JACR: Tools needed for primary care physicians to improve imaging decision requests
A high percentage of CT and MRI examinations are not meeting appropriateness criteria and subsequently yielding negative results, which suggests a need for tools to help primary care physicians hone their imaging decision requests, according to a recent article in the Journal of the American College of Radiology.
Authors Robert L. Bree, MD, and Bruce E. Lehnert, MD, of the department of radiology at the University of Washington Harborview Medical Center in Seattle, sought to retrospectively analyze 459 elective outpatient CT (284, 62 percent) and MRI (175, 38 percent) examinations from primary care physicians to determine appropriateness using evidence-based guidelines.
Evidence-based appropriateness criteria from HealthHelp, a Houston-based radiology benefit management company, were used to determine if the examination would have met criteria for approval. Submitted clinical history at the time of interpretation, clinic notes, and laboratory results preceding the date of the imaging study were examined to simulate a real-time consultation with the referring provider, according to the report. The radiology reports and subsequent clinic visits were analyzed for outcomes as well, according to the authors.
According to the findings, 341, or 74 percent, were considered appropriate while 118, or 26 percent, were not considered appropriate. Sixty-two percent of CT head/brain examinations were considered inappropriate and 53 percent of CT spine examinations were considered inappropriate, the report found.
The most ordered tests were CT for abdomen/pelvis, CT chest and lumbar spine MR for acute back pain. Of those, 18 percent of CT abdomen/pelvis exams were inappropriate, 12 percent of CT chest examinations were inappropriate and 35 percent of MR spine examinations were inappropriate.
Fifty-eight percent of the appropriate studies had positive results and affected subsequent management, whereas only 13 percent of inappropriate studies had positive results and affected management, the report found.
“In the current environment, which stresses cost containment and comparative effectiveness, traditional radiology benefit management tools are being challenged by clinical decision support, with an emphasis on provider education coupled with electronic order entry systems,” the authors concluded. "Clinical decision support, particularly when embedded in order entry systems with an EMR, can greatly enhance a clinician's ability to choose the correct examination or to choose no examination."
"Logistic regression estimates suggested odds 3.5 times higher that a negative finding will be associated with an inappropriate vs. an appropriate examination," wrote the authors. "This is important information for policymakers as they struggle with physicians and patients, who are unhappy with restrictive utilization management programs, and payers and the public, who are looking for ways to decrease healthcare costs and increase the quality and safety of examinations in an era of higher awareness of effects of excess radiation."
"A reasonable compromise might be found in the newly emerging clinical decision support systems," the authors concluded.
Authors Robert L. Bree, MD, and Bruce E. Lehnert, MD, of the department of radiology at the University of Washington Harborview Medical Center in Seattle, sought to retrospectively analyze 459 elective outpatient CT (284, 62 percent) and MRI (175, 38 percent) examinations from primary care physicians to determine appropriateness using evidence-based guidelines.
Evidence-based appropriateness criteria from HealthHelp, a Houston-based radiology benefit management company, were used to determine if the examination would have met criteria for approval. Submitted clinical history at the time of interpretation, clinic notes, and laboratory results preceding the date of the imaging study were examined to simulate a real-time consultation with the referring provider, according to the report. The radiology reports and subsequent clinic visits were analyzed for outcomes as well, according to the authors.
According to the findings, 341, or 74 percent, were considered appropriate while 118, or 26 percent, were not considered appropriate. Sixty-two percent of CT head/brain examinations were considered inappropriate and 53 percent of CT spine examinations were considered inappropriate, the report found.
The most ordered tests were CT for abdomen/pelvis, CT chest and lumbar spine MR for acute back pain. Of those, 18 percent of CT abdomen/pelvis exams were inappropriate, 12 percent of CT chest examinations were inappropriate and 35 percent of MR spine examinations were inappropriate.
Fifty-eight percent of the appropriate studies had positive results and affected subsequent management, whereas only 13 percent of inappropriate studies had positive results and affected management, the report found.
“In the current environment, which stresses cost containment and comparative effectiveness, traditional radiology benefit management tools are being challenged by clinical decision support, with an emphasis on provider education coupled with electronic order entry systems,” the authors concluded. "Clinical decision support, particularly when embedded in order entry systems with an EMR, can greatly enhance a clinician's ability to choose the correct examination or to choose no examination."
"Logistic regression estimates suggested odds 3.5 times higher that a negative finding will be associated with an inappropriate vs. an appropriate examination," wrote the authors. "This is important information for policymakers as they struggle with physicians and patients, who are unhappy with restrictive utilization management programs, and payers and the public, who are looking for ways to decrease healthcare costs and increase the quality and safety of examinations in an era of higher awareness of effects of excess radiation."
"A reasonable compromise might be found in the newly emerging clinical decision support systems," the authors concluded.