Value-Based Radiology — Publications

Translation from Läkartidningen, Jörgen Nordenström & Peter Aspelin, February 2017.

Traditionally, health care has evolved through medical innovation and research, but the disruption of health care now underway is governed primarily by the forces and innovations beyond medicine. Today health care develops from information and communications technology (ICT) that creates new opportunities to measure, analyze and communicate. Health care now takes the path that has for so long been the benchmark in banking, retail and transportation. ICT and big data analytics has the potential to contribute to creating a health care that adapts to patient health care needs and preferences, improves coordination among providers, contributes to the quality development of a safer and more equitable system, provides greater accessibility, and drives evidence-based, efficient care.

This development takes place in all areas of health care; but here we will focus on the opportunities and challenges in radiology. Technical development in recent decades has witnessed explosive growth with the development of technologies such as CT, MRI, PET, MR-PET, PET-CT and ultrasound. This has not only changed the we way we make diagnoses but has also enabled a far more advanced interventional radiology. Radiology today is beneficial for diagnosis but also for treatment, forecasting, and understanding disease at the molecular level.

The introduction of digital radiology has led to improved processes. There are reductions in staff and better communication of both radiographs and radiology reports. In this environment, we are not only able to diagnose diseases that were previously difficult to diagnose but also able to treat patients with minimally invasive interventions. Such improvements generate increased costs which are in part driven by the utilization of various examination modalities for single, specific conditions. Variations across units and regions demonstrate the reality of a problematic notion that more expensive investigations are optimal.

The utilization of various examination modalities makes it difficult for the referring clinician to know with certainty which test is optimal for a specific task, leading to the use of several examinations instead of directly choosing the single most reliable test. This year, the annual Swedish Radiology Week featured Value-Based Radiology as its main theme. The concept has been developed in order to move from a dialog solely considering accomplishments and performance in radiological technology to one including the benefits that radiology creates for the patient.

The concept of Value-Based Radiology has the aim to move the focus from radiological technique and efficiency to patient benefit, and consequentially, from production to value.

Reasoning for previous focus on production rather than on patient value has been the remuneration system which most commonly is based on the number of examinations, the volume, for a specific type of investigation. Such remuneration can be described as counterproductive as health care should be producing as little as possible, but with the highest quality outcomes. A compensation system based on patient benefit is preferable.

Radiological production volume is simple to measure. But a more difficult task, one of critical importance, is to clarify the benefits generated by each examination modalities utilized. Extraneous investigative examinations are driven by both patient related and provider related factors. For providers, multiple examination methods may deliver a more complete observation indicating further that confidence is related to expensive, sophisticated methods that provide the most information possible. Anxieties related to potential mistakes and consequential reporting for incorrect, incomplete investigations may be another source. Patient related factors may include a desire to receive the best treatment without an awareness of associated costs.

There are several initiatives that aim to improve the indications within radiological studies. The Choosing Wisely Initiative (2) identifies studies related to specific diseases across various specialties that have a low or questionable value, refuting many common patient and physician led beliefs. A list on the organization's website includes over 400 measures that are of questionable value – about one third represent radiology. Examples include CT scan of the hip in chronic pelvic pain, CT without intravenous contrast in chronic headaches, CT scan of the lungs for suspected pulmonary embolism with a negative D-dimer, and urography in cases of suspected kidney tumor in patients with blood in their urine.

A more systematic initiative to achieve greater value and better utilization of resources is the development of specialty criteria, or Appropriate Use Criteria (AUC) (3). Various measures and treatments are scored based on treatment recommendations and best practices classified into three groups: ‘appropriate’, ‘may be appropriate’ and ‘rarely appropriate care’.

Measures such as Appropriate Use Criteria have the potential to streamline indications of many measures and to reduce regional variations in diagnostic imaging. Although an adaptation for Swedish practice would be necessary. In the US, AUC has been used in some regions as a basis for reimbursement wherein the caregiver usually must justify procedures conducted within the category of ‘rarely appropriate’ before receiving payment. We do not seek such use in Sweden, but the principles underpinning AUC may be worth our interest. The starting point for Value-Based Radiology should follow evidence-based care programs, utilizing structured examinations and multidisciplinary collaboration whereby the appropriate methodology to a particle question is determined.

Information and communications technology will facilitate the use of artificial intelligence and provide better opportunities for quantified radiology reports. In the future it will also be possible to use structured, standardized reports as an integral part of care mapping.

A significant way to improve the quality and thus value of X-ray examination is to create better follow-up procedures. ICT can help to make comparisons between X-ray findings, surgical findings and pathology reports. Already IT-based systems compare primary and secondary radiology reports utilizing automatic feedback systems for identifying incorrect statements. Radiology will also lead forecasting with use of biomarkers.

Value-Based Radiology and value-based purchasing face many challenges – relevant methods of measurement must be developed (4). Key outcome indicators such as survival and other long-term dimensions are less suited to assess radiology value. Better outcome and process measures are correlated to improve patient value. Such indicators are those that: 1) are directly related to health (i.e. increased survival in lung or breast cancer screening), 2) measure reductions in health care costs (i.e. faster and more reliable diagnosis in acute appendicitis), and 3) measure hospital lengths of stays (faster diagnosis, time to initiate a treatment, evaluation of treatment efficacy, etc.). Other relevant measures include complication rates for interventional radiology, radiation doses, diagnostic yield from biopsies, etc.

Generally, the best strategy to assess radiology’s contribution to better patient value is one which ensures strategic adherence to evidence-based care and best practices, conducted in multidisciplinary teams. In this environment, unjustified variations in diagnostic imaging can be reduced and a better value can be created for patients.

References
1. Wiener DH. Achieving high-value imaging: challenges and opportunities. J Am Soc Echocardiogr 2014; 27: 1-7.
2. www.choosingwisely.org
3. http://www.acr.org/quality-safety/appropriateness-criteria
4. A Sarwar, G Boland, Monks A Kruskal JB. Metrics for radiologists in the era of value-based healthcare delivery. Radio Graphics 2015; 35: 866-878.