Predicted Cost Savings Achieved by the Radiology Support,Communication and Alignment Network from Reducing Medical Imaging Overutilization in the Medicare Population

ObjectiveThe Radiology Support, Communication and Alignment Network (R-SCAN) is a quality improvement program through which patients, referring clinicians, and radiologists collaborate to improve imaging appropriateness based on Choosing Wisely recommendations and ACR Appropriateness Criteria. R-SCAN was shown previously to increase the odds of obtaining an appropriate, higher patient or diagnostic value, imaging study. In the current study, we aimed to estimate the potential imaging cost savings associated with R-SCAN use for the Medicare population.Material and MethodsThe R-SCAN data set was used to determine the proportion of appropriate and lesser value imaging studies performed, as well as the percent change in the total number of imaging studies performed, before and after an R-SCAN educational intervention. Using a separate CMS data set, we then identified the total number of relevant imaging studies and associated total costs using a 5% sample of Medicare beneficiaries in 2017. We applied R-SCAN proportions to the CMS data set to estimate the potential impact of the R-SCAN interventions across a broader Medicare population.ResultsWe observed a substantial reduction in the costs associated with lesser value imaging in the R-SCAN cohort, totaling $260,000 over 3.5 months. When extrapolated to the Medicare population, the potential cost reductions associated with the decrease in lesser value imaging totaled $433 million yearly.ConclusionIf expanded broadly, R-SCAN interventions can result in substantial savings to the Medicare program.     

Radiology Support,Communication, and Alignment Network and Its Role to Promote Health Equity in the Delivery of Radiology Care

Racial, ethnic, and socioeconomic disparities in radiological care have been well documented in both the emergency and outpatient setting. Health IT has the potential to facilitate equitable care across diverse populations. Ordering the appropriate study is the first step in the greater mission of improving access and equity for everyone. Radiology Support, Communication, and Alignment Network (R-SCAN) is an informatics-based solution using clinical decision support (CDS) to promote health equity through optimization in appropriate imaging utilization. R-SCAN and CDS may help combat the potential implicit bias of clinicians by providing evidence-based imaging guidelines at the point of care and ensure that patients will receive equitable and appropriate imaging regardless of ethnic and socioeconomic background. By fostering multidisciplinary collaboration between radiologists and referring clinicians, R-SCAN initiatives across the nation have demonstrated successful reductions in inappropriate imaging utilization, particularly in regions with vulnerable populations.     

A Multidisciplinary Approach to Improving Appropriate Follow-Up Imaging of Ovarian Cysts: A Quality Improvement Initiative

PurposeIncidental ovarian cysts are frequently detected on imaging. Despite published follow-up consensus statements, there remains variability in radiologist follow-up recommendations and clinician practice patterns. The aim of this study was to evaluate if collaborative ovarian cyst management recommendations and a radiologist decision support tool can improve adherence to follow-up recommendations.MethodsGynecologic oncologists and abdominal radiologists convened to develop collaborative institutional recommendations for the management of incidental, asymptomatic simple ovarian cysts detected on ultrasound, CT, and MRI. The recommendations were developed by modifying the published consensus recommendations developed by the Society of Radiologists in Ultrasound on the basis of local practice patterns and the experience of the group members. A less formal process involved the circulation of the published consensus recommendations, followed by suggestions for revisions and subsequent consensus, in similar fashion to the ACR Incidental Findings Committee II. The recommendations were developed by building on the published work of experienced groups to provide the authors’ medical community with a set of recommendations that could be endorsed by both the Department of Gynecology and the Department of Radiology to provide supportive guidance to the clinicians who manage incidental ovarian cysts. The recommendations were integrated into a radiologist decision support tool accessible from the dictation software. Nine months after tool launch, institutional review board approval was obtained, and radiology reports mentioning ovarian cysts in the prior 34 months were retrospectively reviewed. For cysts detected on ultrasound, adherence rates to Society of Radiologists in Ultrasound recommendations were calculated for examinations before tool launch and compared with adherence rates to the collaborative institutional recommendations after tool launch. Additionally, electronic medical records were reviewed to determine the follow-up chosen by the clinician.ResultsFor cysts detected on ultrasound, radiologist adherence to recommendations improved from 50% (98 of 197) to 80% (111 of 139) (P < .05). Overmanagement decreased from 34% (67 of 197) to 10% (14 of 139) (P < .05). A recommendation was considered “overmanaged” if the radiologist recommended follow-up when it was not indicated or if the recommended follow-up time was at a shorter interval than indicated. Clinician adherence to radiologist recommendations showed statistically nonsignificant improvement from 49% (36 of 73) to 57% (27 of 47) (P = .5034).ConclusionsManagement recommendations developed through collaboration with clinicians may help standardize follow-up of ovarian cysts and reduce overutilization.     

Reductions in High-End Imaging Utilization With Radiology Review and Consultation

Following the uptake of value-based purchasing in concert with health care reform in the United States, providers, insurers, and patients are looking for ways to reduce excessive, dangerous, and/or inappropriate high-end imaging utilization (HEIU). Inappropriate HEIU is associated with patient safety risks due to unnecessary exposure to radiation, misappropriation of scarce equipment resources and staff, complications to clinical care, and needless, excessive costs for the patient, hospital, and payer. This paper presents a cost-effective radiology-initiated improvement program piloted in the Christiana Hospital Coordinated Care Network. The pilot demonstrated the effectiveness of regulating high-end imaging orders through radiologists’ review of requests of the order as part of the consult process. Over the 2014-2015 fiscal year, 2,177 high-end imaging orders were reviewed by 26 radiologists for approval, rejection, or recommendation of an alternate examination. Of the orders, 86.7% (1887) were approved, 4.0% (87) were rejected, and 9.3% (203) received recommendation for an alternate examination. Based on improved patient safety, cost savings, and appropriate resource use, these findings suggest that radiologists’ review can effectively reduce excessive HEIU. This method, with an appropriate algorithm to assist with handling a larger volume of orders, would be ideal to implement systemwide to manage HEIU cost efficiency, simultaneously providing radiologists with more control in their area of expertise and positively impacting quality, safety, and value-based purchasing goals.     

Use of a Commercially Available Clinical Decision Support Tool to Expedite Prior Authorization in Partnership With a Private Payer

PurposeThe aim of this study was to determine if a clinical decision support (CDS) tool could be used in partnership with a private payer to successfully expedite the prior authorization process for advanced (ie, MRI, CT, PET, nuclear medicine) imaging requests.MethodsA single academic institution integrated a commercially available CDS tool utilizing the ACR Appropriateness Criteria into the ordering process for outpatient advanced imaging tests within the electronic health record. Ordering providers could elect to use the CDS tool or ignore the available technology. In partnership with a health care insurance company and a contracted radiology benefits management company, orders deemed as “usually indicated” by the CDS tool underwent expedited prior authorization in a pilot program from June 2018 to October 2019.ResultsProviders used the CDS tool for 15% (1,453 of 9,640) of outpatient advanced imaging orders. Of these orders with elective CDS scores, 69% (n = 997) qualified for an expedited prior authorization process.ConclusionsUnder specific circumstances, a commercially available CDS tool was used in partnership with a private payer and a radiology benefits management company to expedite prior authorization of outpatient advanced imaging examination orders deemed likely to be appropriate by multispecialty professional guidelines.     

Medical Imaging Data Reconciliation, Part 4: Reconciliation of Radiology Reports and Clinical Outcomes Data

An accurate clinical assessment of how radiology report data affect health care outcomes cannot be performed without the standardization, integration, and longitudinal analysis of radiology report and clinical outcomes data. The creation of such a technology can be accomplished by creating a standardized finding-specific radiology and clinical database, in which individual report findings are assigned extensible markup language tags and tracked over time with associated clinical data. The derived knowledge can in turn be used to improve overall outcomes through the data-derived analysis of reporting accuracy, imaging utilization, the timeliness of clinical care, and compliance with best practice guidelines.     

医用臭氧作为数字减影成像子宫输卵管造影对比剂的可行性研究

目的 探讨医用臭氧(O3)作为数字减影成像(DSI)子宫输卵管造影(HSG)对比剂的可行性.方法 随机选择226例拟行DSI-HSG的病例,医用O3组113例,对比剂选用浓度30 μg/ml的O3;碘对比剂组113例,对比剂选用320 mgI/ml碘佛醇注射液.分别进行DSA采集成像,对两组DSA图像质量评分采用Wilcoxon秩和检验,输卵管通畅程度造影表现比较采用x2检验.结果 O3组、碘佛醇组共226例,输卵管448条.造影术中、术后无一例发生严重并发症.O3组图像质量优、良、差、采集失败者分别为83.2％、11.5％、3.5％、1.8％,碘佛醇组图像质量优、良、差、采集失败者分别为86.7％、10.6％、2.7％、0％,两组图像质量无显著性差异(Z =0.805,P=0.421).O3组225条输卵管,近段堵塞78条、中远段堵塞34条、通而不畅90条、完全通畅23条;碘佛醇组223条输卵管,近段堵塞81条、中远段堵塞33条、通而不畅89条、完全通畅20条;两组输卵管通畅程度造影表现差异没有统计学意义(P＞0.05).结论 医用O3作为DSI-HSG对比剂是可行的.     

Retrospective Evaluation of Artificial Intelligence Leveraging Free-Text Imaging Order Entry to Facilitate Federally Required Clinical Decision Support

ObjectiveThe Protecting Access to Medicare Act mandates clinical decision support (CDS) at imaging order entry, necessitating the use of structured indications to map CDS scores. We evaluated the performance of a commercially available artificial intelligence (AI) tool leveraging free-text order entry to facilitate provider selection of the necessary structured indications.MethodsOur institution implemented an AI tool offering predicted structured indications based upon the ordering provider’s entry of a free-text reason for examination. Providers remained able to order via the traditional direct search for structured indications. Alternatively, they could take the new free-text–AI approach allowing them to select from AI-predicted indications, perform additional direct searches, indicate no matching indication, or exit CDS workflow. We hypothesized the free-text–AI approach would be elected more often and the AI tool would be successful in facilitating selection of structured indications. We reviewed advanced imaging orders (n = 40,053) for the first 3 months (February to May 2020) since implementation.ResultsProviders were more likely (P < .001) to choose the free-text–AI approach (23,580; 58.9%) to order entry over direct search for structured indications (16,473; 41.1%). The AI tool yielded alerts with predicted indications in 91.7% (n = 21,631) of orders with free text. Ultimately, providers chose AI-predicted indications in 57.7% (n = 12,490) of cases in which they were offered by the tool.DiscussionProviders significantly more often elected the new free-text–AI approach to order entry for CDS, suggesting provider preference over the traditional approach. The AI tool commonly predicted indications acceptable to ordering providers.     

Perspectives on the Value of Advanced Medical Imaging: A National Survey of Primary Care Physicians

PurposeTo understand perceptions of primary care physicians (PCPs) about the value of advanced medical imaging.MethodsA national quantitative survey of 500 PCPs was conducted using an online self-administered questionnaire. Questions focused on advanced medical imaging (CT, MRI, and PET) and its perceived impact on the delivery of patient care. Responses were stratified by physician demographics.ResultsLarge majorities of the PCPs indicated that advanced imaging increases their diagnostic confidence (441; 88%); provides data not otherwise available (451; 90%); permits better clinical decision making (440; 88%); increases confidence in treatment choices (438; 88%), and shortens time to definitive diagnosis (430; 86%]). Most (424; 85%) believe that patient care would be negatively affected without access to advanced imaging. PCPs whose clinical careers predated the proliferation of advanced imaging modalities (>20 years of practice) assigned higher value to advanced imaging on several dimensions compared with younger physicians whose training overlapped widespread technology availability.ConclusionsBy a variety of metrics, large majorities of PCPs believe that advanced medical imaging provides considerable value to patient care. Those whose careers predated the widespread availability of advanced imaging tended to associate it with even higher value.     

Decreasing Duplicative Imaging: Inpatient and Emergency Medicine Abdominal Ultrasound Within 72 Hours of Abdominal CT

PurposeThe aim of this project was to reduce abdominal ultrasound examinations in patients who had undergone abdominal CT within 72 hours previously.MethodsA best practice advisory (BPA) was created in the electronic medical record to advise against the use of abdominal ultrasound in adult inpatients and emergency department patients who had undergone abdominal CT within the preceding 72 hours. Acceptable acknowledgment reasons to proceed with the order were made available if providers chose to override. Frequency of BPA firing and subsequent ordering behavior were evaluated 6 months after integration of the BPA into the electronic medical record. Chart review was conducted for 100 patients whose orders were placed through an override of the alert to determine if the ultrasound study added value and for all patients whose ultrasound studies were canceled to confirm that patient care was not compromised by omitting the ultrasound study.ResultsIn the first 6 months, a total of 614 inpatient and emergency department abdominal ultrasound orders triggered the BPA. A total of 16% of orders (n = 96) were canceled by the provider after the BPA, reflecting 518 overrides. The majority of retained orders were to evaluate the gallbladder (44% [227 of 518]). Chart review confirmed utility for gallbladder imaging and that the canceled ultrasound examinations would not have contributed value to patients’ care.ConclusionsA recently performed abdominal CT scan may obviate the need for inpatient and emergency department abdominal ultrasound, particularly in the setting of hospital-acquired acute kidney injury. A BPA resulted in only 16% of orders’ being canceled, whereas chart review revealed a much larger opportunity to avoid duplicative imaging.     

乳腺影像数据库的建立及其临床意义

随着中国女性乳腺癌发病率的逐年上升,乳腺普查及疾病诊治越来越受到重视,而乳腺影像学检查在其中占有重要地位。本文旨在介绍如何利用大量的乳腺影像学检查资料建立专属于中国女性的乳腺影像数据库,并探讨其在乳腺流行病学研究、临床疾病诊治以及病患随访追踪中的意义。     

法乐氏四联症合并冠状动脉异常的影像学诊断及其临床意义分析

目的：探讨法乐氏四联症合并冠状动脉异常的解剖类型、影像学诊断并对其临床意义加以分析。资料与方法：1986年6月～1996年10月间临床资料完整的126例法四均经手术证实，其中7例合并冠状动脉异常，男5例，女2例，平均9．4岁。术前均采用影像学综合检查。结果：7例法四中，造影显示冠状动脉清晰者4例，有2例因手术中切断横过右心室漏斗部前方的异常冠状动脉而死亡。结论：法四合并严重的冠状动脉异常并非少见，应当引起影像学医师和外科医师足够的重视。