301 students were enrolled in the study. There was 58% (P < .01) and 85% (P < .01) improvement in attitude and knowledge regarding appropriateness of imaging, respectively. The authors also found an 8% increase (P < .01) in students who thought informed consent should be obtained prior to pediatric computed tomographic imaging. Physical assistant students were more likely than medical students to prefer obtaining informed consent at baseline (P = .03). CONCLUSIONS A brief educational session provided to health professions students early in their education showed an increased awareness and knowledge of the utility, limitations, and risks associated with medical imaging. Incorporation of a best imagining practice educational session early during medical education may promote more thoughtful imaging decisions for future medical providers.
Collapse
Affiliation(s)
- Diane Armao
- Department of Radiology, School of
Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC,
USA
- Department of Pathology and Laboratory
Medicine, School of Medicine, The University of North Carolina at Chapel Hill,
Chapel Hill, NC, USA
- Department of Physician Assistant
Studies, Elon University, Elon, NC, USA
| | - Terry S Hartman
- Department of Radiology, School of
Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC,
USA
| | - Christopher M Shea
- Department of Health Policy and
Management, UNC Gillings School of Global Public Health, The University of North
Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Laurence Katz
- Department of Emergency Medicine, School
of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC,
USA
| | - Tracey Thurnes
- Department of Physician Assistant
Studies, Elon University, Elon, NC, USA
| | - J Keith Smith
- Department of Radiology, School of
Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC,
USA
| |
Collapse
|
17
|
Greene AM, Bailey CR, Young M, Wolfgang E, Tekes A, Huisman TA, Durand DJ. Applying the National Committee for Quality Assurance Patient-Centered Specialty Practice Framework to Radiology. J Am Coll Radiol 2017. [DOI: 10.1016/j.jacr.2017.05.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
18
|
Levin DC, Rao VM. Reducing Inappropriate Use of Diagnostic Imaging Through the Choosing Wisely Initiative. J Am Coll Radiol 2017; 14:1245-1252. [DOI: 10.1016/j.jacr.2017.03.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 03/10/2017] [Accepted: 03/14/2017] [Indexed: 01/09/2023]
|
19
|
Alvin MD, Horton KM, Johnson PT. Training Radiology Residents to be Stewards in Healthcare Value. Acad Radiol 2017; 24:755-756. [PMID: 28238603 DOI: 10.1016/j.acra.2016.10.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Accepted: 10/24/2016] [Indexed: 10/20/2022]
Abstract
Medical imaging procedures have become a national target in the campaign to reduce wasteful practices. At a minimum, radiology residency programs must integrate high-value curricula and train residents to practice in accordance with value-based principles and new healthcare policy. A greater portion of radiology resident education needs to be devoted to appropriateness education and consultancy training. Ideally, radiology training programs will instill in residents the importance of embracing the movement and leading the change.
Collapse
|
20
|
Halpern JA, Chughtai B, Ghomrawi H. Cost-effectiveness of Common Diagnostic Approaches for Evaluation of Asymptomatic Microscopic Hematuria. JAMA Intern Med 2017; 177:800-807. [PMID: 28418451 PMCID: PMC5818826 DOI: 10.1001/jamainternmed.2017.0739] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
IMPORTANCE Asymptomatic microscopic hematuria (AMH) is highly prevalent and may signal occult genitourinary (GU) malignant abnormality. Common diagnostic approaches differ in their costs and effectiveness in detecting cancer. Given the low prevalence of GU malignant abnormality among patients with AMH, it is important to quantify the cost implications of detecting cancer for each approach. OBJECTIVE To estimate the effectiveness, costs, and incremental cost per cancer detected (ICCD) for 4 common diagnostic approaches evaluating AMH. DESIGN, SETTING, AND PARTICIPANTS A decision-analytic model-based cost-effectiveness analysis using inputs from the medical literature. PubMed searches were performed to identify relevant literature for all key model inputs, each of which was derived from the clinical study with the most robust data and greatest applicability. Analysis included adult patients with AMH on routine urinalysis with subgroups of high-risk patients (males, smokers, age ≥50 years) seen in the primary care or urologic referral setting. INTERVENTIONS Four diagnostic approaches were evaluated relative to the reference case of no evaluation: (1) computed tomography (CT) alone; (2) cystoscopy alone; (3) CT and cystoscopy combined; and (4) renal ultrasound and cystoscopy combined. MAIN OUTCOMES AND MEASURES At termination of the diagnostic period, cancers detected, costs (payer perspective), and ICCD per 10 000 patients evaluated for AMH. RESULTS Of the 4 diagnostic approaches analyzed, CT alone was dominated by all other strategies, detecting 221 cancers at a cost of $9 300 000. Ultrasound and cystoscopy detected 245 cancers and was most cost-effective with an ICCD of $53 810. Replacing ultrasound with CT detected just 1 additional cancer at an ICCD of $6 480 484. Ultrasound and cystoscopy remained the most cost-effective approach in subgroup analysis. The model was not sensitive to any inputs within the proposed ranges. Using probabilistic sensitivity analysis, ultrasound and cystoscopy was the dominant strategy in 100% of simulations. CONCLUSIONS AND RELEVANCE The combination of renal ultrasound and cystoscopy is the most cost-effective among 4 diagnostic approaches for the initial evaluation of AMH. The use of ultrasound in lieu of CT as the first-line diagnostic strategy will optimize cancer detection and reduce costs associated with evaluation of AMH. Given our findings, we need to critically evaluate the appropriateness of our current clinical practices, and potentially alter our guidelines to reflect the most effective screening strategies for patients with AMH.
Collapse
Affiliation(s)
- Joshua A Halpern
- Department of Urology, Weill Cornell Medicine, New York, New York
| | - Bilal Chughtai
- Department of Urology, Weill Cornell Medicine, New York, New York
| | - Hassan Ghomrawi
- Departments of Surgery and Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| |
Collapse
|
21
|
Green DE, Hamory BH, Terrell GE, O'Connell J. A Case Report: Cornerstone Health Care Reduced the Total Cost of Care Through Population Segmentation and Care Model Redesign. Popul Health Manag 2017; 20:309-317. [PMID: 28106518 DOI: 10.1089/pop.2016.0105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Over the course of a single year, Cornerstone Health Care, a multispecialty group practice in North Carolina, redesigned the underlying care models for 5 of its highest-risk populations-late-stage congestive heart failure, oncology, Medicare-Medicaid dual eligibles, those with 5 or more chronic conditions, and the most complex patients with multiple late-stage chronic conditions. At the 1-year mark, the results of the program were analyzed. Overall costs for the patients studied were reduced by 12.7% compared to the year before enrollment. All fully implemented programs delivered between 10% and 16% cost savings. The key area for savings factor was hospitalization, which was reduced by 30% across all programs. The greatest area of cost increase was "other," a category that consisted in large part of hospice services. Full implementation was key; 2 primary care sites that reverted to more traditional models failed to show the same pattern of savings.
Collapse
Affiliation(s)
- Dale E Green
- 1 University of Georgia College of Public Health , Athens, Georgia
| | | | - Grace E Terrell
- 3 Cornerstone Health Enablement Strategic Solutions , High Point, North Carolina
| | - Jasmine O'Connell
- 3 Cornerstone Health Enablement Strategic Solutions , High Point, North Carolina
| |
Collapse
|
22
|
Jensen JD, Durand DJ. Partnering With Your Health System to Select and Implement Clinical Decision Support for Imaging. J Am Coll Radiol 2016; 14:262-268. [PMID: 27687751 DOI: 10.1016/j.jacr.2016.07.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Revised: 07/25/2016] [Accepted: 07/27/2016] [Indexed: 11/25/2022]
Abstract
Recent legislation mandates the documentation of appropriateness criteria consultation when ordering advanced imaging for Medicare patients to remain eligible for reimbursement. Implementation of imaging clinical decision support (CDS) is a solution adopted by many systems to automate compliance with the new requirements. This article is intended to help radiologists who are employed by, contracted with, or otherwise affiliated with systems planning to implement CDS in the near future and ensure that they are able to understand and contribute to the process wherever possible. It includes an in-depth discussion of the legislation, evidence for and against the efficacy of imaging CDS, considerations for selecting a CDS vendor, tips for configuring CDS in a fashion consistent with departmental goals, and pointers for implementation and change management.
Collapse
Affiliation(s)
- Jeff D Jensen
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University, Baltimore, Maryland.
| | | |
Collapse
|
23
|
Sechtem U, Greulich S, Ong P. [Recommendations of the ESC guidelines regarding cardiovascular imaging]. Herz 2016; 41:362-70. [PMID: 27388914 DOI: 10.1007/s00059-016-4453-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Cardiac imaging plays a key role in the diagnosis and risk stratification in the ESC guidelines for the management of patients with stable coronary artery disease. Demonstration of myocardial ischaemia guides the decision which further diagnostic and therapeutic strategy should be followed in these patients. One should, however, not forget that there are no randomised studies supporting this type of management. In patients with a low pretest probability coronary CT angiography is the optimal tool to exclude coronary artery stenoses rapidly and effectively. In the near future, however, better data is needed showing how much cardiac imaging is really necessary and how cost-effective it is in patients with stable coronary artery disease.
Collapse
Affiliation(s)
- U Sechtem
- Robert-Bosch-Krankenhaus, Auerbachstr. 110, 70376, Stuttgart, Deutschland.
| | - S Greulich
- Robert-Bosch-Krankenhaus, Auerbachstr. 110, 70376, Stuttgart, Deutschland
| | - P Ong
- Robert-Bosch-Krankenhaus, Auerbachstr. 110, 70376, Stuttgart, Deutschland
| |
Collapse
|
24
|
|
25
|
Prabhakar AM, Harvey HB, Misono AS, Erwin AE, Jones N, Heffernan J, Rosenthal DI, Brink JA, Saini S. Imaging Decision Support Does Not Drive Out-of-Network Leakage of Referred Imaging. J Am Coll Radiol 2016; 13:606-10. [DOI: 10.1016/j.jacr.2016.01.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Revised: 12/30/2015] [Accepted: 01/03/2016] [Indexed: 11/29/2022]
|