JACR: Can rads balance standardization and patient-centered care?
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Standardization is appealing, according to Saurabh W. Jha, MBBS, and William W. Boonn, MD, of the department of radiology at the Hospital of the University of Pennsylvania in Philadelphia. Variability in care would seem to indicate that some providers are delivering healthcare that is superior to others. Protocols for imaging might be welcomed by technologists who would have to make fewer judgment calls and deal with less ambiguity.
“The manufacturing industry has long realized that one of the causes of waste is variability. Indeed, healthcare is borrowing conceptual models and science, such as Six Sigma, from the manufacturing industry to reduce or eliminate its own waste,” wrote Jha and Boonn.
Radiologists themselves may feel secure with standardization and may believe that protocols can offer protection in the medicolegal realm, wrote the authors.
The issue? “There is no standard patient,” they wrote. “Patients vary in attributes that affect image optimization.”
Jha and Boonn offered several examples that strained the limits of what standardization can bring to radiology. Protocols for a CT urography, for example, must include precontrast, nephrographic and excretory-phase images since a standardized protocol must make allowances for all eventualities, including normal results, stones, a renal mass, a bladder tumor or some other result. Acquisition parameters also must be set at a level that works best for most patients.
A patient-centered approach, explained Jha and Boonn, would have the radiologist scout the precontrast images for stones which could forgo further acquisition. Tube voltage would be set according to the patient’s body type. CT studies of the chest could be localized to reduce the radiation dose to the patient.
“Examples abound whereby patient-centered imaging may reduce the number of acquisitions and even the need for contrast,” wrote the authors.
That’s not to say there are not barriers to patient-centered imaging. It’s more time consuming, requires more manpower and resources and requires the acceptance that judgment calls will not always be correct. Regulations, coding issues and departmental policy may push a radiologist to perform the contrast component of a contrast-enhanced CT or MRI even if it is deemed clinically unnecessary after viewing the initial images.
“Thus, radiologists may find themselves in the unenviable position of being caught between hospital administrators who excel at thinking within the box and policymakers who almost exclusively think outside the box, while pandering to the media's and the public's desire to push relentlessly toward individualized medicine,” wrote Jha and Boonn.
The authors concluded that there is a balance to be found between mandated procedures and individual judgment. Guidelines can provide boundaries, even if they can’t cover every single scenario. “Stated differently, no guideline can ever determine when judgment should be used, but judgment can often determine when the guidelines should be followed.”
For more on patient-centered care, read “The Pampered Patient” in the March issue of Health Imaging.
Evan Godt, Writer
Evan joined TriMed in 2011, writing primarily for Health Imaging. Prior to diving into medical journalism, Evan worked for the Nine Network of Public Media in St. Louis. He also has worked in public relations and education. Evan studied journalism at the University of Missouri, with an emphasis on broadcast media.