AR: The $1.1B, double-edged sword of comparative effectiveness
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The American Recovery and Reinvestment Act ushered CER into the national spotlight with a $1.1B allocation. Aimed at leveling and improving healthcare quality, CER also has been tagged as an opportunity to rein in skyrocketing costs.
CER is a challenge for all of healthcare; however, radiology faces additional and unique challenges, according to James V. Rawson, MD, from the department of diagnostic, therapeutic and interventional radiology at Georgia Health Science University in Augusta.
Rawson shared key data surrounding the CER discussion, including:
- A survey of 235 internists revealed that MRI and CT top the list of innovations whose loss would most adversely affect patients;
- Annual Medicare diagnostic imaging spending per beneficiary rose from $220 in 2000 to $419 in 2006;
- The U.S. spends an estimated $210 billion annually on defensive medicine, according to PricewaterhouseCoopers.
Radiology’s conundrum
The Institute of Medicine has created a list of the top 100 CER priorities, with nine impacting radiology. “Themes include cancer imaging, the role of specialists in imaging, the effectiveness of studies ordered by specialists compared to nonspecialists and comparison of the effectiveness of imaging performed by radiologists and nonradiologists.
“This represents an opportunity to identify practices that do not improve patient outcomes as well as standardize care using practices that do improve patient outcomes,” wrote Rawson.
However, seizing the opportunity represents a hefty challenge for radiology. Unlike surgical procedures or prescription medication, the link between diagnostic imaging and patient outcomes is lengthy and fragmented. There are multiple steps and permutations between the imaging study and patient outcome.
“How does one isolate a single chest x-ray during an admission or an outpatient workup and show the survival benefit to the patient? How does one demonstrate the benefit of one step in a multistep process?”
Current mechanisms such as the National Oncology PET Registry rely on a link between imaging and a change in patient management. But Rawson warned that CER ups the ante and requires imaging to demonstrate a link to significant patient outcomes.
This could be an opportunity for radiologists to build relationships with patients and embrace a patient education role, according to Rawson.
As CER studies begin to take shape, researchers will need to attend to key elements such as precise definitions of the patient population. When studies evaluating the efficacy of virtual colonoscopy overlooked the Medicare population, the end result was a negative coverage decision for virtual colonoscopy.
Another CER challenge for radiology is the rapid evolution of technology. For example, as studies were underway to evaluate 16-slice CT systems, 64-slice systems were in development.
In addition, radiologists don’t order imaging studies, so CER needs to change referring physicians’ behavior, which represents a tall order. Rawson offered the backlash against the U.S. Preventive Services Task Force screening mammography recommendations as indicative of the challenge. Moreover, changing behavior takes time; the Institute of Medicine estimates that it takes 17 years for new medical knowledge to be integrated into clinical practice.
“Some of these potential obstacles to implementation,” wrote Rawson, “could be tackled with new tools (e.g. patient-radiologist relationships, decision support software).”
Another piece of the CER puzzle is policy change. Rawson referred to a study conducted by the Massachusetts Medical Society suggesting that 28 percent of CT and MRI exams were ordered for defensive reasons. Tort reform could trim, but likely not eliminate, such studies, he wrote.
“[The] radiology community needs new tools to be able to successfully implement CER results. These include decision support at order entry, a more visible role in patients’ eyes and data mining of electronic medical records to demonstrate the link between radiology exams and patient outcomes,” summed Rawson.
The end result could be a new business model with better aligned incentives and an evolving practice model characterized by more patient contact.