SYMPOSIUM REVIEW ARTICLE
Cardiothoracic Imaging Guidelines in Quality Improvement Jacobo Kirsch, MD* and Daniel Vargas, MDw
Abstract: The goal of this review article is to highlight the appropriateness criteria programs available to clinicians, to review the current state of decision-support systems for imaging, and to briefly review the accreditation requirements currently in place in cardiothoracic imaging. Key Words: peer review, quality improvement, cardiothoracic imaging
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T
he US Agency for Healthcare Research and Quality defines quality health care as “doing the right thing, at the right time, in the right way, for the right person—and having the best possible results.”1 The past couple of decades have witnessed a significant number of advances in both medicine and technology. These advances have not only helped push the limits of science, but have also created a highly complex environment dense in information and decision-making algorithms. Despite this complex medical environment, to do the right thing, at the right time, in the right way, and for the right person, physicians still primarily rely on paper tools, memory, and hard work.2 It is estimated that the abyss between what physicians know should be done for patients and what is actually done accounts for >$9 billion per year in lost productivity and nearly $2 billion per year in hospital costs.2,3 Furthermore, according to the American College of Radiology (ACR), imaging is one of the fastest-growing services in medicine, with costs reaching approximately $100 billion annually, increasing the relevance of improving quality in this area.4 The goal of this review is to highlight the appropriateness criteria (AC) programs available to clinicians, to review the current state of decision-support systems for imaging, and to briefly review the accreditation requirements currently in place in cardiac imaging.
AC GUIDELINES AC guidelines are evidence-based guidelines created by expert panels consisting of leaders in imaging and other specialties. Currently, the ACR offers their own Appropriateness Criteria Guidelines (ACR AC), representing the most comprehensive evidence-based guidelines for diagnostic imaging selection, radiotherapy protocols, and image-guided interventional procedures.5 First introduced in 1993, the role of these guidelines is to assist referring physicians and other providers in making the most From the *Imaging Institute, Cardiothoracic Radiology, Cleveland Clinic Florida, Weston, FL; and wDepartment of Radiology, University of Colorado, Anschutz Medical Center, Aurora, CO. The authors declare no conflicts of interest. Correspondence to: Jacobo Kirsch, MD, Imaging Institute, Cardiothoracic Radiology, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, 33331, FL (e-mail: [email protected]). Copyright r 2014 by Lippincott Williams & Wilkins
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appropriate imaging or treatment decisions for a specific clinical condition. The latest version published in November of 2013 covers 197 topics with >900 clinical variants.5,6 Other societies, such as the American College of Cardiology (ACC) and the American Heart Association (AHA), publish guidelines and medical scientific statements on various cardiovascular diseases, sometimes individually and sometimes in combination with other subspecialty groups.7 Similar to the ACR AC, the ACC Foundation (ACCF) creates and updates its AC guidelines by reviewing and categorizing clinical situations in which diagnostic tests and procedures are utilized by physicians caring for patients with cardiovascular diseases. This process is based on the current understanding of the technical capabilities of the different imaging modalities examined and is not intended to be entirely comprehensive.8 The ACR has participated in many of these processes in conjunction with the ACC, AHA, and/or other subspecialty societies. Although cardiac imaging encompasses a large pool of modalities and has garnered the interest of several specialties, in many respects the ACR appears to be the best positioned and most appropriate organization to inform and influence imaging utilization decisions. The use of AC guidelines by general practitioners has been reported to lead to better utilization of testing (ie, an increase in the rate of performance of appropriate examinations and a decrease in the rate of performance of inappropriate examinations).4,9,10 A few studies have further measured this impact by comparing how updated AC guidelines fare against their previous iterations. These studies have shown increased acceptance and inclusiveness of the different clinical variants with evolving technology and evidence, highlighting the importance of continuously updating the guidelines. For example, 2 recent studies by Rich and colleagues10 and Wasfy and colleagues11 showed the effect of the 2010 update of the original 2006 Cardiac CT Appropriate Use Criteria revealing a substantial effect of the revised criteria on the proportion of computed tomography (CT) examinations that could be classified, and the proportion of scans deemed as appropriate. When compared with the 2006 AC, the 2010 AC provided improved clarification of examination appropriateness. This shift was due to the inclusion of many previously unaddressed indications and the designation of more examinations as either appropriate or inappropriate.10,11 Gurzun and Ionescu12 compared applicability of American-developed AC for transthoracic echocardiography and showed that AC utilization yields similar results in the United Kingdom, results that may be translated to other AC to the rest of the western countries. Unfortunately, despite these reports that support the use of AC to improved utilization of testing, a study from 2009 by Bautista and colleagues showed significantly low utilization of the ACR AC.4 In their paper, the authors attribute this to a probable general lack of awareness about their existence. Interestingly, more popular and widely www.thoracicimaging.com |
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accessible resources such as UpToDate, MD Consult, PubMed, and a physician’s specialty journal were the preferred method of consult. Furthermore, 35 of the 126 physicians interviewed (27.8%) selected Google as 1 of their top 3 resources, an especially popular choice among resident respondents. However, an important observation was that 81 of 126 physicians (64%) still indicated that they consult a radiologist as 1 of their top 3 resources, the most popular choice for both residents and attending physicians.9 Studies showing that significant numbers of patients were deemed to have inappropriate indications have suggested opportunities for improving appropriate utilization and propose this finding to relate to a lack of dissemination of guidelines and AC across specialties.13 In addition, it has been well documented that educational interventions on the use of imaging testing results in improved utilization.14 A noteworthy finding in an interesting study by Dym et al,15 in which they sought to gauge the competence of emergency medicine residents in ordering appropriate imaging examinations for various commonly encountered clinical scenarios, was the lack of improvement in the ability to choose appropriate imaging studies over the course of residency, which raises the question of training lacking in education on appropriate imaging examination ordering practices. Studies have tried different methods to change the radiologic test-ordering behavior of clinicians. Leschied and colleagues introduced second-year medical students to the ACR AC in an interactive case-based elective to demonstrate their use in common emergency department (ED) scenarios, seeking to improve their knowledge of appropriate image utilization and perceived awareness of the indications, contraindications, and effects of radiation exposure related to medical imaging. After the intervention, the students’ confidence in ordering appropriate imaging improved nearly 2-fold.16 Covington and colleagues implemented an educational intervention for residents incorporating the ACR AC with lectures on costconsciousness and on the actual hospital charges for abdominal imaging resulting in a significant reduction in mean abdominal imaging studies per patient following the intervention. The avoidance of charges solely due to the reduction in abdominal CT scans following the intervention was estimated at $129 per patient.17 Strother et al18 incorporated a phased quality improvement initiative designed to educate referring clinicians and departmental radiologists about the recommendations of the ACR AC for dual-phase head CT examinations and demonstrated a reduction in the number of dual-phase head CT examinations that were not indicated. Griffith et al19 showed that implementation of a clinical education initiative in the ED resulted in improved adherence to ACR AC and improved clinical effectiveness of cervical spine x-rays by increasing fracture detection rate. An interesting study by Kanaan and colleagues evaluated the appropriate utilization rates for CT pulmonary angiography in a tertiary center ED before and after a health care provider educational intervention. They showed that a single educational intervention had no effect on appropriate utilization rates and suggested that repeated and sustained educational interventions may help improve imaging ordering patterns.20 Clearly, continuous education, monitoring, and appropriate feedback should lead to stricter adherence to the AC guidelines and improve imaging utilization, and, although further education of our peers and trainees in the
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appropriate use of imaging testing is needed, the use of advanced informatics to curb inappropriate imaging growth is on the horizon.
DECISION-SUPPORT TOOLS As mentioned, imaging utilization will continue to be scrutinized, and it is expected that decision-support tools for both referring providers and radiologists will become the norm. It is expected that AC, such as those produced by the ACR, will be implemented into all imaging order entry decision-support systems and will be continuously refined to ensure medically necessary imaging.21 Furthermore, these criteria will likely become the benchmark against which insurers will reimburse testing,22 and, although traditional Medicare has not established preauthorization requirements for radiology, regional carrier reimbursement policy is becoming increasingly stringent.23 Much of the potential value of electronic health record systems comes in the form of clinical decision-support (CDS) tools that can help make care safer, more efficient, and more cost-effective. Broadly defined, CDS is a method of delivering organized clinical knowledge and recommendations to a clinician to assist in selecting the best course of action for a specific clinical scenario.24 As stated before, there is a relative lack of awareness about the existence of AC guidelines in the medical profession. Allowing these guidelines to be presented electronically rather than by distribution of hardcopy formats has the potential to change physician clinical behavior to best current practice. The highest probability of guideline effectiveness in CDS appears to be a specific reminder delivered to the clinician about best practice relevant to a specific patient at the time of consultation with that patient.25 With regard to imaging, the purpose of CDS is to assist a referring physician in requesting the most appropriate imaging study for a specific clinical scenario.24 At the time of writing this review, at least 1 large university-affiliated group practice (Partners HealthCare, Boston, MA) had successfully implemented computer order entry for radiology with specific (ACR AC based) decision support.23 In addition, other CDS systems for imaging have been integrated into electronic ordering systems of other institutions with success. Most of the reports from these institutions show adoption across virtually all specialties, reduction in lowyield imaging, and even elimination of the need for preauthorization by third-party payers when using CDS.24 A study by Curry and colleagues measuring the improvement in practice by the use of electronic guidelines with this methodology showed a median improvement of 14% as compared to half that amount from dissemination of educational materials (8%), audit and feedback (7%), and multifaceted educational intervention involving educational outreach (detailing) (6%).25,26 Two studies assessed the use of CDS in the ED in an effort to curve the ordering of CT angiography studies for the diagnosis of pulmonary embolism (PE). Raja et al27 reported that implementation of evidence-based CDS was associated with a significant (20.1%) decrease in the use, as well as a significant (69.0%) increase in the yield, of CT pulmonary angiography for the evaluation of acute PE in the ED during a 2-year period. A similar study by Prevedello and colleagues showed an overall increase in the yield of PE-CT despite substantial heterogeneity in yield among individual ordering providers.28 Their study shed light on persistent significant increase in interphysician variability in yield r
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after CDS. The authors suggested that despite overall improved performance, substantial—and likely unwarranted—variability in practice persisted after CDS. They propose that consequences for ignoring high-quality evidence, and other strategies such as academic detailing or benchmarking, may be needed to increase the acceptance of evidence presented in CDS to help optimize practice.28 Evidence is accumulating that computerized provider order entry by itself has a positive effect in reducing unnecessary diagnostic imaging orders.25,29–31 Some of the key elements that enhance CDS adoption by clinicians include acceptance of the clinical content, speed of the ordering process, provision of real-time recommendations rather than just assessments, integration into physicians’ workflows, easy usability, execution through simple steps to minimize data entry, and allowance for change in the direction of the action as opposed to stopping its execution. Although many, if not all of these variables, are essential for successful implementation of CDS, some authors have suggested that physicians’ acceptance of the clinical content is the most crucial step for CDS adoption.28
PHYSICIAN CERTIFICATION The 2005 ACCF Clinical Competence Statement on Cardiac Imaging with Computed Tomography and Magnetic Resonance: A Report of the American College of Cardiology Foundation/AHA/American College of Physicians Task Force on Clinical Competence and Training and the ACR Practice Guideline for the Performance and Interpretation of Cardiac CT provides the framework and parameters for recommended initial training and maintenance of competency in cardiac CT.8,32,33 With the increasing emphasis on quality and pay for performance, it is anticipated most payers will mandate physician certification. As a background on the certification process, it should be noted that there has been increasing recognition and acceptance by state and federal regulatory organizations and payers of NBE and Certification Board of Nuclear Cardiology. For example, the Certification Board of Nuclear Cardiology has been recognized by the Nuclear Regulatory Commission and many of the Agreement States as the basis for licensure for the use of radioactive materials for nuclear cardiology tests. Many of the payers have mandated certification in these areas as the basis for physicians to provide services and be reimbursed to members enrolled in the health plans.34 We will concentrate on the necessary criteria and requirements for certification on cardiac CT. It is important to recognize that there are 3 progressive levels of initial training for the purpose of competency in cardiac CT angiography, with 2 general pathways to achieve these levels. The first path is through formal fellowship training that involves both case experience criteria as well as recommended cumulative time of experience in cardiac CT. The second pathway is for those already in practice and recognizes the challenges to attaining formal fellowship training while practicing medicine full time.35 According to the ACCF, there are 3 main levels of training that can be obtained in cardiac CT. Level 1 training provides minimal introductory training in cardiac CT, which is not sufficient for independent performance and interpretation of cardiac CT examinations. Level 2 of training is intended for those who plan to independently perform and interpret cardiac CT examinations. The r
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highest level attainable, level 3 of training, is for those physicians who intend to direct a CT laboratory.35 The ACR Practice Guidelines for the Interpretation of Cardiac CT describe the physician’s responsibility as including, but not limited to, reviewing all indications for the examination, specifying the imaging sequences to be performed, specifying the methods of image reconstruction, specifying the use and dosage of contrast and pharmacologic agents, assuring the quality of the images and of the official study interpretation, and communicating any urgent or emergent findings. To further document proficiency in cardiac CT, 2 examinations to certify advanced training and experience have been developed. Initial experience with the certification process for cardiac imagers by the nuclear cardiology and echocardiography boards served as the foundation for the first certification examination on cardiac CT, the Certification Board in Cardiovascular Computed Tomography in 2006. This examination was established by the ACC, the American Society of Nuclear Cardiology, the Society for Cardiovascular Angiography and Interventions, and the Society of Cardiovascular Computed Tomography.34 In addition, the ACR provides an opportunity for those cardiac imagers meeting their eligibility requirements to undergo a Certificate of Advanced Proficiency examination, incorporating both knowledge-based, multiple choice, and practical examination components. Table 1 lists the eligibility and training requirements to obtain certification from the Certification Board in Cardiovascular Computed Tomography and ACR. An interesting piece of information came from an informal survey of clinical members within the division of cardiovascular medicine at The Ohio State University (n = 35 responders), in which 56% of respondents reported they would prefer clinical imaging studies on their patients to be interpreted by faculty who practice in a single modality for 3 to 4 days per week rather than faculty with credentialing/certification in multiple modalities, reading each modality 1 to 2 days per week. This suggests that experience may be perceived as being more valuable than having a certificate for many clinicians.36 In contrast, a study by Taylor and colleagues demonstrated the relationship that exists between prior training and experience in cardiac CT and performance on the Certifying Examination in Cardiovascular Computed Tomography. In general, level 3 examinees performed better than level 2 examinees, and a relationship existed between the number of scans interpreted by the examinee or their time in practice and pass rate.32 Therefore, board certification may be considered as a surrogate for competency through experience-based or formal training program in cardiovascular CT. In recent years, the ABR proposal to develop an MOC Focused Practice pilot program in cardiac CT was approved by the American Board of Medical Specialties. Initiatives such as this one are designed for areas in clinical practice for which there are no ACGME-approved fellowships. Individuals who fulfill requirements will be listed on the ABR and ABMS websites as ABR board certified with focused practice recognition in cardiac CT. Applicants must be board certified in Diagnostic Radiology by the ABR for at least 1 year and enrolled in the ABR MOC program. Applicants must have completed at least 150 gated, contrast-enhanced cardiac CT examinations in the past 36 months, 75 of which are protocoled and interpreted by the applicant. Applicants should complete 4 www.thoracicimaging.com |
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TABLE 1. Summary of Requirements for the American College of Radiology Cardiac CT Certificate of Advanced Proficiency and the Board of Cardiovascular Computed Tomography Certification
Certificate of Advanced Proficiency Examination (CoAP)—ACR
Certification Board of Cardiovascular Computed Tomography
Medical License
Hold current, unrestricted medical license.
Board Certification and Training Experience
(1) Certification in Radiology by the ABR, AOBR, RCPSC, CdMdQ, or other recognized foreign equivalent; AND involvement in 150 cardiac CT studies in the past 36 mo, 75 of which must be primarily protocoled and interpreted by the applicant. OR (2) Completion of ACGME-approved or AOAapproved Radiology residency program as well as involvement in 500 CT cases of which at least 150 must be contrast-enhanced cardiac CT. Of these, 75 must be primarily protocoled and interpreted by the applicant in the past 36 mo. OR (3) Completion of ACGME-approved residency program, 200 AMA PRA Category 1 Credits, involvement in 500 CT cases of which at least 150 are contrast-enhanced cardiac CT and 75 of these primarily protocoled and interpreted by the applicant.
Continuing Medical Education
Minimum of 25 cardiovascular AMA PRA Category 1 Credits in the 24 mo preceding application, unless applying according to the path described above under (2).
Other
Filled application, supporting documentation, and examination fees.
Hold current, unrestricted medical license. Individuals holding a training medical license will gain Testamur status until a medical license is issued. Board certification in Cardiovascular Disease by the ABIM, certificate in Cardiology from the AOBIM; Board certification in Nuclear Medicine by the ABNM or AOBNM; Board certification in Radiology by the ABR or AOBR. Fellows and residents may sit for the examination in a Testamur status. Those training outside the United States must provide evidence of certification or letter of completion of training. Cardiology and Nuclear Medicine applicants: ACCF/AHA Level 2 (or 3) training: Level 2 training entails 150 contrast-enhanced cardiac CT examinations, for 50 of which the applicant must be physically present and involved with, AND evaluation of 50 noncontrast cardiac CT examinations. Radiology Applicants: (1). ACCF/AHA Level 2 (or 3) training. OR (2). Case requirements for cardiac CT as outlined by the ACR practice guidelines: supervision and/or interpretation of 50 contrast-enhanced cardiac CT cases in the 12 mo before application AND interpretation of 300 thoracic CT in the past 36 mo if qualified in thoracic CT or 500 general CT in the past 36 mo of which 100 are thoracic CT if not qualified in thoracic CT. ACCF/AHA Level 2 or 3 applicants: 20 h of Category 1 CME in general or cardiac CT in the 36 mo preceding application. ACR Practice Guidelines applicants: 30 h of Category 1 CME in cardiac CT and/or cardiac anatomy and physiology in the 36 mo preceding application if qualified in thoracic CT. If not qualified in thoracic CT, then 200 h of Category 1 CME are required. Filled application, supporting documentation, and examination fees.
ABIM indicates American Board of Internal Medicine; ABNM, American Board of Nuclear Medicine; ACGME, Accreditation Council for Graduate Medical Education; AOA, American Osteopathic Association; AOBIM, American Osteopathic Board of Internal Medicine; AOBNM, American Osteopathic Board of Internal Medicine; AOBR, American Osteopathic Board of Radiology; CdMdQ, le Colle`ge dus me´dicins du Que´bec; RCPSC, Royal College of Surgeons and Physicians of Canada.
ABR-qualified SAM in cardiac CT, at least 50 AMA PRA Category 1 Credits in cardiac CT, and 1 practice quality improvement project in cardiac CT. In addition, applicants must obtain a passing score on the ACR Cardiac CT Advanced Proficiency Examination. Recognized individuals are expected to fulfill requirements for continued participation, including a number of CME, SAM, and PQI projects in cardiac imaging during MOC cycle as well as a yet to be determined number of gated contrast-enhanced cardiac CT studies.
CONCLUSIONS In view of the many challenges that the present and future health care environment provide, the imaging community should make every effort to improve the value of its services by adhering to the available AC guidelines and setting in place a review process for the accreditation requirements of its members. Decision-support systems are
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a reality, and early adoption may prove to be beneficial in creating an environment for physician’s acceptance and utilization. REFERENCES 1. Agency for Healthcare Research and Quality, US Department of Health and Human Services. Your guide to choosing quality healthcare: a quick look at quality. Available at: http:// archive.ahrq.gov/consumer/qnt/qntqlook.htm. Accessed April 26, 2007. 2. Varkey P, Reller MK, Resar RK. Basics of quality improvement in health care. Mayo Clin Proc. 2007;82:735–739. 3. National Committee for Quality Assurance. The state of health care quality: 2004. Available at: http://www.ncqa.org/portals/ 0/Publications/Resource%20Library/SOHC/SOHC_2004.pdf. Accessed April 26, 2007. 4. Bautista AB, Burgos A, Nickel BJ, et al. Do clinicians use the American College of Radiology Appropriateness criteria in the management of their patients? Am J Roentgenol. 2009;192: 1581–1585. r
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5. American College of Radiology Website. ACR appropriateness criteria: background and development. Available at: http:// www.acr.org/Quality-Safety/Appropriateness-Criteria/About-AC. Accessed January 13, 2008. 6. Cascade PN. Setting appropriateness guidelines for Radiology. Radiology. 1994;192:50A–54A. 7. Statements and Guidelines from the American Heart Association and American Stroke Association. Available at: http:// my.americanheart.org/professional/StatementsGuidelines/State ments-Guidelines_UCM_316885_SubHomePage.jsp. Accessed January 13, 2014. 8. CARDIAC RADIONUCLIDE IMAGING WRITING GROUP, Hendel RC, Berman DS, Di Carli MF, et al. ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 Appropriate Use Criteria for Cardiac Radionuclide Imaging: A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the American Society of Nuclear Cardiology, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the Society of Cardiovascular Computed Tomography, the Society for Cardiovascular Magnetic Resonance, and the Society of Nuclear Medicine: Endorsed by the American College of Emergency Physicians. Circulation. 2009;119:e561–e587. 9. Levy G, Blachar A, Goldstein L, et al. Nonradiologist utilization of ACR appropriateness criteria in a preauthorization center for MRI requests: applicability and effects. Am J Roentgenol. 2006;187:855–858. 10. Rich ME, Utsunomiya D, Simprini LA, et al. Prospective evaluation of the updated 2010 ACCF Cardiac CT Appropriate Use Criteria. J Cardiovasc Comput Tomogr. 2012;6:108–112. 11. Wasfy MM, Brady TJ, Abbara S, et al. Comparison of cardiac computed tomography examination appropriateness under the 2010 revised versus the 2006 original Appropriate Use Criteria. J Cardiovasc Comput Tomogr. 2012;6:99–107. 12. Gurzun MM, Ionescu A. Appropriateness of use criteria for transthoracic echocardiography: are they relevant outside the USA? Eur Heart J Cardiovasc Imaging. 2014;15: 450–455. 13. Miller JA, Raichlin E, Williamson EE, et al. Evaluation of coronary CTA Appropriateness Criteria in an academic medical center. J Am Coll Radiol. 2010;7:125–131. 14. Bhatia RS, Milford CE, Picard MH, et al. An educational intervention reduces the rate of inappropriate echocardiograms on an inpatient medical service. JACC Cardiovasc Imaging. 2013;6:545–555. 15. Dym RJ1 Burns J, Taragin BH. Appropriateness of imaging studies ordered by emergency medicine residents: results of an online survey. Am J Roentgenol. 2013;201:W619–W625. 16. Leschied JR, Knoepp US, Hoff CN, et al. Emergency radiology elective improves second-year medical students’ perceived confidence and knowledge of appropriate imaging utilization. Acad Radiol. 2013;20:1168–1176. 17. Covington MF, Agan DL, Liu Y, et al. Teaching costconscious medicine: impact of a simple educational intervention on appropriate abdominal imaging at a community-based teaching hospital. J Grad Med Educ. 2013;5:284–288. 18. Strother MK, Robert EC, Cobb JG, et al. Reduction in the number and associated costs of unindicated dual-phase head CT examinations after a quality improvement initiative. Am J Roentgenol. 2013;201:1049–1056. 19. Griffith B, Vallee P, Krupp S, et al. Screening cervical spine CT in the emergency department, phase 3: increasing effectiveness of imaging. J Am Coll Radiol. 2014;11:139–144. 20. Kanaan Y, Knoepp UD, Kelly AM. The influence of education on appropriateness rates for CT pulmonary angiography in emergency department patients. Acad Radiol. 2013;20:1107–1114. 21. Krishnaraj A, Weinreb JC, Ellenbogen PH, et al. Radiology in 2022: challenges and opportunities in the coming decadeproceedings of the 12th Annual ACR Forum. J Am Coll Radiol. 2013;10:15–20. r
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22. Naqvi TZ, Perese S. Noninvasive vascular appropriateness criteria— review and comments on the American College of Cardiology (ACC) Guidelines. J Am Soc Echocardiogr. 2013;26:A34. 23. Sistrom CL. In support of the ACR Appropriateness Criteria. J Am Coll Radiol. 2008;5:630–635. 24. Williams A, Sachs PB, Cain M, et al. Adopting a commercial clinical decision support for imaging product: our experience. J Am Coll Radiol. 2014;11:202–204. 25. Curry L, Reed MH. Electronic decision support for diagnostic imaging in a primary care setting. J Am Med Inform Assoc. 2011;18:267–270. 26. Grimshaw JM, Thomas RE, MacLennan G, et al. Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol Assess. 2004;8:iii–iv, 1–72. 27. Raja AS, Ip IK, Prevedello LM, et al. Effect of computerized clinical decision support on the use and yield of CT pulmonary angiography in the emergency department. Radiology. 2012;262:468–474. 28. Prevedello LM, Raja AS, Ip IK, et al. Does clinical decision support reduce unwarranted variation in yield of CT pulmonary angiogram? Am J Med. 2013;126:975–981. 29. Vartanians VM, Sistrom CL, Weilburg JB, et al. Increasing the appropriateness of outpatient imaging: effects of a barrier to ordering low-yield examinations. Radiology. 2010;255:842–849. 30. Sistrom CL, Dang PA, Weilburg JB, et al. Effect of computerized order entry with integrated decision support on the growth of outpatient procedure volumes: seven-year time series analysis. Radiology. 2009;251:147–155. 31. Rosenthal DI, Weilburg JB, Schultz T, et al. Radiology order entry with decision support: initial clinical experience. J Am Coll Radiol. 2006;3:799–806. 32. Taylor AJ, Cerqueira M, Hodgson JM, et al. American College of Cardiology Foundation Appropriate Use Criteria Task Force; Society of Cardiovascular Computed Tomography; American College of Radiology; American Heart Association; American Society of Echocardiography; American Society of Nuclear Cardiology; North American Society for Cardiovascular Imaging; Society for Cardiovascular Angiography and Interventions; Society for Cardiovascular Magnetic Resonance. ACCF/SCCT/ ACR/AHA/ASE/ASNC/NASCI/SCAI/SCMR 2010 Appropriate Use Criteria for Cardiac Computed Tomography. A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the Society of Cardiovascular Computed Tomography, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the American Society of Nuclear Cardiology, the North American Society for Cardiovascular Imaging, the Society for Cardiovascular Angiography and Interventions, and the Society for Cardiovascular Magnetic Resonance. J Cardiovasc Comput Tomogr. 2010;4:407.e1–407.e33. 33. Hendel RC, Patel MR, Kramer CM, et al. ACCF/ACR/ SCCT/SCM- R/ASNC/NASCI/SCAI/SIR 2006 appropriateness criteria for cardiac computed tomography and cardiac magnetic resonance imaging: a report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group, American College of Radiology, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, American Society of Nuclear Cardiology, North American Society for Cardiac Imaging, Society for Cardiovascular Angiography and Interventions, and Society of Interventional Radiology. J Am Coll Cardiol. 2006;48:1475–1497. 34. Cerqueira MD, Arrighi JA, Geiser EA. Physician certification in cardiovascular imaging: rationale, process, and benefits. JACC Cardiovasc Imaging. 2008;1:801–808. 35. Pelberg R, Budoff M, Goraya T, et al. Society of Cardiovascular Computed Tomography. Training, competency, and certification in cardiac CT: a summary statement from the Society of Cardiovascular Computed Tomography. J Cardiovasc Comput Tomogr. 2011;5:279–285. 36. Auseon AJ. Logistical barriers to career development in academic cardiovascular multimodality imaging-challenges for future mentors. Am Heart Hosp J. 2009;7:E99–103.
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Cardiothoracic Imaging Guidelines in Quality Improvement Jacobo Kirsch, MD* and Daniel Vargas, MDw
Abstract: The goal of this review article is to highlight the appropriateness criteria programs available to clinicians, to review the current state of decision-support systems for imaging, and to briefly review the accreditation requirements currently in place in cardiothoracic imaging. Key Words: peer review, quality improvement, cardiothoracic imaging
(J Thorac Imaging 2014;29:279–283)
T
he US Agency for Healthcare Research and Quality defines quality health care as “doing the right thing, at the right time, in the right way, for the right person—and having the best possible results.”1 The past couple of decades have witnessed a significant number of advances in both medicine and technology. These advances have not only helped push the limits of science, but have also created a highly complex environment dense in information and decision-making algorithms. Despite this complex medical environment, to do the right thing, at the right time, in the right way, and for the right person, physicians still primarily rely on paper tools, memory, and hard work.2 It is estimated that the abyss between what physicians know should be done for patients and what is actually done accounts for >$9 billion per year in lost productivity and nearly $2 billion per year in hospital costs.2,3 Furthermore, according to the American College of Radiology (ACR), imaging is one of the fastest-growing services in medicine, with costs reaching approximately $100 billion annually, increasing the relevance of improving quality in this area.4 The goal of this review is to highlight the appropriateness criteria (AC) programs available to clinicians, to review the current state of decision-support systems for imaging, and to briefly review the accreditation requirements currently in place in cardiac imaging.
AC GUIDELINES AC guidelines are evidence-based guidelines created by expert panels consisting of leaders in imaging and other specialties. Currently, the ACR offers their own Appropriateness Criteria Guidelines (ACR AC), representing the most comprehensive evidence-based guidelines for diagnostic imaging selection, radiotherapy protocols, and image-guided interventional procedures.5 First introduced in 1993, the role of these guidelines is to assist referring physicians and other providers in making the most From the *Imaging Institute, Cardiothoracic Radiology, Cleveland Clinic Florida, Weston, FL; and wDepartment of Radiology, University of Colorado, Anschutz Medical Center, Aurora, CO. The authors declare no conflicts of interest. Correspondence to: Jacobo Kirsch, MD, Imaging Institute, Cardiothoracic Radiology, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, 33331, FL (e-mail: [email protected]). Copyright r 2014 by Lippincott Williams & Wilkins
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appropriate imaging or treatment decisions for a specific clinical condition. The latest version published in November of 2013 covers 197 topics with >900 clinical variants.5,6 Other societies, such as the American College of Cardiology (ACC) and the American Heart Association (AHA), publish guidelines and medical scientific statements on various cardiovascular diseases, sometimes individually and sometimes in combination with other subspecialty groups.7 Similar to the ACR AC, the ACC Foundation (ACCF) creates and updates its AC guidelines by reviewing and categorizing clinical situations in which diagnostic tests and procedures are utilized by physicians caring for patients with cardiovascular diseases. This process is based on the current understanding of the technical capabilities of the different imaging modalities examined and is not intended to be entirely comprehensive.8 The ACR has participated in many of these processes in conjunction with the ACC, AHA, and/or other subspecialty societies. Although cardiac imaging encompasses a large pool of modalities and has garnered the interest of several specialties, in many respects the ACR appears to be the best positioned and most appropriate organization to inform and influence imaging utilization decisions. The use of AC guidelines by general practitioners has been reported to lead to better utilization of testing (ie, an increase in the rate of performance of appropriate examinations and a decrease in the rate of performance of inappropriate examinations).4,9,10 A few studies have further measured this impact by comparing how updated AC guidelines fare against their previous iterations. These studies have shown increased acceptance and inclusiveness of the different clinical variants with evolving technology and evidence, highlighting the importance of continuously updating the guidelines. For example, 2 recent studies by Rich and colleagues10 and Wasfy and colleagues11 showed the effect of the 2010 update of the original 2006 Cardiac CT Appropriate Use Criteria revealing a substantial effect of the revised criteria on the proportion of computed tomography (CT) examinations that could be classified, and the proportion of scans deemed as appropriate. When compared with the 2006 AC, the 2010 AC provided improved clarification of examination appropriateness. This shift was due to the inclusion of many previously unaddressed indications and the designation of more examinations as either appropriate or inappropriate.10,11 Gurzun and Ionescu12 compared applicability of American-developed AC for transthoracic echocardiography and showed that AC utilization yields similar results in the United Kingdom, results that may be translated to other AC to the rest of the western countries. Unfortunately, despite these reports that support the use of AC to improved utilization of testing, a study from 2009 by Bautista and colleagues showed significantly low utilization of the ACR AC.4 In their paper, the authors attribute this to a probable general lack of awareness about their existence. Interestingly, more popular and widely www.thoracicimaging.com |
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accessible resources such as UpToDate, MD Consult, PubMed, and a physician’s specialty journal were the preferred method of consult. Furthermore, 35 of the 126 physicians interviewed (27.8%) selected Google as 1 of their top 3 resources, an especially popular choice among resident respondents. However, an important observation was that 81 of 126 physicians (64%) still indicated that they consult a radiologist as 1 of their top 3 resources, the most popular choice for both residents and attending physicians.9 Studies showing that significant numbers of patients were deemed to have inappropriate indications have suggested opportunities for improving appropriate utilization and propose this finding to relate to a lack of dissemination of guidelines and AC across specialties.13 In addition, it has been well documented that educational interventions on the use of imaging testing results in improved utilization.14 A noteworthy finding in an interesting study by Dym et al,15 in which they sought to gauge the competence of emergency medicine residents in ordering appropriate imaging examinations for various commonly encountered clinical scenarios, was the lack of improvement in the ability to choose appropriate imaging studies over the course of residency, which raises the question of training lacking in education on appropriate imaging examination ordering practices. Studies have tried different methods to change the radiologic test-ordering behavior of clinicians. Leschied and colleagues introduced second-year medical students to the ACR AC in an interactive case-based elective to demonstrate their use in common emergency department (ED) scenarios, seeking to improve their knowledge of appropriate image utilization and perceived awareness of the indications, contraindications, and effects of radiation exposure related to medical imaging. After the intervention, the students’ confidence in ordering appropriate imaging improved nearly 2-fold.16 Covington and colleagues implemented an educational intervention for residents incorporating the ACR AC with lectures on costconsciousness and on the actual hospital charges for abdominal imaging resulting in a significant reduction in mean abdominal imaging studies per patient following the intervention. The avoidance of charges solely due to the reduction in abdominal CT scans following the intervention was estimated at $129 per patient.17 Strother et al18 incorporated a phased quality improvement initiative designed to educate referring clinicians and departmental radiologists about the recommendations of the ACR AC for dual-phase head CT examinations and demonstrated a reduction in the number of dual-phase head CT examinations that were not indicated. Griffith et al19 showed that implementation of a clinical education initiative in the ED resulted in improved adherence to ACR AC and improved clinical effectiveness of cervical spine x-rays by increasing fracture detection rate. An interesting study by Kanaan and colleagues evaluated the appropriate utilization rates for CT pulmonary angiography in a tertiary center ED before and after a health care provider educational intervention. They showed that a single educational intervention had no effect on appropriate utilization rates and suggested that repeated and sustained educational interventions may help improve imaging ordering patterns.20 Clearly, continuous education, monitoring, and appropriate feedback should lead to stricter adherence to the AC guidelines and improve imaging utilization, and, although further education of our peers and trainees in the
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appropriate use of imaging testing is needed, the use of advanced informatics to curb inappropriate imaging growth is on the horizon.
DECISION-SUPPORT TOOLS As mentioned, imaging utilization will continue to be scrutinized, and it is expected that decision-support tools for both referring providers and radiologists will become the norm. It is expected that AC, such as those produced by the ACR, will be implemented into all imaging order entry decision-support systems and will be continuously refined to ensure medically necessary imaging.21 Furthermore, these criteria will likely become the benchmark against which insurers will reimburse testing,22 and, although traditional Medicare has not established preauthorization requirements for radiology, regional carrier reimbursement policy is becoming increasingly stringent.23 Much of the potential value of electronic health record systems comes in the form of clinical decision-support (CDS) tools that can help make care safer, more efficient, and more cost-effective. Broadly defined, CDS is a method of delivering organized clinical knowledge and recommendations to a clinician to assist in selecting the best course of action for a specific clinical scenario.24 As stated before, there is a relative lack of awareness about the existence of AC guidelines in the medical profession. Allowing these guidelines to be presented electronically rather than by distribution of hardcopy formats has the potential to change physician clinical behavior to best current practice. The highest probability of guideline effectiveness in CDS appears to be a specific reminder delivered to the clinician about best practice relevant to a specific patient at the time of consultation with that patient.25 With regard to imaging, the purpose of CDS is to assist a referring physician in requesting the most appropriate imaging study for a specific clinical scenario.24 At the time of writing this review, at least 1 large university-affiliated group practice (Partners HealthCare, Boston, MA) had successfully implemented computer order entry for radiology with specific (ACR AC based) decision support.23 In addition, other CDS systems for imaging have been integrated into electronic ordering systems of other institutions with success. Most of the reports from these institutions show adoption across virtually all specialties, reduction in lowyield imaging, and even elimination of the need for preauthorization by third-party payers when using CDS.24 A study by Curry and colleagues measuring the improvement in practice by the use of electronic guidelines with this methodology showed a median improvement of 14% as compared to half that amount from dissemination of educational materials (8%), audit and feedback (7%), and multifaceted educational intervention involving educational outreach (detailing) (6%).25,26 Two studies assessed the use of CDS in the ED in an effort to curve the ordering of CT angiography studies for the diagnosis of pulmonary embolism (PE). Raja et al27 reported that implementation of evidence-based CDS was associated with a significant (20.1%) decrease in the use, as well as a significant (69.0%) increase in the yield, of CT pulmonary angiography for the evaluation of acute PE in the ED during a 2-year period. A similar study by Prevedello and colleagues showed an overall increase in the yield of PE-CT despite substantial heterogeneity in yield among individual ordering providers.28 Their study shed light on persistent significant increase in interphysician variability in yield r
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after CDS. The authors suggested that despite overall improved performance, substantial—and likely unwarranted—variability in practice persisted after CDS. They propose that consequences for ignoring high-quality evidence, and other strategies such as academic detailing or benchmarking, may be needed to increase the acceptance of evidence presented in CDS to help optimize practice.28 Evidence is accumulating that computerized provider order entry by itself has a positive effect in reducing unnecessary diagnostic imaging orders.25,29–31 Some of the key elements that enhance CDS adoption by clinicians include acceptance of the clinical content, speed of the ordering process, provision of real-time recommendations rather than just assessments, integration into physicians’ workflows, easy usability, execution through simple steps to minimize data entry, and allowance for change in the direction of the action as opposed to stopping its execution. Although many, if not all of these variables, are essential for successful implementation of CDS, some authors have suggested that physicians’ acceptance of the clinical content is the most crucial step for CDS adoption.28
PHYSICIAN CERTIFICATION The 2005 ACCF Clinical Competence Statement on Cardiac Imaging with Computed Tomography and Magnetic Resonance: A Report of the American College of Cardiology Foundation/AHA/American College of Physicians Task Force on Clinical Competence and Training and the ACR Practice Guideline for the Performance and Interpretation of Cardiac CT provides the framework and parameters for recommended initial training and maintenance of competency in cardiac CT.8,32,33 With the increasing emphasis on quality and pay for performance, it is anticipated most payers will mandate physician certification. As a background on the certification process, it should be noted that there has been increasing recognition and acceptance by state and federal regulatory organizations and payers of NBE and Certification Board of Nuclear Cardiology. For example, the Certification Board of Nuclear Cardiology has been recognized by the Nuclear Regulatory Commission and many of the Agreement States as the basis for licensure for the use of radioactive materials for nuclear cardiology tests. Many of the payers have mandated certification in these areas as the basis for physicians to provide services and be reimbursed to members enrolled in the health plans.34 We will concentrate on the necessary criteria and requirements for certification on cardiac CT. It is important to recognize that there are 3 progressive levels of initial training for the purpose of competency in cardiac CT angiography, with 2 general pathways to achieve these levels. The first path is through formal fellowship training that involves both case experience criteria as well as recommended cumulative time of experience in cardiac CT. The second pathway is for those already in practice and recognizes the challenges to attaining formal fellowship training while practicing medicine full time.35 According to the ACCF, there are 3 main levels of training that can be obtained in cardiac CT. Level 1 training provides minimal introductory training in cardiac CT, which is not sufficient for independent performance and interpretation of cardiac CT examinations. Level 2 of training is intended for those who plan to independently perform and interpret cardiac CT examinations. The r
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highest level attainable, level 3 of training, is for those physicians who intend to direct a CT laboratory.35 The ACR Practice Guidelines for the Interpretation of Cardiac CT describe the physician’s responsibility as including, but not limited to, reviewing all indications for the examination, specifying the imaging sequences to be performed, specifying the methods of image reconstruction, specifying the use and dosage of contrast and pharmacologic agents, assuring the quality of the images and of the official study interpretation, and communicating any urgent or emergent findings. To further document proficiency in cardiac CT, 2 examinations to certify advanced training and experience have been developed. Initial experience with the certification process for cardiac imagers by the nuclear cardiology and echocardiography boards served as the foundation for the first certification examination on cardiac CT, the Certification Board in Cardiovascular Computed Tomography in 2006. This examination was established by the ACC, the American Society of Nuclear Cardiology, the Society for Cardiovascular Angiography and Interventions, and the Society of Cardiovascular Computed Tomography.34 In addition, the ACR provides an opportunity for those cardiac imagers meeting their eligibility requirements to undergo a Certificate of Advanced Proficiency examination, incorporating both knowledge-based, multiple choice, and practical examination components. Table 1 lists the eligibility and training requirements to obtain certification from the Certification Board in Cardiovascular Computed Tomography and ACR. An interesting piece of information came from an informal survey of clinical members within the division of cardiovascular medicine at The Ohio State University (n = 35 responders), in which 56% of respondents reported they would prefer clinical imaging studies on their patients to be interpreted by faculty who practice in a single modality for 3 to 4 days per week rather than faculty with credentialing/certification in multiple modalities, reading each modality 1 to 2 days per week. This suggests that experience may be perceived as being more valuable than having a certificate for many clinicians.36 In contrast, a study by Taylor and colleagues demonstrated the relationship that exists between prior training and experience in cardiac CT and performance on the Certifying Examination in Cardiovascular Computed Tomography. In general, level 3 examinees performed better than level 2 examinees, and a relationship existed between the number of scans interpreted by the examinee or their time in practice and pass rate.32 Therefore, board certification may be considered as a surrogate for competency through experience-based or formal training program in cardiovascular CT. In recent years, the ABR proposal to develop an MOC Focused Practice pilot program in cardiac CT was approved by the American Board of Medical Specialties. Initiatives such as this one are designed for areas in clinical practice for which there are no ACGME-approved fellowships. Individuals who fulfill requirements will be listed on the ABR and ABMS websites as ABR board certified with focused practice recognition in cardiac CT. Applicants must be board certified in Diagnostic Radiology by the ABR for at least 1 year and enrolled in the ABR MOC program. Applicants must have completed at least 150 gated, contrast-enhanced cardiac CT examinations in the past 36 months, 75 of which are protocoled and interpreted by the applicant. Applicants should complete 4 www.thoracicimaging.com |
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TABLE 1. Summary of Requirements for the American College of Radiology Cardiac CT Certificate of Advanced Proficiency and the Board of Cardiovascular Computed Tomography Certification
Certificate of Advanced Proficiency Examination (CoAP)—ACR
Certification Board of Cardiovascular Computed Tomography
Medical License
Hold current, unrestricted medical license.
Board Certification and Training Experience
(1) Certification in Radiology by the ABR, AOBR, RCPSC, CdMdQ, or other recognized foreign equivalent; AND involvement in 150 cardiac CT studies in the past 36 mo, 75 of which must be primarily protocoled and interpreted by the applicant. OR (2) Completion of ACGME-approved or AOAapproved Radiology residency program as well as involvement in 500 CT cases of which at least 150 must be contrast-enhanced cardiac CT. Of these, 75 must be primarily protocoled and interpreted by the applicant in the past 36 mo. OR (3) Completion of ACGME-approved residency program, 200 AMA PRA Category 1 Credits, involvement in 500 CT cases of which at least 150 are contrast-enhanced cardiac CT and 75 of these primarily protocoled and interpreted by the applicant.
Continuing Medical Education
Minimum of 25 cardiovascular AMA PRA Category 1 Credits in the 24 mo preceding application, unless applying according to the path described above under (2).
Other
Filled application, supporting documentation, and examination fees.
Hold current, unrestricted medical license. Individuals holding a training medical license will gain Testamur status until a medical license is issued. Board certification in Cardiovascular Disease by the ABIM, certificate in Cardiology from the AOBIM; Board certification in Nuclear Medicine by the ABNM or AOBNM; Board certification in Radiology by the ABR or AOBR. Fellows and residents may sit for the examination in a Testamur status. Those training outside the United States must provide evidence of certification or letter of completion of training. Cardiology and Nuclear Medicine applicants: ACCF/AHA Level 2 (or 3) training: Level 2 training entails 150 contrast-enhanced cardiac CT examinations, for 50 of which the applicant must be physically present and involved with, AND evaluation of 50 noncontrast cardiac CT examinations. Radiology Applicants: (1). ACCF/AHA Level 2 (or 3) training. OR (2). Case requirements for cardiac CT as outlined by the ACR practice guidelines: supervision and/or interpretation of 50 contrast-enhanced cardiac CT cases in the 12 mo before application AND interpretation of 300 thoracic CT in the past 36 mo if qualified in thoracic CT or 500 general CT in the past 36 mo of which 100 are thoracic CT if not qualified in thoracic CT. ACCF/AHA Level 2 or 3 applicants: 20 h of Category 1 CME in general or cardiac CT in the 36 mo preceding application. ACR Practice Guidelines applicants: 30 h of Category 1 CME in cardiac CT and/or cardiac anatomy and physiology in the 36 mo preceding application if qualified in thoracic CT. If not qualified in thoracic CT, then 200 h of Category 1 CME are required. Filled application, supporting documentation, and examination fees.
ABIM indicates American Board of Internal Medicine; ABNM, American Board of Nuclear Medicine; ACGME, Accreditation Council for Graduate Medical Education; AOA, American Osteopathic Association; AOBIM, American Osteopathic Board of Internal Medicine; AOBNM, American Osteopathic Board of Internal Medicine; AOBR, American Osteopathic Board of Radiology; CdMdQ, le Colle`ge dus me´dicins du Que´bec; RCPSC, Royal College of Surgeons and Physicians of Canada.
ABR-qualified SAM in cardiac CT, at least 50 AMA PRA Category 1 Credits in cardiac CT, and 1 practice quality improvement project in cardiac CT. In addition, applicants must obtain a passing score on the ACR Cardiac CT Advanced Proficiency Examination. Recognized individuals are expected to fulfill requirements for continued participation, including a number of CME, SAM, and PQI projects in cardiac imaging during MOC cycle as well as a yet to be determined number of gated contrast-enhanced cardiac CT studies.
CONCLUSIONS In view of the many challenges that the present and future health care environment provide, the imaging community should make every effort to improve the value of its services by adhering to the available AC guidelines and setting in place a review process for the accreditation requirements of its members. Decision-support systems are
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a reality, and early adoption may prove to be beneficial in creating an environment for physician’s acceptance and utilization. REFERENCES 1. Agency for Healthcare Research and Quality, US Department of Health and Human Services. Your guide to choosing quality healthcare: a quick look at quality. Available at: http:// archive.ahrq.gov/consumer/qnt/qntqlook.htm. Accessed April 26, 2007. 2. Varkey P, Reller MK, Resar RK. Basics of quality improvement in health care. Mayo Clin Proc. 2007;82:735–739. 3. National Committee for Quality Assurance. The state of health care quality: 2004. Available at: http://www.ncqa.org/portals/ 0/Publications/Resource%20Library/SOHC/SOHC_2004.pdf. Accessed April 26, 2007. 4. Bautista AB, Burgos A, Nickel BJ, et al. Do clinicians use the American College of Radiology Appropriateness criteria in the management of their patients? Am J Roentgenol. 2009;192: 1581–1585. r
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5. American College of Radiology Website. ACR appropriateness criteria: background and development. Available at: http:// www.acr.org/Quality-Safety/Appropriateness-Criteria/About-AC. Accessed January 13, 2008. 6. Cascade PN. Setting appropriateness guidelines for Radiology. Radiology. 1994;192:50A–54A. 7. Statements and Guidelines from the American Heart Association and American Stroke Association. Available at: http:// my.americanheart.org/professional/StatementsGuidelines/State ments-Guidelines_UCM_316885_SubHomePage.jsp. Accessed January 13, 2014. 8. CARDIAC RADIONUCLIDE IMAGING WRITING GROUP, Hendel RC, Berman DS, Di Carli MF, et al. ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 Appropriate Use Criteria for Cardiac Radionuclide Imaging: A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the American Society of Nuclear Cardiology, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the Society of Cardiovascular Computed Tomography, the Society for Cardiovascular Magnetic Resonance, and the Society of Nuclear Medicine: Endorsed by the American College of Emergency Physicians. Circulation. 2009;119:e561–e587. 9. Levy G, Blachar A, Goldstein L, et al. Nonradiologist utilization of ACR appropriateness criteria in a preauthorization center for MRI requests: applicability and effects. Am J Roentgenol. 2006;187:855–858. 10. Rich ME, Utsunomiya D, Simprini LA, et al. Prospective evaluation of the updated 2010 ACCF Cardiac CT Appropriate Use Criteria. J Cardiovasc Comput Tomogr. 2012;6:108–112. 11. Wasfy MM, Brady TJ, Abbara S, et al. Comparison of cardiac computed tomography examination appropriateness under the 2010 revised versus the 2006 original Appropriate Use Criteria. J Cardiovasc Comput Tomogr. 2012;6:99–107. 12. Gurzun MM, Ionescu A. Appropriateness of use criteria for transthoracic echocardiography: are they relevant outside the USA? Eur Heart J Cardiovasc Imaging. 2014;15: 450–455. 13. Miller JA, Raichlin E, Williamson EE, et al. Evaluation of coronary CTA Appropriateness Criteria in an academic medical center. J Am Coll Radiol. 2010;7:125–131. 14. Bhatia RS, Milford CE, Picard MH, et al. An educational intervention reduces the rate of inappropriate echocardiograms on an inpatient medical service. JACC Cardiovasc Imaging. 2013;6:545–555. 15. Dym RJ1 Burns J, Taragin BH. Appropriateness of imaging studies ordered by emergency medicine residents: results of an online survey. Am J Roentgenol. 2013;201:W619–W625. 16. Leschied JR, Knoepp US, Hoff CN, et al. Emergency radiology elective improves second-year medical students’ perceived confidence and knowledge of appropriate imaging utilization. Acad Radiol. 2013;20:1168–1176. 17. Covington MF, Agan DL, Liu Y, et al. Teaching costconscious medicine: impact of a simple educational intervention on appropriate abdominal imaging at a community-based teaching hospital. J Grad Med Educ. 2013;5:284–288. 18. Strother MK, Robert EC, Cobb JG, et al. Reduction in the number and associated costs of unindicated dual-phase head CT examinations after a quality improvement initiative. Am J Roentgenol. 2013;201:1049–1056. 19. Griffith B, Vallee P, Krupp S, et al. Screening cervical spine CT in the emergency department, phase 3: increasing effectiveness of imaging. J Am Coll Radiol. 2014;11:139–144. 20. Kanaan Y, Knoepp UD, Kelly AM. The influence of education on appropriateness rates for CT pulmonary angiography in emergency department patients. Acad Radiol. 2013;20:1107–1114. 21. Krishnaraj A, Weinreb JC, Ellenbogen PH, et al. Radiology in 2022: challenges and opportunities in the coming decadeproceedings of the 12th Annual ACR Forum. J Am Coll Radiol. 2013;10:15–20. r
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