Bruce E. Lehnert, MD a, Robert L. Bree, MD, MHSA a,b

Transcription

1 Analysis of Appropriateness of Outpatient CT and MRI Referred From Primary Care Clinics at an Academic Medical Center: How Critical Is the Need for Improved Decision Support? Bruce E. Lehnert, MD a, Robert L. Bree, MD, MHSA a,b Purpose: The aim of this study was to retrospectively analyze a large group of CT and MRI examinations for appropriateness using evidence-based guidelines. Methods: The authors reviewed medical records from 459 elective outpatient CT and MR examinations from primary care physicians. Evidence-based appropriateness criteria from a 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 and clinic notes and laboratory results preceding the date of the imaging study were examined to simulate a real-time consultation with the referring provider. The radiology reports and subsequent clinic visits were analyzed for outcomes. Results: Of the 459 examinations reviewed, 284 (62%) were CT and 175 (38%) were MRI. Three hundred forty-one (74%) were considered appropriate, and 118 (26%) were not considered appropriate. Examples of inappropriate examinations included brain CT for chronic headache, lumbar spine MR for acute back pain, knee or shoulder MRI in patients with osteoarthritis, and CT for hematuria during a urinary tract infection. Fifty-eight percent of the appropriate studies had positive results and affected subsequent management, whereas only 24% of inappropriate studies had positive results and affected management. Conclusion: A high percentage of examinations not meeting appropriateness criteria and subsequently yielding negative results suggests a need for tools to help primary care physicians improve the quality of their imaging decision requests. 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. Key Words: Appropriateness criteria, utilization management, evidence-based guidelines, clinical decision support, radiology benefit management, primary care J Am Coll Radiol 2010;7: Copyright 2010 American College of Radiology INTRODUCTION Health care spending in the United States continues to grow dramatically, significantly outpacing the rate of growth of the gross national product. Advanced imaging This study was supported by University of Washington/Harborview Medical Center, Radiology Health Services Research, Seed Grant Program. a Department of Radiology, University of Washington, Harborview Medical Center, Seattle, Washington. b HealthHelp, Inc, Houston, Texas. Corresponding author and reprints: Robert L. Bree, MD, University of Washington, Harborview Medical Center, Department of Radiology, 325 Ninth Avenue, Box , Seattle, WA ; breer@u. washington.edu. 192 services spending by Medicare, including CT, MRI, nuclear medicine, and PET, increased from $3.6 billion to $7.6 billion from 2000 through This represents a 17% average increase per year [1]. National expenditures on all medical imaging are now approaching $100 billion [2]. Even within a group-model health maintenance organization, the rise in cross-sectional imaging utilization in a full population including Medicare nearly doubled [3]. The rapid rise in imaging spending prompted Congress and CMS to request the US Government Accountability Office to review imaging services in Medicare. The resulting 6-year analysis demonstrated that advanced imaging expenditures, including CT and MRI, 2010 American College of Radiology /10/$36.00 DOI /j.jacr

2 Lehnert, Bree/Appropriateness of Outpatient CT and MRI 193 increased faster than other imaging modalities, with CT spending rising from $975 million in 2000 to $2.17 billion in 2006 and MRI spending rising from $1 billion to $2.98 billion over the same time period [4]. Radiologists, hospitals, health plans, and policymakers have struggled with ways to improve the rate of appropriate utilization of imaging studies, particularly CT, MRI, and PET. The ACR began developing its Appropriateness Criteria more than 15 years ago. These have not been well accepted by clinicians [2]. Inpatient consultation services have been attempted with little success [5]. Payershaveadoptedseveral methods to control utilization, most commonly radiology benefits management (RBM) programs [1]. Clinical decision support systems have been introduced as an alternative to RBM programs [6]. Most recently, the Obama administration has suggested using RBM programs in the Medicare program. The Government Accountability Office study also demonstrated a trend toward increased in-office imaging, with imaging spending per Medicare beneficiary varying nearly 8-fold across geographic regions. The magnitude of variability is too large to be explained by regional variations in patient health and is likely due to differences in physician practice methods [4].Fisheret al [7] demonstrated that regional variability in Medicare spending did not correlate well with improved outcomes. Causes of inappropriate utilization include medical liability fears, economically motivated in-office self-referral, patient demand, regional differences in practice style, and physician experience and training in the appropriate use of newer imaging modalities. Primary care physicians are particularly challenged with a wide variety of outpatient clinical problems. Clinical decision support systems are particularly well suited to helping primary care physicians navigate through evidence-based guidelines. We performed this study to identify potential targets for imaging clinical decision support within a university hospital primary care setting. We retrospectively analyzed a large group of CT and MRI examinations for appropriateness and outcomes using evidence-based appropriateness criteria. METHODS Institutional review board approval was obtained for this HIPAA-compliant study. We retrospectively reviewed the radiology reports and medical records from 459 consecutive nonurgent outpatient CT and MR examinations requested from adult primary care clinics at a large urban university hospital over a 6-month period in All studies performed in that time frame were reviewed. Proprietary evidence-based appropriateness criteria used by a national RBM program (HealthHelp, Inc, Houston, Texas) were used to determine if each examination would have met criteria for approval on the basis of clinical history. These criteria are updated quarterly, maintained by a physician advisory committee, and monitored for consistency with the ACR Appropriateness Criteria and other evidence-based guidelines. One of the authors (R.L.B.) is a medical director for the company and was given permission to use the guidelines. The ACR Appropriateness Criteria were not used because many clinical problems are not addressed by these criteria. The radiology reports associated with the included outpatient examinations were reviewed only for the clinical history or examination indication available at the time of interpretation. No attention was given to the report findings, impression, or diagnosis. In 90% of cases, the radiology reports did not provide adequate information for the assessment of examination appropriateness. Consequently, the medical records were reviewed for additional clinical history and context. Real-time radiologist consultation with the referring clinical provider or a direct application of evidence-based appropriateness criteria by the clinician (such as with a decision support program) was simulated by examining only the clinic notes, laboratory results, and radiology reports available preceding the request date of the CT or MR study in question. The studies were rated as either appropriate or not appropriate on the basis of the information available. Because the clinics are part of an electronic medical record system, we had access to complete clinic notes from the visits preceding the imaging study dates. In an actual RBM model, there might be 3 levels of review, including peer-to-peer physician conversation. Because of the robustness of the clinical information available, we felt that the studies designated as inappropriate would not have been found to be appropriate, although in some cases, the examinations might have been changed to more appropriate ones (eg, head CT to head MRI). We did not track the percentage of studies for which changes would have been recommended. The application of the appropriateness criteria was performed by a senior radiology resident, and questionable cases were reviewed with an attending academic radiologist. After the initial analysis, and to test the validity of the analysis, we reviewed the radiology report and medical record subsequent to the examination analyzed. Using the radiology and medical record information, the studies were placed in 4 categories: negative results, positive results with findings unrelated to the presenting complaint (incidental findings), positive results with findings related to the clinical

3 194 Journal of the American College of Radiology/Vol. 7 No. 3 March 2010 problem that affected clinical management, and positive results with findings related to the clinical problem that did not affect clinical management. This analysis was done by the attending academic radiologist to limit bias from the initial appropriateness analysis. Two statistical approaches were used to evaluate differences in the number and pattern of imaging examinations classified as appropriate compared with those classified as inappropriate. First, an overall 2 test was used to assess differences in the number of examinations for these classifications (appropriate vs inappropriate). Second, a logistic regression approach estimated the odds ratio associated with ordering an examination that resulted in a negative finding compared with a positive finding, conditional on an examination s being classified as appropriate vs inappropriate. A 2-tailed 95% confidence interval was calculated to provide a range of expected variability in the odds of having a negative finding given that an examination was classified as inappropriate. RESULTS Four hundred fifty-nine outpatient examinations performed from June 2007 to November 2007 were reviewed. Two hundred eighty-four studies (62%) were CT, and 175 (38%) were MRI. Overall, 341 (74%) examinations were considered appropriate. One hundred eighteen (26%) were not considered appropriate on the basis of the information available from the medical record (Table 1). Table 2 illustrates a breakdown of the types of examinations and the percentage rated as inappropriate. The highest percentage of inappropriate examinations (62%) was found for CT examinations of the brain without contrast. These examinations were primarily done for nonacute symptoms with absence of neurologic findings. The majority of these likely would not have required any imaging, but some might have had MRI. We did not analyze how many would have been changed to MRI. Other high percentages included CT maxillofacial (36%), CT spine (53%), MR spine (35%), and MR shoulder (37%). Examples of inappropriate examinations with criteria are illustrated in Table 3. Major reasons for inappropriate studies included head CT for chronic headache, lumbar spine MR for acute back pain without conservative therapy, knee or shoulder MRI in patients with no histories of trauma and documented osteoarthritis on plain-film Table 1. Results of all CT and MR reviews n % Appropriate Inappropriate Table 2. Examination-specific inappropriate rates Number Examination Inappropriate/ Total % Inappropriate CT head/brain 28/45 62 CT maxillofacial 5/14 36 CT spine 9/17 53 MR spine 19/55 35 MR shoulder 7/19 37 CT chest 8/67 12 CT chest/ 3/10 30 abdomen/pelvis CT abdomen/pelvis 18/ Miscellaneous 6/29 21 CT and CT angiography MR brain and 5/40 13 orbits MR pelvis 1/5 20 MR knee 5/36 14 MR abdomen 1/14 7 Miscellaneous MR and MR angiography 3/6 50 radiography, screening CT of the abdomen and chest, and CT for hematuria during a urinary tract infection. Outcomes of the examinations using report results and medical records reviews are illustrated in Table 4.In the appropriate study group, 68 (20%) had negative findings, while 199 (58%) had positive findings and affected management. This is compared with the inappropriate group, in which 55 (47%) had negative results, and only 15 (13%) had positive findings and affected management. For the inappropriate group, 20 studies (17%) had positive findings but did not affect management. This included patients with many comorbidities studied for back pain or headache without attempts at conservative therapy or watchful waiting. In many of these patients, at the next visit, the results of the imaging studies were not discussed or the symptoms had resolved. The overall 2 test for Table 4 indicated that there was a statistically significant difference in the two columns of classification (appropriate vs inappropriate, P.0001). The logistic regression estimated an odds ratio of 3.5 (95% confidence interval, ; P.0001), interpreted as the odds of having an examination being classified as having negative vs positive results, for the inappropriate examination group compared with the appropriate examination group. This indicates odds 3 times higher of having negative results for those imaging examinations classified as inappropriate, compared with those identified as appropriate. The lower bound of the

4 Lehnert, Bree/Appropriateness of Outpatient CT and MRI 195 Table 3. Examples of inappropriate examination indications Examination Indications CT brain Chronic headache without associated neurologic findings Migraine variant Family history of brain tumor CT maxillofacial Simple sinusitis CT spine Back pain MR spine Low back pain with or without radiculopathy prior to 6 weeks of conservative therapy MR shoulder Shoulder pain with no conservative therapy Osteoarthritis in older patients CT chest Very small lung nodules Screening for cancer Follow-up proven benign lesion CT abdomen/pelvis One episode of microscopic hematuria during urinary tract infection Follow-up of benign lesions MR knee Osteoarthritis in older patients confidence interval (2.23) indicates high confidence that the odds of a negative result from an examination classified as inappropriate are expected to be at least double, in comparison with scans considered appropriate. DISCUSSION Table 4. Outcomes of imaging for appropriate and inappropriate examinations Outcome Appropriate (n 341) Inappropriate (n 118) Negative 68 (20%) 55 (47%) Positive, unrelated 66 (19%) 28 (24%) Positive, affected 199 (58%) 15 (13%) management Positive, did not affect management 8 (2%) 20 (17%) We believe this study to be one of the only examples of a rigorous scientific analysis of individual examination requests being systematically subjected to appropriateness guidelines. Taragin et al [8] administered 12 multiplechoice questions in an examination format to medical residents and found that senior residents in internal medicine at a large university medical center would have ordered the wrong imaging test one-third of the time. Even though Martin et al [9] showed that 76% of imaging requests from a general internal medicine clinic were addressed by the ACR Appropriateness Criteria, Bautista et al [2] showed a very low utilization rate of the ACR Appropriateness Criteria among attending physicians and house officers at another university medical center. Others have shown in meta-analyses that providing explicit guidelines to health care providers improves clinical practice and outcomes [10]. Our study shows that CT and MR examinations ordered in the outpatient primary care setting are frequently not appropriate on the basis of the application of a national RBM company s evidence-based imaging guidelines. The most frequent inappropriate uses of imaging services included head CT for chronic headache, lumbar spine MR for acute back pain without radiculopathy, and knee or shoulder MRI in patients with no histories of trauma and documented osteoarthritis on plain-film radiography. These results match with a recent national analysis of utilization trends among Medicare beneficiaries showing that almost 30% of patients underwent imaging studies within the first 28 days of an episode of acute low back pain [11]. Appropriateness guidelines from many specialties, including those of the ACR, do not recommend any imaging before 6 weeks in an episode of acute back pain without red flags suggesting serious disease [12]. Our results demonstrate an opportunity to provide tools to improve evidence-based utilization of medical imaging by primary care providers. Payment policy change and preauthorization programs have demonstrated success in controlling costs; however, the inappropriate utilization demonstrated here represents a potential target for health care provider education as a utilization and cost control measure [13]. Radiology benefits management companies contract with many health plans to decrease inappropriate imaging utilization through precertification implementation. The Government Accountability Office examined a sample of 17 private health plans that used precertification to control costs (16 plans used RBM companies). Officials from the plans reported decreases in utilization after the imple-

5 196 Journal of the American College of Radiology/Vol. 7 No. 3 March 2010 mentation of a preauthorization program [4]. The guidelines used in our study are from a national RBM company (HealthHelp Inc). The population of physicians in this study was limited to primary care. In view of a lower inappropriate examination rate from RBM companies working with health plans covering all specialties, our conclusions are valid only for the primary care population. Primary care physicians can often see 20 to 30 patients per day in 15- minute sessions. It is difficult to keep abreast of all the possible imaging guidelines for all of medicine. The average primary care physician requests 5 to 10 advanced imaging examinations per month. Clinical decision support, particularly when embedded in order entry systems with an electronic medical record, can greatly enhance a clinician s ability to choose the correct examination or to choose no examination. The RBM program model fails in the real-time education of physicians because requests are most often processed in a back office, and physicians get little feedback [1,6]. Our results also demonstrate the validity of evidencebased guidelines as used by HealthHelp and other RBM companies. The cases that were categorized as inappropriate had a statistically significantly higher negativity rate than those categorized as appropriate. Prior studies evaluating the ability of automated analytical tools for report assessments indicate the strong belief that groups of examinations with high negativity rates may be inappropriate, or groups of physicians having a high rate of examinations with negative results are ordering inappropriate examinations [14,15]. Computer-based decision support programs have been tested at Massachusetts General Hospital and others, providing recommendations to referring physicians when studies are requested. Despite the ability of ordering physicians to override program recommendations, this technique resulted in an attenuation of the rate of imaging utilization increase [6].Our study was actually stimulated by our desire to test a clinical decision support system within the clinics evaluated. It was their desire to see a baseline data set prior to the study being performed. Radiation exposure associated with increased imaging has become an additional area of concern. Brenner and Hall [16], in a recent review, extrapolated previously published cancer rates due to CT imaging to account for current imaging trends to suggest that 1.5% to 2% of all cancers in the United States may be attributed to CT ionizing radiation. Others have shown similar but lesser estimates from excessive radiation [17]. This represents an additional argument for reducing unnecessary or inappropriate imaging utilization. One limitation of this study was the simulation of a real-time preauthorization transaction using the retrospective approach. Although we lacked the ability to have a discussion with referring physicians, in almost all cases, we found adequate supporting information in the medical record to ensure that the information served as an adequate surrogate for the physician-to-physician discussion inherent in the RBM process, even when coupled with clinical decision support. In summary, 26% of elective outpatient imaging examinations from an academic medical center did not meet appropriateness criteria that were analyzed retrospectively using medical record information. Additionally, there was a high negativity rate among these inappropriate examinations. Logistic regression estimates suggested odds 3.5 times higher (95% confidence interval, ) that a negative finding will be associated with an inappropriate vs an appropriate examination. 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 health care 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. ACKNOWLEDGMENT The authors would like to thank Brian Bresnahan, PhD, for assistance with statistical analysis. REFERENCES 1. Iglehart JK. Health insurers and medical-imaging policy a work in progress. N Engl J Med 2009;360: Bautista AB, Burgos A, Nickel BJ, Yoon JJ, Tilara AA, Amorosa JK. Do clinicians use the American College of Radiology Appropriateness Criteria in the management of their patients? AJR Am J Roentgenol 2009;192: Smith-Bindman R, Miglioretti DL, Larson EB. 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