The current state of unnecessary imaging-and what you can do about it.
For more than a decade, the specter of unnecessary imaging and over-utilization has plagued radiology. Not only has it been costly, but it’s also exposed countless patients to unneeded-and cumulatively harmful-radiation.
But, with radiologists being the gatekeepers to advanced imaging services, it begs the question: how much responsibility do you, as providers, have in controlling how much imaging is ordered and completed within the healthcare environment? And, what, if anything, can you do to ensure your referring physicians and your facility overall aren’t contributing to the problem?
According to several industry leaders, it’s a role you’re obligated to take on.
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“Radiologists have an irreplaceable role in terms of helping to select the studies that are going to be clinically useful,” says Craig Clark, MD, JD, a radiologist with Radiology Consultants of Iowa, PLC, the largest radiology group in the state. “We’re the experts in the field, and we know the modality that is most likely to answer specific questions. That’s the critical point.”
Ultimately, he says, your greatest contribution is providing information.
The current state
Advanced imaging usage has held relatively steady for several years, but the price tag has still been hefty. According to a 2014 report from big data survey company peer60, spending for diagnostic services has hovered between $7.47 billion and $11.95 billion annually. Much of that can be attributed to images that likely shouldn’t have been ordered.
In fact, a Robert Wood Johnson Foundation report revealed 72% of referring physicians knowingly order at least one unnecessary test each week. And, 50% of that group do so mainly as a preventive measure against medical malpractice claims.
Recently, however, the trend for imaging utilization in starting to shift. While exact numbers aren’t available, radiology is starting to see the pendulum begin to swing again, says Richard Duszak, MD, vice chair for health policy and practice in Emory University School of Medicine’s radiology department.
“Utilization in imaging was going fast and crazy up to 2006. Then, it plateaued,” he says. “Now, we’re starting to see it increase again.”
Factors behind the rise
Even though the American College of Radiology (ACR) has promoted its Image Wisely campaign for many years, there are still several drivers pushing image utilization growth, says Duszak, who is also a senior fellow for the Harvey L. Neiman Health Policy Institute.
First, the patient population itself is partly responsible. Patients are living longer, and advanced imaging is often required to meet their clinical needs.
Second, not all providers have the same level of education around how best to use diagnostic imaging. According to data from the Neiman Institute, physician extenders, such as nurse practitioners and physician assistants, are 1.3 times more likely to order advanced imaging than their physician counterparts.
“These providers are very well trained, but they have a different level of training compared to the years of medical school and residency,” he says. “Providing them with more education and instruction on how best to use imaging would be productive.”
Third, Clark says, the spike in emergency department (ED) visits is also directly correlated to a rise in imaging use. As more patients turn to the ED for care, they’re seen by doctors with whom they don’t have existing relationships. These doctors are more likely to use imaging as a means of gathering a patient history, as well as safeguarding themselves from any accusations of malpractice.
“The ED is a place where medical imaging can be regularly overused,” says Clark, who has published about unnecessary imaging. “The fallback explanation for doing marginal imaging almost always includes talk of medical malpractice. It’s not a fictional explanation. It’s real.”
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Lastly, Duszak says, there’s a significant financial component behind the rise in imaging utilization. Existing data shows radiologists who own imaging equipment are more likely to order a diagnostic study.
What you can do
To help you address this issue, the ACR recently launched R-Scan, a program designed to help radiologists bolster their existing relationships with referring providers. The initiative offers radiology-referring physician partnerships web-based and clinical decision support tools that help identify areas of unnecessary imaging and design strategies that lead to imaging reductions. For example, a recent partnership at Northwestern University Feinberg School of Medicine led to a 16% reduction in emergency department pediatric head CTs.
Alongside following ACR guidance, one of the biggest things you can do is work with the administrations for the hospitals you serve to identify areas where your referring providers can cut away at unnecessary imaging says Erin Lane, MD, a researcher with the Advisory Board’s Imaging Performance Partnership. Present the findings to the ordering physicians, highlighting the spots where they’re requesting either the too many or incorrect tests.
“Make your presentations data-driven and specific to your audience. General education doesn’t stick with them,” she says. “Over the course of a year, they’re ordering tests of five body parts, and there’s no way they can keep all the appropriateness rules straight in their heads. Remember what they’ll be struggling with.”
Consider setting up a call line or launching an online chat function where referring providers can contact you with any questions, she says.
In addition, investigate whether your hospitals use standing orders or order sets. Many facilities rely on these protocols that were created when their electronic medical record systems were installed several years ago and that haven’t been updated since. Often advanced imaging services are included in those bundles.
“Even in cases where some studies are no longer considered appropriate, some facilities will continue to conduct them because they’re part of the standing order,” Lane says. “Working with hospitals to update their protocols can reduce unnecessary imaging.”
For example, she says, one facility she included in her research discovered it was in the 90th percentile compared to its peers for ordering chest X-rays for intensive care patients-every patient received a daily scan regardless of their condition. The standing order was changed, calling for a chest X-ray only after a status change, and usage fell by 38%.
There are also other, more day-to-day strategies you can employ to maximize your impact on image utilization, Duszak says. Part of your job, he says, is educating referring providers about which test might be optimal for individual patients. If you receive an order for an imaging study that might be inappropriate, call the ordering physician. In most cases, he says, they’ll be receptive to hearing there might be a better way to get answers for their patients.
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But, more importantly, he says, get out of the reading room. Spend time in the doctors’ lounge interacting with your colleagues from other specialties. It sends the message that you’re accessible.
“Conversations that come up in the lounges often find their way to workflow solutions or open the door for questions that need answers,” Duszak says. “A lot of it is also developing the relationships so that doctors are more willing to come to you proactively and ask for guidance.”
These methods for managing imaging utilization might not be revolutionary, he says, but they’re necessary and steadfast. And, they’ll continue to evolve as time passes.
Lane agrees, adding these steps are vital. The current healthcare industry’s trajectory makes your involvement in controlling imaging utilization critical.
“As we’re moving toward more population health management and as value-based care isn’t a far-off idea, reducing unnecessary imaging is a way radiology can help manage total costs,” she says.