Quality and Value: We’re Doing it Wrong

May 4, 2015

Radiology needs to step up to prove its value.

I finally had a fleeting smile when I read one of Dr. Kaye's answers to the 10 questions posed by Diagnostic Imaging. Finally someone said it, but will it get heard?

Dr. Kaye's quote:

"I am also concerned about declining utilization, regardless of appropriateness, as a result of economic incentives, in that they reward physicians for not ordering imaging. Self-referral of imaging has always been abhorrent to me. To the extent that you interject personal economic factors in the person who is directing care, you have the potential for doing harm to patients. That works in both directions – ie, incentivizing referring physicians to lower costs can deprive patients of care they need. "

I was delighted to read that someone, besides me, is concerned about economically remunerating physicians for ordering fewer studies. The public has absolutely no idea that the ACA, Federal and State governments, Medicare, Accountable Care Organizations, and, now physicians, are all being not merely encouraged but forced to become united and economically aligned and incentivized to minimize and marginalize the real quality and quantity of medical care. All the while pretending to be in the noble pursuit of the holy grail of quality and value-which can never be adequately uniformly defined. Once defined, it will be ever so easy for the unsavory facilities to focus solely on meeting only those particular defined quality measures while ignoring absolutely everything else related to quality. 

The public will ultimately receive exactly what they are being propagandized to want: accountable care (please pay attention to "count" in the word "accountable"), the Walmartization and McDonaldization of medical care (realizing that both Walmart and McDonalds do provide legitimate value for the masses). Fine for everyone else, but is this want individuals want for themselves or their families? 

I have been hearing of only a few current radiology quality measures.

Creating an aggressive annual compliance for getting patients to return for mammograms. The problem is that this has certainly never been proven over time as “outcome beneficial” in a statistically significant population sample compared to patients just following the typical e-mail, snail mail, and phone call reminder methods we all use. 

Monitoring radiation dose: easy for everyone to do (but there are no evidence-based outcome-proved studies - just statistical theoretical cancer rate extrapolations). This is also easily beaten merely by lowering mAs and increasing pitch for CT scans.

Assessing quality based on patient satisfaction: all too often affected by ease of parking, a smile from the receptionist, minimal wait time, and friendliness of the technologist.

Bear in mind, all of these differentiating measures are designed to be divisive by comparing us to (and de facto) against each other-beat everyone's average. Not one of these measures helps serve to prove value of the entire field of radiology.[[{"type":"media","view_mode":"media_crop","fid":"34754","attributes":{"alt":"Steven L. Mendelsohn, MD","class":"media-image media-image-right","id":"media_crop_6099537524694","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3703","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":"Steven L. Mendelsohn, MD","typeof":"foaf:Image"}}]]

Our radiology leadership, pundits, and scholars must stop parroting the same suggestions again and again: talk to patients, use portals for patient results, communicate better with referring doctors, develop rapport with hospital administrators, sit at the table with ACOs and payors, etc. All very nice for that one individual radiologist or that one group, but these individualized divisive tactics are of no benefit to the entire field. None of those ideas prove our field's quality and value one single iota. We must do more than espouse that we radiologists must be ready to accept change. We must study, prove, and most importantly, publish for the salvation of our entire field.

I could not find a single published study that helps "prove" new 3T MRIs yield any improved patient outcomes compared to the 10-year-old 1.5T units or even the 20-year-old 0.3T open units. There are no studies that "prove" value to the patient by having the entire study performed in 8 minutes rather than 45 minutes. So one can't plead superior quality or value for the millions of dollars of modern equipment, which is completely devalued under the new regime of quality and value measures. The same goes for low-dose CT scanners: no published evidence-based outcome proven study. Even so, it would be divisive, pitting radiologists against each other. 

We radiologists (all of us, non-divisively) have yet to prove that obtaining an MRI is a better value than letting the patient go unscanned and symptoms go unanswered. We all need to study a large group of patients that we image and age/symptom/pathology-match with a large group that we don’t image. We clearly will need the help of our (what seems to be unmotivated) orthopedic, neuro, and other colleagues to perform these studies for radiology's exclusive benefit. We need clinical outcomes, subsequent expenses, days lost wages, indemnity payments, and much more follow-up information, none of which is contained in any of our databases.

Our radiologic research and publications, unfortunately, still focus on pure science and radiology. We must all put that completely aside for now as we are in a battle for radiology's survival. All radiology research for the next few years should be solely and exclusively focused on developing, proving, and most importantly, publishing radiology's quality and value. If we don't survive now, there will be nothing whatsoever left in the future to research. 

I would love it if the editors of the JACR or Radiology took some initiative: promote quality and value research, specifically goal-oriented in demonstrating the quality and value of radiology. Perhaps start by devoting half of each and every future publication to articles demonstrating and proving the value of radiology: improved outcomes, evidence-based, cost-effectiveness, etc. of performing the examination rather than the few bucks saved by not performing the study.

Our radiology colleagues who love to research and publish could help tremendously if they focus on salvation of the field by proving and publishing quality and value peer-reviewed, evidence-based, outcome-proven studies. How about a population-based economic study showing improved patient economic outcomes and ability to return to work by having the radiologic study and the associated answers, etc.?

We need to avoid accepting divisive measures, such as patient return compliance rates or proposed satisfaction surveys. We need to become professionally united: research and publish now to prove the value of the entire field of radiology.