Health focus: Imaging
Resource for doctors facilitates high-value imaging
Imaging is life-saving. But too much imaging leads to unnecessary costs, not to mention the risk to patients of needless exposure to radiation.
Radiologists understand this. The American College of Radiology has been working to help its members, referring physicians and the public differentiate high-value (appropriate) imaging from low-value (unnecessary) imaging. ACR has done so through its participation in programs such as Choosing Wisely®, Image Gently® and Image Wisely®.
With the ACR’s R-SCAN™ program, radiologists are trying to get the message across to their referring physicians – that is, the primary care physicians whom Repertoire readers call on.
Launched in September 2015, R-SCAN brings together radiologists and referring clinicians to improve imaging appropriateness based upon a list of imaging-related Choosing Wisely topics. (Choosing Wisely is an initiative of the ABIM Foundation that seeks to advance a national dialogue on avoiding unnecessary medical tests, treatments and procedures.) Today, nearly 100 referring practices representing 4,000 referring physicians from a variety of medical specialties are teaming up with radiologists on R-SCAN projects, reports the ACR.
R-SCAN offers radiologists and referring physicians tools to study image ordering practices, institute educational interventions to improve ordering, and conduct post-intervention analyses. Among these tools is a web-based clinical decision support (CDS) system, CareSelect Imaging™, which provides access to the ACR Appropriateness Criteria® (AC), evidence-based guidelines to optimize image ordering and reduce unnecessary imaging exams.
Radiology and referring clinician practices participating in the CMS Merit-based Incentive Payment System (MIPS) can fulfill “Improvement Activity” credit requirements by using R-SCAN.
Harris Health and Baylor
In a case study on its website, R-SCAN describes how radiologists at Baylor College of Medicine worked with Harris Health System in Harris County, Texas, in 2016 to reduce the number of MRIs being ordered for patients with low back pain (one of the Choosing Wisely topics). The project helped the health system reduce MRIs by nearly 38 percent and increase the appropriateness rating for such orders 23 percent.
Christie M. Malayil Lincoln, M.D., assistant professor of radiology and neuroradiology and faculty senator at Baylor College of Medicine, and Melissa M. Chen, M.D., who was a neuroradiology fellow at Baylor College of Medicine at the time, led Baylor’s effort to reduce inappropriate imaging for low back pain. They selected the topic after noticing that two of Harris Health System’s high-volume family practice clinics were ordering more imaging studies for low back pain than were probably necessary.
Lincoln and Chen approached Brian C. Reed, M.D., director of disease control and clinical prevention at Harris County Public Health, who at the beginning of the project was the vice chair of community health in the Department of Family & Community Medicine. Reed introduced the two to Samuel Willis, M.D., and Luu Phong, M.D., the directors of the two Harris Health clinics with the highest incidence of inappropriate image ordering for low back pain. Both clinicians were receptive to using R-SCAN, and they recommended a third clinic that also struggled with appropriate image ordering.
With the referring clinicians on board, Lincoln and Chen partnered with three other members of the radiology group. Together, the radiologists reviewed the 300 MRIs that referring clinicians from the three clinics ordered for patients experiencing low back pain during a 10-month period. The team determined whether the MRIs ordered met the ACR Appropriateness Criteria by using the web-based clinical-decision-support tool through the R-SCAN portal.
The review process confirmed that the referrers were in fact ordering a significant number of lumbar spine MRIs inappropriately based on the evidence-based guidelines.
In response, the radiologists attended the monthly continuing medical education (CME) luncheons at each of the three health clinics and taught referring providers, nurse practitioners and physician assistants about appropriate image ordering for lumbar spine, explains the ACR in the case study.
In the 10 months following the educational intervention, clinicians from the three clinics ordered a combined 187 MRIs for low back pain, down from the 300 orders made during the pre-intervention period. In addition, the appropriateness of the exams ordered increased by 23 percent over the pre-intervention period.
These results indicated that the educational intervention led to improved image ordering, according to the R-SCAN team. The results also indicate that referring clinicians are now looking for other ways to treat lower back pain before turning to advanced imaging.
What’s more, as Reed had hoped, the reduction in unnecessary imaging also seems to have reduced wait times for patients who urgently needed MRIs. The Baylor team is working to measure this reduction in patient wait times for MRI as part of the next iteration of the project.
Refer your physician customers to www.rscan.org, or email rscaninfo@acr.org, to learn more about R-SCAN.
Choosing Wisely
An R-SCAN project begins with the physician practice and radiologists selecting a Choosing Wisely® topic to tackle. Following are imaging-related topics and recommendations.
Abdominal imaging
- Avoid ordering CT of the abdomen and pelvis in otherwise health emergency-department patients (age <50) with known histories of kidney stones, or urolithiasis, presenting with symptoms consistent with acute uncomplicated renal colic. (Recommended by the American College of Emergency Physicians.)
Cardiac imaging
- Don’t routinely order coronary CT angiography for screening asymptomatic individuals. (Recommended by the Society of Cardiovascular Computed Tomography.)
Chest imaging
- Avoid admission or preoperative chest X-rays for ambulatory patients with unremarkable history and physical exam. (Recommended by the American College of Emergency Physicians and the American College of Surgeons.)
- Do not perform chest CT angiography to evaluate for possible pulmonary embolism in patients with a low clinical probability and negative results of a highly sensitive D-dimer assay. (Recommended by the American College of Physicians, the American College of Chest Physicians, the American Thoracic Society and the American College of Radiology.)
Genitourinary imaging
- Do not recommend follow-up imaging for clinically inconsequential adnexal cysts. (Recommended by the American College of Radiology.)
- Don’t perform PET, CT, and radionuclide bone scans in the staging of early prostate cancer at low risk for metastasis. (Recommended by the American College of Radiology.)
Musculoskeletal imaging
- Avoid imaging for low back pain within the first six weeks, unless red flags are present. (Recommended by the North American Spine Society, the American College of Physicians, and the American Academy of Family Physicians.)
Neuroimaging
- Don’t order sinus CT or indiscriminately prescribe antibiotics for uncomplicated acute rhinosinusitis. (Recommended by the American Academy of Allergy, Asthma, & Immunology, the American Academy of Otolaryngology – Head and Neck Surgery Foundation)
- Don’t do imaging for uncomplicated headache. (Recommended by the American College of Radiology.)
- CT scans are not necessary in the immediate evaluation of minor pediatric head injuries. Clinical observation/Pediatric Emergency Care Applied Research Network criteria should be used to determine whether imaging is indicated. (Recommended by the American Academy of Pediatrics.)
- Neuroimaging (CT, MRI) is not necessary in a child with simple febrile seizure. (Recommended by the American Academy of Pediatrics.)
- For adult minor head trauma, avoid CT scans of the head in emergency department patients who are at low risk based on validated decision rules. (Recommended by American College of Emergency Physicians.)
Choosing Wisely is an initiative of the ABIM Foundation that seeks to advance a national dialogue on avoiding unnecessary medical tests, treatments and procedures. The initiative now has more than 540 specialty society recommendations. For more information go to www.choosingwisely.org
Image gently, image wisely
Image Gently® and Image Wisely® are two programs – both supported by the American College of Surgeons – designed to reduce patient’s unnecessary exposure to radiation.
The Image Gently campaign was launched in 2008 to raise awareness about methods to reduce radiation dose during pediatric medical imaging exams. The campaign is an initiative of the Alliance for Radiation Safety in Pediatric Imaging, a coalition founded by the Society for Pediatric Radiology, the American Society of Radiologic Technologists, the American College of Radiology and the American Association of Physicists in Medicine. The Alliance has now grown to more than 40 organizations.
Image Wisely focuses on radiation safety in adult medical imaging. The American College of Radiology and the Radiological Society of North America formed the Joint Task Force on Adult Radiation Protection to address concerns about the surge of public exposure to ionizing radiation from medical imaging. The Joint Task Force collaborated with the American Association of Physicists in Medicine and the American Society of Radiologic Technologists to create the Image Wisely campaign.
Image Wisely (www.imagewisely.org) offers resources and information to radiologists, medical physicists, other imaging practitioners, and patients.