Same-Day Sinus and Brain CT Imaging in the Medicare Population: Are Practice Patterns Changing in Association with Medicare Policy Initiatives?

Observational Trends in Publicly Reported Quality Measures of Hospital Outpatient Quality Reporting Program, 2013-2019

In 2011, the Centers for Medicare & Medicaid Services (CMS) implemented the Hospital Outpatient Quality Reporting Program to assess the quality of outpatient imaging efficiency (OIE). In this study, trends in hospital performance on these national hospital OIE measures a year after inception and public reporting were described. An observational trend analysis was conducted using 2013-2019 data from CMS 6 OIE measures. The trend analysis of metric scores indicates year-to-year variability in all 6 OIE variables. The reporting of these measures appears to have effectively improved the efficiency of most of the measures since the inception of the program.

How hospitals can improve their public quality metrics: a decision-theoretic model

The public reporting of hospitals' quality of care is providing additional motivation for hospitals to deliver high-quality patient care. Hospital Compare, a consumer-oriented website by the Centers for Medicare and Medicaid Services (CMS), provides patients with detailed quality of care data on most US hospitals. Given that many quality metrics are the aggregate result of physicians' individual clinical decisions, the question arises if and how hospitals could influence their physicians so that their decisions positively contribute to hospitals' quality goals. In this paper, we develop a decision-theoretic model to explore how three different hospital interventions-incentivization, training, and nudging-may affect physicians' decisions. We focus our analysis on Outpatient Measure 14 (OP-14), which is an imaging quality metric that reports the percentage of outpatients with a brain computed tomography (CT) scan, who also received a same-day sinus CT scan. In most cases, same-day brain and sinus CT scans are considered unnecessary, and high utilizing hospitals aim to reduce their OP-14 metric. Our model captures the physicians' imaging decision process accounting for medical and behavioral factors, in particular the uncertainty in clinical assessment and a physician's diagnostic ability. Our analysis shows how hospital interventions of incentivization, training, and nudging affect physician decisions and consequently OP-14. This decision-theoretic model provides a foundation to develop insights for policy makers on the multi-level effects of their policy decisions.

Repeated sinus CT imaging after recent head imaging

OBJECTIVES

Excessive use of sinus CT is a significant problem in medical imaging, resulting in unnecessary costs and radiation exposure. This study assesses frequency of sinus CT performed after recent head imaging has already adequately evaluated the sinuses.

METHODS

A retrospective search of the PACS database of an academic medical center was performed to identify cases of sinus CT imaging in 2017. Cases were excluded if sinus CT was performed related to trauma, tumor, operative evaluation, or acute infection other than sinusitis (orbital cellulitis, intracranial abscess). Studies with separate imaging covering the sinuses ordered at the same time as sinus CT or performed previously within 4 weeks were identified and clinical information was recorded.

RESULTS

Of 735 sinus CTs performed, 19 (5%) had same-day head imaging and 30 (8%) had previous head imaging within 4 weeks, adding up to a cumulative 13% of cases with recent head imaging. The average patient age was 42, with 13 pediatric cases. Of ordering providers, residents ordered the highest percentage of sinus CTs with same-day head imaging (84%) and previous imaging within 4 weeks (63%). The sinuses were described in all head CT radiology reports, while 10 of 12 brain MRI reports did not mention the sinuses.

CONCLUSION

In one year, 13% of patients receiving sinus CTs at our institution had recent head imaging. A focused education effort for ordering providers to avoid repeating sinus imaging, and for radiology to comment on sinuses on head imaging, may reduce unnecessary sinus CTs.

Changes in Hospital Outpatient Quality Reporting Program Brain CT Efficiency Performance, 2013 to 2018

BACKGROUND AND PURPOSE

Inefficient imaging practices merit renewed attention in preparation for full implementation of the Appropriate Use Criteria Program. This study's purpose is to quantify changes in outpatient brain CT imaging efficiency from 2013 to 2018, including changes in relative efficiency by hospital category.

MATERIALS AND METHODS

Imaging efficiency data were obtained from the Medicare Hospital Compare website. Summary statistics were calculated for rates of unnecessarily combined brain and sinus CT scans from 2013 to 2018. Relative performance was compared by hospital Medicare payment structure, type of ownership, and affiliation with a radiology residency program. The predictive value of these hospital characteristics on brain CT efficiency was determined using linear regression analysis.

RESULTS

From 2013 to 2018, the mean frequency of unnecessarily combined brain and sinus CT scans decreased by 1.82% (95% confidence interval, 1.74%-1.90%). Proprietary and physician-owned hospitals exhibited a higher mean frequency of combined scans than other hospitals in 2013 (P < .001), and government-owned hospitals exhibited a lower mean frequency of combined scans than other hospitals in 2018 (P < .001). Radiology residency-affiliated hospitals exhibited no significant difference in 2013 but exhibited a higher mean frequency in 2018 (difference: 0.45%; 95% confidence interval, 0.29%-0.61%). Critical access hospital status and nonaffiliation with a radiology residency program were the strongest predictors of brain CT efficiency in the regression model.

CONCLUSION

Recent changes in hospitals' relative brain CT efficiency suggest category-specific differences in responsiveness to quality improvement efforts and may foreshadow similar trends under forthcoming initiatives.

Trends in Publicly Reported Quality Measures of Hospital Imaging Efficiency, 2011-2018

OBJECTIVE. In 2011, the Centers for Medicare & Medicaid Services (CMS) initiated public reporting of outpatient imaging efficiency measures to reduce potentially inappropriate imaging and unnecessary exposure to ionizing radiation performed in hospital outpatient departments. Three CMS quality measures were designed to reduce duplicative CT in the Medicare population: OP-10, which CMS lists as "Abdomen Computed Tomography-Use of Contrast Material"; OP-11, which CMS lists as "Thorax CT-Use of Contrast Material"; and OP-14, which CMS lists as "Simultaneous Use of Brain CT and Sinus CT." We describe trends in hospital performance on these national hospital outpatient imaging efficiency measures since the inception of their public reporting. MATERIALS AND METHODS. This observational analysis used standard Medicare fee-for-service administrative claims to calculate hospital-specific scores for OP-10, OP-11, and OP-14. Consistent with CMS specifications, each measure was calculated as a percentage with appropriate exclusions and minimum case count requirements to ensure measure score validity and reliability. We report national performance as well as distributions of hospital performance scores for each annual public reporting period. Trend analyses were performed to examine changes in annual mean performance over time. Secondary analyses assessed trends and hospital performance by location (rural vs urban) and hospital characteristics. RESULTS. Between 2011 and 2018, the national mean rate of duplicate imaging declined for all three measures (OP-10, 18.9% vs 7.7%; OP-11, 5.6% vs 2.0%; OP-14, 2.5% vs 1.0%). For OP-10 and OP-11, most outlier hospitals were rural, small, and government-owned. For OP-10, rural facilities accounted for 32.2% of all facilities but 46.0% of outliers by the end of the study period. Similarly, for OP-11, rural facilities accounted for 30.1% of all facilities but 47.0% of outliers by the end of the study period. In general, the proportion of outliers located in rural areas decreased over time. CONCLUSION. National performance on CMS quality measures of duplicative CT has improved over time, with reduced variation observed between hospitals since the inception of public reporting. These successes support recent CMS policy initiatives to retire duplicative imaging measures from public reporting. Future work should seek to identify opportunities to use national public reporting initiatives to yield similar improvements across broader indications and settings.