Pediatr Radiol (2014) 44 (Suppl 3):S404–S408 DOI 10.1007/s00247-014-3016-y

IMAGE GENTLY ALARA CT SUMMIT: HOW TO USE NEW CT TECHNOLOGIES FOR CHILDREN

Deciding why and when to use CT in children: a radiologist’s perspective Donald P. Frush

Received: 7 February 2014 / Revised: 16 March 2014 / Accepted: 25 April 2014 # Springer-Verlag Berlin Heidelberg 2014

Abstract Defining what is appropriate or inappropriate with respect to CT scanning is challenging. There are a variety of influences on scan utilization in children, some more widely recognized and acknowledged than others. It is important to understand the contribution of these elements as we move toward improved utilization. This must be through partnerships and shared efforts and accountability. These efforts include improved resources such as consensus appropriateness criteria and guidelines including decision rules and support. But there also need to be trench-based strategies on the part of practicing radiologists to model cooperative behavior rather than blame-centered behavior. Keywords Computed tomography . Pediatric . Appropriateness . Utilization . Radiation

Introduction The tenets of radiation protection are justification, optimization (the two most recognized by clinical radiologists), as well as dose limitation. The conversation that follows is really focused on the shared responsibility for the justification aspect of radiation protection in medical imaging, especially related to CT in children. Although we as radiologists do not order examinations, the responsibility for justification should be as relevant to Radiology as any other specialty. Because intertwined issues of radiation dose, potential risks and diagnostic benefits are center-stage topics, it is important to have an understanding of why we image patients; that is, there are a D. P. Frush (*) Departments of Radiology and Pediatrics, 1905 McGovern-Davison Children’s Health Center, Duke University Medical Center, Erwin Road, Durham, NC 27710, USA e-mail: [email protected]

number of influences on why we do what we do. Why even explore this? Because even given the uncertainties of radiation risk and medical imaging, there is unfortunately a very public and inexact extraction of elements of doing harm to children. Reports that approximately one-third of imaging is inappropriate [1–3], together with observations that about 10% of all imaging is performed in children [4], including a relatively large proportion of CT examinations [5], warrant this discussion. The implication (and from some, accusation) is that a substantial number of examinations are unwarranted and unduly cause harmful exposure to radiation. Moreover, as noted in a recent consensus article on imaging in the emergency setting [6], because one-third of all CT imaging occurs in the emergency setting, a discussion of this environment of imaging is especially relevant. There are two points to emphasize. First, how much inappropriate imaging is there? One of the most cited references for this was from the original ALARA Conference in April 2001, at which Dr. Tom Slovis [1] polled the audience and the outcome of this poll was that 30% of studies were not necessary. However data can also be found that argue that specialists do conform to guidelines. For example Linscott et al. [7] showed in children younger than 2 years that imaging did conform to published guidelines (cited Pediatrics 2001 guidelines) for obtaining a head CT in the setting of trauma in 97.4% of cases. Suffice it to say that the true number of unjustified examinations, whatever that is, is difficult to determine across ages, practice environments and clinical situations. This is addressed in greater detail below. The second point is that, to a large extent, the responsibility for utilization (and potentially unjustified use of imaging) is also ours, as radiologists. Our business, based on fee-forprocedure, has been profitable; why should we have discouraged this? Consider also that we have isolated ourselves from the current tides of patient care, exactly contrary to the patientcentric care called for in medical professionalism [8]. This

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isolation is a direct result of picture archiving and communication systems (PACS) and nighthawk services. Many of us simply do not want to be bothered off-hours. Now this does not apply to everyone and most would argue that it does not apply to them but most would also argue that these observations are certainly defensible. Whether it is “me” or “we,” the first step in the process of improving utilization is to avoid being offensive by being on the defense. That is, we must accept our responsibility for the use of imaging and not blame others for this entirely. The House of Radiology has some cleaning to do. That said, many factors conspire and contribute to the “why” and subsequently “when” outside of this Radiology domain of responsibility. For the collective medical community to improve what we do we must first recognize what the various influences are, isolate those that are significant, and develop a collective strategy to address them.

Influences on imaging use Who or what, then, drives medical use? Drivers are found in Table 1 and are discussed subsequently. First and foremost the medical and scientific community determines use. This could be through evidence-based medicine or consensus or individual experiences and recommendations. The majority of what we do in medical imaging is predominantly justified through one of the above or other supportable mechanisms that underscore that imaging is extremely beneficial [9]. For example, new guidelines on lung cancer screening will almost certainly increase CT in the relevant population in adults [10]. Many of the benefits of CT in the setting of medical necessity are recognized by health care providers and imaging experts, as well as more broadly in the scientific, medical and lay communities. Table 1 Influences on imaging utilization

• The medical/scientific imaging community • Industry (i.e. CT manufacturers) • Non-radiology physicians • Payers • Government • Lawyers • Practice/hospital administration • The public • Regulators • Health policy makers • Patients • Parents/caretakers • News media

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In the radiology community, many of the advances in refining justification can be found through appropriateness criteria and practice guidelines and technical standards from the American College of Radiology [11, 12], decision rules, and like mechanisms through organizations such as the U.S. National Guideline Clearinghouse [13] and other organizations [14]. Whether evidence-based or through expert and consensus development, these guidelines certainly direct what we do in delivering safe and effective imaging health care. Attitudes also play a part as a driver of CT use. Referrer perspectives such as “I want it now” or “I am taking care of the patient and I will decide what is appropriate” are not unfamiliar to radiologists. On the other hand, we must confess that we also drive imaging through our own dictation and embedded, often implicit, perspectives such as “Cannot exclude”; “Consider x, y, or z modality as more sensitive imaging test”; “Recommend clinical correlation”; “Technically limited,” and “Incidentally noted.” Some literature does suggest that these do not drive imaging [15]; however, it is my experience and a well-known observation by many clinical colleagues that these are certainly factors compelling them to obtain additional imaging. Another influence on decision-making and imaging utilization is found in the availability of resources, such as ultrasound, at limited hours during the day, varying expertise in pediatric radiology (including teleradiology), or availability of consistent (or any) clinical consultations off-hours. For example, CT for possible appendicitis at 3 a.m. may be obtained in a child otherwise amenable to ultrasound because a sonographer is not available or the imaging expertise necessary to interpret an examination is not present [16]. So is it wrong to get a CT for appendicitis in a 5-year-old at 3 a.m.? Is this inappropriate? Using a constricted domain, yes; accepting that mindful use of available resources may dictate different strategies, no. So how do we define why and when here? What is inappropriate in such a setting? The standard of care is actually a standard range of care, which is somewhat dynamic and has multiple dimensions based on some of the factors outlined above as well as influences discussed subsequently. Moreover in Radiology we typically have not taught justification; we teach and ask, “What do you see and what does it mean?” or “How do you do it?” There has traditionally been less emphasis on how you build partnership pathways for obtaining imaging. Another factor in driving imaging is industry. The business is selling equipment, and discouraging the use of equipment by the very people who manufacture it is not good business. Would a car dealer suggest that you don’t really want or need this car, that what you have now will probably be good for a few more years? Now I am not equating any sort of profession in terms of sales to any other sort of profession but we must realize that selling more equipment and increasing its use as a result is what capitalism is about. Administration also drives

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use, again based on revenue. Simply stated, metrics for performance and departmental success are commonly based on revenue, such as what type of examinations are you performing? How many? Is this increasing? To discourage examinations is not good for the “business” of Radiology [17]. Non-radiologists drive use. In-office use of equipment by those who have financial interests results in an increased frequency of examinations over that at imaging facilities where there is no financial interest [18–20]. In one article investigators demonstrated that the ratio of mean images per episode in modalities by physicians with a financial interest in a modality was 2.95 for CT (nearly 300% greater) and 1.46 for MR but only 1.11 for radiography (a cheaper test) compared to those physicians without a financial interest [20]. Payers also determine use. These payers, whether they are third-party or other reimbursement agencies such as Medicare and Medicaid, determine what is reimbursable, what is not, and at what rate. Open competitive imaging markets influence what, when and how imaging is performed, and the frequency of imaging can be determined on payer status [21]. Moreover, the entrenchment of relative value units (RVUs) has certainly directed imaging care. Would the imaging that we do be the same if all examinations were valued and reimbursed equally? It is interesting to speculate here. We may shortly see that changes in health care reimbursement of value over volume foster more efficient and economical (and hopefully quality) imaging strategies. Defensive medicine drives imaging. In one study using a multispecialty physician survey, Studdert et al. [22] indicated that 93% practiced defensive medicine and 43% used imaging technology in clinically unnecessary situations. For the group of emergency physicians, 63% ordered CT or MRI as their most recent act of defensive medicine as opposed to admitting the patient (14%), obtaining a cardiac workup (12%), obtaining additional laboratory studies (11%), or referring the patient to anther provider (5%) [22]. In a Massachusetts statewide survey on defensive medicine in 2007–2008 of 3,650 physicians, 83% reported they practiced defensive medicine, with 28% of CT scans ordered for defensive purposes [23]. Patients and caregivers can influence the performance of studies. There are often expectations of what should and should not be done on patients and their loved ones. Patient demographics drive what is done. In a study by Hryhorczuk et al. [21] investigators concluded that frequency of imaging studies in children who presented with abdominal pain in the emergency department varied widely and was influenced by gender, age, race, insurance status and other demographic factors. For example, the odds of having a CT examination were significantly lower among children with public insurance than those with private insurance [21].

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Finally, and this should be no surprise to those in almost any specialty within radiology, news media drive the use. This can be through reports supporting obtaining imaging examinations as well as reports of ineffective or unsafe imaging. There have been several New York Times articles related to potential risks with medical imaging in children [24–26], even as recently as Jan. 31, 2014 [27]. The presence or absence of information technology also has a direct role in the utilization of imaging. Importing transfer studies into PACS can reduce repeat examinations when transferring care [28], and the same applies to image-sharing networks.

Strategies for accountable imaging care What strategies, then, can be used to assure that we are using imaging appropriately? Strategies can be considered in topdown or bottom-up perspectives. Top-down strategies are those that regulate directly or provide guidance or resources. Bottom-up strategies depend on the behaviors of those who request and those who provide imaging examinations. Some mainly top-down strategies have been recently well-outlined in an article by Hendee et al. [29] in a summary of the 2010 American Board of Radiology Foundation meeting. These strategies include decision support at the point of care, evidence-based appropriateness criteria, greater use (and implied, availability) of practice guidelines, education of stakeholders, accreditation of facilities, management of self-referral in defensive medicine, and payment reform. An additional blend of top-down and bottom-up strategies was recently outlined in a consensus group of imaging specialists and emergency medical physicians [6]. Summary recommendations included consensus guidelines and appropriateness criteria; sufficient support through the electronic medical record; strategies that are the fastest, safest and most likely to affect immediate care according to limited information; agreement on common scenarios on available case-based consultations; joint development of training and pathway skills to reduce the need for CT imaging; radiologists who are responsible for procedure and consultation (and outside studies should be available); and the need for radiologists to inform about new and used technologies. Some of the latter points align with the bottom-up perspective to improved image utilization. Decision support [30] is further discussed by Dr. James Brink elsewhere in this supplement. This is a compelling strategy for improving medical use, and I offer that it is the most widely supported recommendation for improved justification. Contemporary decision support should be embedded at the point of care and certainly take advantage of the electronic medical record. We must remember, however, that decision support has been with us for decades. In the olden days decision support was the act of a clinician or team

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coming to round in Radiology. We have succeeded in distancing ourselves from this, partly based on advancements in technology through digital imaging. This decision support has included the telephone, and more recently e-mail conversations. These mechanisms are still sound and can be effective but are relatively inefficient in terms of being the “fastest and most likely to affect immediate care.” We need to continue to have face time as a digital (helping to build decision support) point-of-care consultant and to be available beyond the digital paradigm when necessary; we must be an added value as specialists in the imaging care of children. This may mean walking to the emergency department or picking up the phone and talking to someone when there is a somewhat confusing history on a request for an examination. At the same time, we must also understand where our colleagues are coming from (and Dr. Karen Frush discusses these important considerations elsewhere in this supplement). It is crucial that we are not judgmental. As an example, we are asked to perform and interpret a head CT examination, perhaps in a preschool child with 2 weeks of intermittent headaches. We see a normal head CT examination and are not surprised. On the surface, this is one of these inappropriate examinations. But consider that the emergency medicine physician who ordered the CT might have experienced a family that just lost an elderly loved one to vasospasm from a subarachnoid hemorrhage as a result of a ruptured aneurysm that started with intermittent headaches, or that the child with a headache may be a special needs child who has been the loving focus of these parents for years and they are sure their child is just not right. The parents in such a case may have been in three other settings in the last 2 weeks and are simply exhausted because no one will listen to them and the dad just lost his job and the mom found out her sister has breast cancer. Somewhat extreme? Spend a night in the shoes of a pediatric emergency department physician. We (should) recognize that in Radiology we operate in a landscape of visual information and recognition without the need to filter all of this history (although pertinent history is generally welcomed and helpful); our clinical colleagues often have a tremendously difficult task in distilling the salient from the sentiment and acting purely on this filtered assessment. But in the above example, these are all factors that we have to realize can also influence what we do. If we recognize this, then can we accept this? When does right become wrong? Would empathy for our colleagues' encounters change our sense of an examination that is inappropriate? How about unjustified, unwarranted, unindicated, unnecessary? These descriptors are familiar and plentiful. In the setting of justification of medical imaging, I believe using the word “inappropriate” is itself inappropriate. That is not to say that everything we do can be rightfully defended. But we should be shaking hands instead of pointing fingers. We must model commitment and value through our own behavior. We must put in effort, be visible as stakeholders in the care of patients, and we must partner. In my opinion, these

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are the three key elements of the road to successful imaging strategies and improved utilization. The mantra that radiologists come late, leave early and make lots of money is far from dead. Understanding where we need to focus our efforts also requires a realization of what challenges exist. Returning to decision support, for example, one might override the suggestive pathways, and there may be independent and conflicting pathways and stated value of modalities, and there is potentially tremendous resource utilization including costs in developing decision support. Consider a moment the tens of thousands of diagnoses in ICD-10. Moreover, a Google search for “decision rules” and “medicine” and “review” in late 2012 yielded approximately 45,400,000 hits. In addition, who is responsible for the audit and maintenance of decision support? What are the metrics for success? Impact analysis will be important. Do you punish bad behavior or reward good behavior — or both? What are the penalties for not using such strategies? Who will leverage these penalties? In the end we must realize that the right steps and the right strategies will not necessarily increase our financial well-being, help with our maintenance of certification, get us a promotion, or make the day shorter or less hectic. It is just something we have to do by investing through effort (such as contributing to the ACR programs such as the appropriateness criteria or practice guidelines), availability and strengthened relationships with clinical colleagues. We also need to model these elements in our dayto-day behaviors. Our conversations and attitudes are unquestionably picked up by medical students, radiology residents, fellows and our own partners and faculty. We should strive to have an early and sufficiently comprehensive exposure to radiology during medical school. At Duke we have established a core rotation in radiology that resides alongside medicine, surgery and pediatrics as required clinical rotations for second-year medical students (the curriculum at Duke has all science courses during the first year, clinical rotations during the second, and research during the third). We need to be careful of our engagements with each other in the reading rooms and continue to portray a professional, respectful and cooperative approach to imaging care delivery. There is a mandate for improved utilization. Our actions must be harmonious with value over volume. We must pursue this with advocacy over adversity. The reduction in inappropriate examinations will follow the reduction of inappropriate attitudes and behaviors.

Conflicts of interest Dr. Frush has no financial interests, investigational or off-label uses to disclose.

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Deciding why and when to use CT in children: a radiologist's perspective.

Defining what is appropriate or inappropriate with respect to CT scanning is challenging. There are a variety of influences on scan utilization in chi...
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