Pamela T. Johnson, MD, FACR, vice president of care transformation for the Johns Hopkins Health System, vice chair of Quality & Safety in Radiology and professor of Radiology & Oncology at Johns Hopkins Medicine, and Founder of the High Value Practice Academic Alliance, and Norman J. Beauchamp, Jr., MD, MHS, executive vice president for Health Sciences at Michigan State University (MSU), and past dean of the MSU College of Human Medicine, contributed this post.
According to the Organization for Economic Cooperation and Development 2017 Health Statistics, the United States spends more on healthcare than any other country. It does so despite having one of the younger populations and a relatively low consumption of healthcare services, as reported in the book Priced Out: The Economic and Ethical Costs of American Health Care. A recent article in the Journal of the American Medical Association estimates 2019 healthcare expenditure at $3.8 trillion and wasteful expenditure as high as $935 billion.
If we can reduce the magnitude of the dollars lost in waste, we can help safeguard healthcare affordability and ensure more resources to spend on social determinants of health such as education, job creation and neighborhood environment. The question many would ask is, “When will they do something about this?”
As medical providers, we are accountable for three of the six categories of waste: failure of care delivery, failure of care coordination and overuse or low-value care. Recognizing a responsibility to refine care delivery, clinicians across the country are implementing performance improvement initiatives to increase efficiency, effectiveness and affordability of medical care.
Imaging has become a cornerstone for diagnosis and management decision making, but utilization does not always adhere to appropriate use criteria, despite an expansive library championed by the American College of Radiology® (ACR®) – including the ACR Appropriateness Criteria® evidence-based guidelines. Overuse adds unwarranted risk and cost for the patient. Unnecessary imaging can be reduced by bolstering adherence to appropriate use criteria through education, clinical decision support and provider feedback reports.
An equally important goal in imaging stewardship efforts is to increase use of radiology exams that can reduce more costly elements of care, like hospitalizations, surgery and chemotherapy. Examples include evidence-based breast and lung cancer screening, diagnosis of coronary artery disease in stable chest pain with coronary CTA and surveillance of abdominal aortic aneurysms. Despite evidence that imaging improves outcomes for these clinical conditions, many patients are not benefitting from the radiology due to lack of adherence to best practice guidelines and disparities in care delivery.
Value-based care transformation prioritizes quality, safety and outcomes while reducing cost of care. Diagnostic radiology effectiveness assessments have been limited to process measures like report turnaround time, and our existing peer review platforms do not effectively determine how interpretations affect management decision making. We need more robust clinical measures for imaging quality, which reflect how our interpretations affect patient outcomes. Efforts to develop quantitative, scalable measures are evolving and, as a profession, it is incumbent on us to once again demonstrate accountability.
Radiologists’ potential to lead care transformation goes beyond improving imaging appropriateness and developing imaging-related outcome measures. With knowledge of all aspects of medicine and surgery required for board certification and an understanding of the importance of diagnostic and management efficiency and effectiveness, radiologists are uniquely poised to lead all of care transformation. This begins by serving on the teams directing care transformation in your medical center, and if there are no dedicated committees, creating one by inviting faculty from medicine, surgery, emergency medicine, pediatrics, etc., to partner on imaging, lab and medication stewardship as a start. Value-based performance improvement requires multispecialty collaboration to be successful.
Our field has a unique opportunity to substantively impact our society in a time of great need by refining care. We chose this field because we could have a scalable impact on the care of a great number of patients every day. Our specialty is defined by being interprofessional, collaborative, innovative, patient-centered and ever-evolving. Let’s apply our aptitudes and values to the imperative of care transformation.
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