Sustainability

Path to better imaging utilization is clear: straight talk

Thanks to collaboration among radiologists and ordering physicians, a little education and some data crunching, great strides are being made to cut the amount of low-yield imaging in clinical settings.

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Those outcomes are part of the recently concluded Transforming Clinical Practice Initiative (TCPI), through which the Centers for Medicare & Medicaid Services (CMS) awarded $840 million for organizations, including the AMA, to create evidence-based, peer-led collaboratives and practice-transformation networks to help physicians provide high-quality care.

Explore how the AMA has joined dozens of health care collaborative networks selected to take part in the TCPI.

The Radiology Support Communication and Alignment Network (R-SCAN)—a program of the American College of Radiology—set out to bring radiologists and referring physicians together to improve the number of high-value images that are ordered.

Making wise choices

Radiologists worked with emergency physicians, primary care physicians and other specialists to educate them about when it is best to order images. They created education materials that could be handed to patients to explain why a certain imaging test would not yield much of value. Also, they looked at data to determine how often low-yield images were being ordered—images that exposed patients to radiation when they weren’t going to help make a diagnosis.

The project focused on Choosing Wisely recommendations such as not ordering imaging for uncomplicated headaches and not ordering an image for suspected pulmonary embolism without a moderate or high pretest probability for pulmonary embolism.

Initial results show that among 70 practices that participated, the ordering of high-yield imaging improved by nearly 22% after the R-SCAN intervention. Researchers reviewed about 9,000 cases retrospectively—4,950 baseline cases and 4,060 cases after an educational intervention had taken place.

As of December 2018, R-SCAN supported 189 registered projects, engaged 120 radiology practices and recruited more than 10,000 clinicians.

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How to improve your practice

At Bayhealth—the largest health system in the central and southern part of Delaware, radiologist Thomas E. Vaughan, MD, and emergency physician Craig D. Hochstein, MD, worked together with the system’s emergency department to successfully improve the number of high-yield images emergency physicians ordered.

Bayhealth Clinical Integration and HealthVisions Delmarva Practice Transformation Network also were moving forces behind the initiative, collaborating with Bayhealth’s ED and radiology departments and reaching out to ACR and the American College of Emergency Physicians.

Drs. Vaughan and Hochstein offered this advice to those looking to incorporate an R-SCAN effort.

Bring together a group of people who work well together. Include a radiologist, a physician from the specialty you are working with and an administrative person to be part of the leadership of the project. “Cooperation and teamwork is one of the keys to being successful,” Dr. Vaughan said.

Make sure it’s not a negative thing for the frontline emergency physicians, or other frontline physicians you are teaming up with.

Make sure physicians have the tools they need to make decisions and give them evidence-based support of why an image may produce low-yield results in certain situations. This can be done through education sessions and e-mails. Also, create posters describing when imaging is needed and when it’s not that can be hung for physicians and patients to see.

A big part of the project involved giving physicians “permission to not order the test. Many felt like they were obliged to order tests, especially tests that the patient wanted,” Dr. Hochstein said. The focus was to educate patients and doctors about “why imaging was often not needed or appropriate.”

Follow through by taking the time and effort to track results and be sure to share the results with everyone so they can see the progress.

Reach out to a physician if you find he or she is responsible for a larger percentage of the low-yield images being ordered and provide reinforcement materials on high-yield image ordering.

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Give patients a stake in process

Ashima Lall, MD, echoed the advice of Drs. Vaughan and Hochstein. Dr. Lall, who is chair of the Quality Experience Committee—part of the ACR’s Commission on Patient- and Family-Centered Care Quality Experience Committee—added that physicians also should consider inviting patients to play a bigger role.

“You can’t conduct a quality improvement project without understanding the patient perspective. This project placed our patients at the center of the conversation about utilization,” said Dr. Lall. As system chief of performance improvement for Radiology Associates of Main Line Health in suburban Philadelphia, Dr. Lall collaborated with emergency physicians to successfully reduce low-value CT imaging for pulmonary embolism at Riddle Hospital.

Dr. Lall helped create The R-SCAN Patient Engagement Toolkit that guides physicians on how to engage patients in these projects and notes that radiologists can access a plethora of materials at R-SCAN to start their own projects.