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| Ed Clark, MD, President of the University of Utah Medical Group (left) and Yoshimi Anzai, MD, Professor of Radiology and Chair of the Value-Driven Imaging Core Committee. |
By Michael Mozdy
It’s a common scene in emergency departments across the country. A 67-year-old man has arrived with chest pain, shortness of breath, anxiety, and lightheadedness. There are a number of life-threatening issues that a doctor must consider: heart attack, heart muscle inflammation, blood clot that has traveled to the lung, esophageal disorders, and many more. Each of these has a number of tests, scans, and workups to help diagnose the issue, some tests more sensitive, more accurate, more expensive, and perhaps riskier than others.
After an initial exam, the physician suspects a blood clot in the lungs, called a pulmonary embolism. Over the past 20 years, a radiologic study called CT pulmonary angiography (CTPA) has emerged as the “first line imaging study” for suspected pulmonary embolism. CTPA is minimally invasive and very quick, provides spectacular images of the arteries in the lungs, and can be very effective at showing blood clots in the major arteries. If you were that 67-year-old-man, you might jump at the chance to have a CTPA as soon as possible.
But like all of medicine, our understanding of the risks and benefits of imaging studies continues to evolve. CTPA uses a contrast agent and exposes patients to a fair amount of radiation. For those over the age of 50, the contrast agent has very real risks of kidney damage. A simple, much less expensive blood test that checks for clotting problems, called a d-dimer, has been shown to help exclude pulmonary embolism when the chance of having one is low. If this test detects problems, the patient should get a CTPA to check for a pulmonary embolism. If the d-dimer is negative, however, patients can avoid getting a CTPA and the risks of kidney damage and radiation.1
Using a d-dimer isn’t for everyone, though: for those at high risk for a pulmonary embolism, it’s better to skip the d-dimer and go straight to the CTPA. This is why our imaging experts recommend first stratifying patients as high risk or low risk based on their clinical history and physical exam. When we take the time to understand our patients and the latest advancements in tests and scans, we are best serving them. What’s more, our health care system – from patient to hospital to insurance company – might also avoid the unnecessary cost of a CT study in this case.
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| Busy care providers in the ER must make many imaging and diagnostic decisions. Stock image. |
Because of rapid advancements in medicine, there are countless examples where imaging studies and other tests can be better utilized for the patient’s and the system’s benefit. Sometimes a more expensive test might be recommended because it offers a safer and more accurate diagnosis. A significant question is: who defines what tests are recommended and when?
This question is at the heart of a multi-year effort spearheaded by Yoshimi Anzai, MD, Professor of Radiology, Associate Chief Medical Quality Officer, and Chair of the Value-Driven Imaging Core Committee. Thanks to Anzai and the Value-Driven Imaging team, University of Utah Health has put our experienced physicians in the driver’s seat and we can now be the ones who define the appropriate imaging pathways for our patients.
We are one of just 17 entities nationwide to be qualified as a Provider-Led Entity (PLE) by the Centers for Medicare and Medicaid Services.
“This is a very important distinction for University of Utah Health,” commends Ed Clark, MD, Associate Vice President for Clinical Affairs and President of the University of Utah Medical Group, and Chair of the Department of Pediatrics. “Imaging is at the heart of so many diagnoses, and being a Provider-Led Entity rightly places the development of appropriate guidelines in the hands of expert physicians.”
The use of imaging studies is an important issue facing health care: studies show that they can account for 10% of total health care costs. Some studies report that up to 30% of imaging tests are used unnecessarily. Anzai and the Value-Driven Imaging Committee have set out to ensure that they are used as appropriately as possible here at University of Utah Health.
Defining Imaging Pathways that Fit our System and Patients
“Our priority is to provide guidance so our clinical teams can select the right test for the right patient at the right time,” emphasizes Anzai, reiterating a mantra that drives much of our work around high-value care for patients. “The PLE qualification allows us to be a leader, not a follower, of the development of ‘appropriate use criteria’ based on the most current evidence available.”
Anzai has built a diverse Value-Driven Imaging team to drive a rigorous development process for appropriate use criteria, also called AUC. The committee includes physicians with both imaging and clinical expertise, health services researchers, and experts at the Eccles Health Sciences Library who provide an independent evidentiary review process for each AUC in development.
Because of the costs related to advanced imaging tests, insurances require pre-authorization for outpatient advanced imaging tests. Yet the pre-authorization process makes the health system inefficient from diagnosis to treatment. More importantly, it is difficult for patients to navigate.
Keeping health care costs low is important, but physicians have to decide what diagnostic test is most appropriate for each patient. A PLE designation allows our system to put physicians in the driver’s seat for making these decisions and avoiding inefficient pre-authorizations when possible.
What’s more, not all systems are equal – a small, rural hospital, for instance, does not have the same resources and imaging equipment that exist at a large academic medical center like University of Utah Health. This makes it impossible to define a “one size fits all” pathway for providers to follow from hospital to hospital and state to state.
The federal Centers for Medicare and Medicaid Services are the biggest payers for health care costs in our country, and what they decide to cover generally sets the bar for what other insurance companies cover. With our PLE qualification, “we can help inform CMS on appropriate imaging guidelines,” explains Anzai. “It would be ideal to streamline patient care by removing pre-authorization for studies we’ve defined as highly appropriate.”
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| Yoshimi Anzai, MD. |
Because of our expertise in so many clinical areas, we treat very complex patients at the University of Utah who need advanced treatments with high risk of adverse effects. There is not as much data for which imaging studies should guide these complex cases, and our physicians are the best ones to help develop these imaging recommendations. Our PLE qualification gives us the latitude to define imaging pathways that maximize the technological sophistication we can provide, and we can then work with the CMS to get these imaging studies covered for patients needing advanced treatments.
There are other physician-led efforts to help guide the appropriate use of imaging studies. Notably, the American College of Radiology, also a qualified PLE, has spent over 10 years developing the largest repository of AUC for imaging studies. Anzai sees the benefit of collaborating with them and other qualified PLEs to further define and improve the current AUC together.
Anzai argues for a shift in thinking when developing AUC. “The problem with many existing imaging guidelines is that they’re based on a suspected disease, let’s say, suspect pulmonary embolism or suspect Alzheimer’s Disease. But the recommended studies are the ones confirming the diagnosis.” Instead, she and the Value Imaging team aim to develop guidelines based on clinical symptoms and medical history, such as low back pain in patients with a history of cancer. This way, clinicians aren’t as tempted to jump to a conclusion about a diagnosis and instead follow what the patient presents to them. “Diagnosis is an entry point for all patient care,” asserts Anzai, “and we feel that AUC based on symptoms or clinical history are very useful for primary care providers.”
The Value-Driven Imaging and AUC Committees evaluate AUC for many diagnoses and clinical conditions. Then they face the challenge of integrating their AUC with clinical decision support tools so that front-line physicians have quick access to the best recommendations on what studies to order. They’re also looking ahead to examine how AUC and clinical decision support tools may impact overall imaging use, efficiency, and the cost of patient care.
Their workload may be large, but Anzai is excited at the prospect given the new PLE qualification. “It’s like a certificate of excellence,” she glows, “now we’re qualified to develop guidelines, and we’re ready to get to work.”