Introduction to Imaging Appropriateness PDF

Introduction to Imaging Appropriateness INSTRUCTOR: Jeanne G. Hill, M.D. Professor of Radiology and Pediatrics Email: [email protected] OUTLINE: 1. US Health Care Costs a. Costs vs. Outcomes b. Waste 2. Imaging Utilization and Contribution to Health Care Costs a. Utilization of Imaging Clinical Decisio...

Introduction to Imaging Appropriateness INSTRUCTOR: Jeanne G. Hill, M.D. Professor of Radiology and Pediatrics Email: [email protected] OUTLINE: 1. US Health Care Costs a. Costs vs. Outcomes b. Waste 2. Imaging Utilization and Contribution to Health Care Costs a. Utilization of Imaging Clinical Decision Support b. ACR Appropriateness Criteria – Imaging Guidelines 3. Imaging Guidelines for Acute Abdominal Pain - Suspected Appendicitis 4. Imaging Guidelines for Acute Headache 5. Imaging Guidelines for Acute Ankle Injury OBJECTIVES: After studying this unit you should be able to: 1. Describe US health care expenditures and outcomes compared to other developed nations. 2. Describe the amount of waste in US health care expenditures. 3. Utilize the ACR Appropriateness Criteria to order the most appropriate imaging test for a patient with suspected appendicitis. 4. Utilize the ACR Appropriateness Criteria to order the most appropriate imaging test for a patient with headache. 5. Utilize the ACR Appropriateness Criteria to order the most appropriate imaging test for a patient with an acute ankle injury. 6. Describe the benefits of appropriate imaging and potential consequences of inappropriate imaging. READING REFERENCE: 1. Khan R et al. (2013) Radiology Essentials in Lewis PJ and McNulty NJ (ed.) Oxford American Handbook of Radiology. 2. Papanicolas et al. HealthCare Spending in the United States and Other HighIncome Countries. JAMA 2018;319(10):1024-1039. doi:10.1001/jama.2018.1150 3. ACR Appropriateness Criteria. https://www.acr.org/Clinical-Resources/ACRAppropriateness-Criteria INTRODUCTION TO IMAGING APPROPRIATENESS Jeanne G. Hill Fall 2023 OBJECTIVES The student will be able to: Utilize ACR Appropriateness Criteria to order the most appropriate imaging tests for common clinical scenarios OBJECTIVES The student will be able to:  Describe the potential consequences of inappropriate imaging From: Health Care Spending in the United States and Other High-Income Countries JAMA. 2018;319(10):1024-1039. doi:10.1001/jama.2018.1150 Figure Legend: Health Spending as a Percentage of Gross Domestic Product Date of download: 8/13/2018 Copyright 2018 American Medical Association. All Rights Reserved. KFF analysis of OECD Health Statistics https://www.healthsystemtracker.org/brief/whatdrives-health-spending-in-the-u-s-compared-toother-countries/ KFF Analysis of OECD Health Statistics https://www.healthsystemtracker.org/brief/what-drives-health-spending-in-the-u-scompared-to-other-countries/ DIAGNOSTIC IMAGING • Comprises ~ 10% of US Healthcare expenditures Jackson, Whitney. Imaging Utilization Trends and Reimbursement . Diagnostic Imaging. 7.2014 IMAGING UTILIZATION • US performed the second highest number of MRI scans 118 MRIs/1000 people - mean 82/1000 • US performed the highest number of CT scans 245 CTs /1000 people - mean of 151/1000 From: Health Care Spending in the United States and Other High-Income Countries JAMA. 2018;319(10):1024-1039. doi:10.1001/jama.2018.1150 FACTORS DRIVING IMAGING UTILIZATION • Aging population • ACA – larger insured population • Defensive Medicine • Patient Sophistication FACTORS DRIVING IMAGING UTILIZATION • Added Clinical Pressure • Lack of knowledge of Imaging Guidelines • Self-Referral - (59.7%) of all Imaging FACTORS MITIGATING IMAGING UTILIZATION • Increased Cost Sharing - patients have to pay for more of healthcare costs • Pre-Authorization – Radiology Business Managers SOCIETAL RESPONSIBILITY • Wise and cost-effective management of limited imaging resources SOCIETAL RESPONSIBILITY • Commitment to working with other radiologists, other physicians, hospitals, and payers to develop guidelines for cost-effective care. Minnesota Pilot Data: Use of Imaging Clinical Decision Support PROTECTING ACCESS TO MEDICARE ACT (2014) • Promote the use of Appropriate Use Criteria (AUC) for imaging services • January 1, 2017—Medicare will no longer pay claims for advanced imaging services unless the ordering physician has consulted with AUC before making the order. PROTECTING ACCESS TO MEDICARE ACT (2014) • January 1, 2020—Ordering professionals that CMS has identified as “outliers” with low rates of AUC adherence relative to their peers, will be required to obtain prior authorization from CMS before advanced imaging orders can be furnished. ACR APPROPRIATENESS CRITERIA • The ACR Appropriateness Criteria® (AC) are evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for a specific clinical condition. PATIENT #1 • A 27 yo male presents to the emergency room complaining of abdominal pain which started 10 hours ago around his belly button and within the last 3-4 hours has moved to the right lower quadrant. ACR APPROPRIATENESS • Narrative Review of Literature CT OF APPENDICITIS MR OF APPENDICITIS IN PREGNANT FEMALE Published in: "MR Imaging Evaluation of Abdominal Pain during Pregnancy: Appendicitis and Other Nonobstetric Causes“ Spalluto et al.RadioGraphics Vol. 32, No. 2: 317-334 Copyright RSNA, 2012 ACUTE APPENDICITIS • 13 yo female with Type 1 Diabetes with 5 days of abdominal pain most severe on the right side • US – couldn’t identify appendix but concerned for inflammation • CT – for evaluation RUPTURED APPENDICITIS IMAGING OF APPENDICITIS: SUMMARY • CT • US • MRI IMAGING OF APPENDICITIS: CT • ++ CT of the Abdomen and Pelvis has great sensitivity and specificity • + Available • + Fast • + Reproducible • - Radiation Exposure IMAGING OF APPENDICITIS: US • + Good sensitivity and specificity for appendicitis, but < CT • + Available • + Inexpensive • + Painless • + Fast • + No Radiation exposure IMAGING OF APPENDICITIS: US • + /- Good sensitivity and specificity for appendicitis, but < CT • - Operator Dependence • - Sensitivity of test decreases with patient size IMAGING OF APPENDICITIS: MRI • + MRI of Abdomen and Pelvis has good sensitivity and specificity • + Reproducible • + No radiation exposure • -Takes time, sensitive to motion, anesthesia? • - Limited resource/availability • - Limited interpreter skill ACR APPROPRIATENESS PATIENT # 2 • A 43 yo female presents to her primary care physician complaining of headaches. Upon questioning, she has had headaches off and on for years. Her history and physical exam are otherwise normal. • In patients with unspecified headache, only 0.4-0.5% have a treatable lesion • Don’t Do Imaging for Uncomplicated Headache! • Several weeks later, she returns with increasing severity of headaches and associated numbness and weakness in her right face. • Concern for Stroke or Tumor – Brain MRI is most sensitive for this PATIENT #3 • A mother brings her 5 year old child to the pediatrician because he has been vomiting the last 3 days. Upon further questioning, the mother reports the child has had recent headaches and several falls at preschool. Revised 2017 PATIENT # 4 • A 32 yo male presents to the ER complaining of the worst headache of his life that started acutely 45 minutes ago. IMAGING OF HEADACHE SUBARACHNOID HEMORRHAGE • In multiple series, as many as 47% of patients with a “thunderclap” headache had a subarachnoid hemorrhage • CT is the imaging modality of choice to identify intracranial hemorrhage. PATIENT # 5 • A 15 year old girl presents to the urgent care center after she twisted her ankle playing basketball. On physical examination, her ankle is swollen, tender to the touch, and she can’t bear any weight on it. ACUTE ANKLE TRAUMA OTTAWA ANKLE RULES • Inability to bear weight immediately after injury • Point tenderness • Inability to ambulate for 4 steps in the ER RIGHT ANKLE NORMAL LEFT ANKLE SUMMARY ACUTE ANKLE INJURY ACR APPROPRIATENESS CRITERIA • Employing the ACR Appropriateness Criteria® helps providers enhance quality of care and contribute to the most efficacious use of imaging. POTENTIAL BENEFITS • Decrease in potential imaging related harm • Radiation Injury • Contrast Injury • Contrast allergy • Complications of strong magnetic field POTENTIAL BENEFITS • Decrease in repeat exams / delay in diagnosis • Decrease in denial of claims/ inappropriate patient billing POTENTIAL BENEFITS • More appropriate allocation of resources POTENTIAL BENEFITS • Appropriate imaging and treatment of the patient • While minimizing costs and risks REFERENCES Khan R et al. (2013) Radiology Essentials in Lewis PJ and McNulty NJ (ed.) Oxford American Handbook of Radiology. Papanicolas et al. HealthCare Spending in the United States and Other High-Income Countries. JAMA 2018;319(10):1024-1039. doi:10.1001/jama.2018.1150 REFERENCES • ACR Appropriateness Criteria https://www.acr.org/ClinicalResources/ACR-AppropriatenessCriteria