H e a l t h C a r e Po l i c y a n d Q u a l i t y • R ev i ew
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Griffith et al. Practice Quality Improvement Health Care Policy and Quality Review
Improving Imaging Utilization Through Practice Quality Improvement (Maintenance of Certification Part IV): A Review of Requirements and Approach to Implementation
Brent Griffith1 Manuel L. Brown1 Rajan Jain2
OBJECTIVE. The purposes of this article are to review the American Board of Radiology requirements for practice quality improvement and to describe our approach to improving imaging utilization while offering a guide to implementing similar projects at other institutions, emphasizing the plan-do-study-act approach. CONCLUSION. There is increased emphasis on improving quality in health care. Our institution has undertaken a multiphase practice quality improvement project addressing the appropriate utilization of screening cervical spinal CT in an emergency department.
Griffith B, Brown ML, Jain R
I
Keywords: imaging utilization, maintenance of certification, practice quality improvement DOI:10.2214/AJR.13.11607 Received July 23, 2013; accepted after revision September 20, 2013. 1 Department of Radiology, Henry Ford Health System, 2799 W Grand Blvd, Detroit, MI 48202. Address correspondence to B. Griffith ([email protected]). 2 Department of Radiology, New York University Langone Medical Center, New York, NY.
mproving quality and safety remains a major focus in health care. In 2001, the Department of Health and Human Services and the Centers for Medicare and Medicaid Services began quality initiatives for assuring quality health care “through accountability and public disclosures” [1]. Insurance companies, too, have become more actively involved in quality assurance measures with the institution of programs specifically aimed at improving quality and service [2]. More importantly, however, patients themselves now bear a greater share of their own health care costs and are increasingly encouraged to become engaged in their health care choices and, in doing so, compel providers to improve the quality of care [3, 4]. This new emphasis on quality improvement could not have come at a better time for radiology, which has struggled in recent years with a push toward commoditization of imaging [5]. Although radiology offers many opportunities to improve quality, one area of particular importance is addressing the appropriate use of imaging. The dependence of health care on imaging and the growing need to reduce health care costs have positioned radiology to take a central role in addressing these issues.
This article is available for credit. AJR 2014; 202:797–802 0361–803X/14/2024–797 © American Roentgen Ray Society
Value-Added Reimbursement: A Change in Thinking Beyond the demands for improved quality, reimbursement itself is increasingly linked to performance and quality metrics rather than
payment for simple delivery of a service [2]. According to a 2013 report by the Medical Group Management Association, in 2012, 2% of total compensation for specialists was based on quality metrics [6]. An example of this quality-based reimbursement is the federally mandated Physician Quality Reporting System (PQRS), which uses a combination of incentive payments and payment adjustments to promote the reporting of quality information [7]. Beginning in 2015, a payment adjustment will be applied to those failing to satisfactorily report data on quality measures for covered professional services [7]. In addition to the PQRS incentive, the Centers for Medicare and Medicaid Services allows physicians to earn an additional 0.5% incentive payment between 2011 and 2014 for reporting quality metric data through a maintenance of certification (MOC) program [8]. Qualification for this extra incentive requires successful participation in PQRS for 1 calendar year; participation in an MOC program; and successful completion of a qualified MOC program practice assessment [8]. Regarding this final requirement, a qualified MOC program practice assessment is defined as one that includes an initial assessment of the practice showing use of evidence-based medicine; a survey of patient experience with care; implementation of a quality improvement intervention to address a practice weakness identified in the initial assessment; and reassessment of performance improvement after the intervention [9].
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Griffith et al. Maintenance of Certification: The New Standard To address the many new challenges facing health care providers, particularly given the increased demands for accountability and public disclosures, the American Board of Medical Specialties mandated the institution of specialty-specific MOC programs. The MOC program for diagnostic radiology was initiated in 2007 and greatly influenced the way the American Board of Radiology (ABR) and those it certifies interact—moving away from a system based on limited interactions during residency toward one characterized by a continuous relationship throughout one’s professional career [10]. The objective of the new MOC process was to “improve the quality of health care through diplomate-initiated learning and quality improvement” [10]. Through the MOC process, participating physicians show a commitment to lifelong learning and ongoing self-assessment in six core competencies: professionalism, patient care and procedural skills, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, and systems-based practice [11]. Although the criteria for MOC vary by specialty, the MOC process itself is standard and includes the following four parts: I, professional standing; II, lifelong learning and periodic self-assessment; III, cognitive expertise; and IV, evaluation of practice performance [11]. Part IV: Evaluation of Practice Performance Shifts toward quality-based reimbursement have compelled medical professionals, including radiologists, to justify their contributions to improving the quality of patient care. Documenting this influence on quality of care is central to maintaining the integral role of radiology in health care delivery. With its emphasis on critical evaluation of one’s own performance in practice, part IV of the MOC process, referred to as practice quality improvement (PQI), provides a means by which the aforementioned goals can be achieved. Through part IV, radiologists “demonstrate commitment to practice quality improvement and competence in clinical practice” and are required to select projects that can “improve the quality of the diplomate’s practice and enhance quality of care” [10]. PQI projects may be completed individually or by groups, institutions, or societies. Regardless of the number of participants, to satisfy the ABR part IV requirements, a project must be relevant to one’s practice, be achievable in 798
one’s practice setting, produce results suited for repeat measurement during an MOC cycle, and be reasonably expected to result in quality improvement [12]. To meet the needs of a diverse group of radiology practices, the ABR identified five PQI topic categories: patient safety, accuracy of interpretation, report turnaround time, practice guidelines and technical standards, and referring physician surveys [10]. Although the number of PQI projects to be completed once was defined for a specific 10year MOC cycle and depended on one’s cycle starting date and discipline [13], the ABR implemented a new process, known as continuous certification, beginning with certificates issued in 2012 [14]. In this new system, progress is evaluated annually in March with a rolling calendar year look-back. To obtain the status of meeting requirements, candidates must have completed at least one PQI project in the previous 3 years [14]. Pathway to Success: Plan-DoStudy-Act Plan-do-study-act (PDSA) is a four-step process used for continuous quality improvement and is an important tool used to link repeated PQI cycles [13]. After an initial cycle to obtain baseline data, repeated cycles are performed to assess the effects of the quality improvement initiatives [13]. Because of the importance of each PDSA step in successful completion of PQI projects, understanding the components of a step is essential. Initially, participants should identify a practice area in need of improvement and devise a measurement to assess the degree of change needed, develop a plan to implement the measure and obtain the required data, and set a target or goal to reach the measure (plan) [13]. The plan should then be implemented and the data collected (do) [13]. The measurements are then compared with the desired goal, and possible causes of failing to achieve the goal are evaluated (study) [13]. Finally, means of addressing the causes of failing to achieve the goal are considered, and an improvement plan for the next PDSA cycle is developed (act) [13]. After implementation of the improvement plan, the next PDSA cycle should be started and the degree of improvement assessed [13]. This process can be repeated until the goal is met or be performed periodically to assess the stability of the improvement [13]. Practice Quality Improvement in Action: Addressing Utilization of Imaging An example of using the principles of PDSA to improve the quality of care in a spe-
cific clinical scenario is utilization of imaging. Inappropriate use of imaging (i.e., overuse) has become a topic of great interest in recent years, particularly given the increased focus on reducing health care costs. In addition, heightened awareness of medical radiation exposure has led to further scrutiny of imaging modalities, such as CT, that are associated with higher levels of radiation. Although inappropriate use of imaging, or overuse, is often loosely applied, it is generally considered use of an imaging procedure that is unlikely to improve patient outcome [15]. For the purposes of this discussion, however, inappropriate imaging studies are considered those ordered despite the presence of guidelines or criteria suggesting that imaging is not warranted. In 2009 at our institution, a collaborative group composed of neuroradiologists and emergency department physicians undertook a multiphase PQI project aimed at decreasing the inappropriate use of screening cervical spinal CT in the emergency department after blunt trauma (Fig. 1). All phases of the project were HIPAA compliant and approved by our institutional review board. The following sections describe the step-by-step approach taken to complete this project and serve as a template for implementing similar PQI projects aimed at improving utilization of imaging services. They emphasize our use of the PDSA approach. Phase 1: Identifying the Problem Step 1: Plan—Identifying and Describing the Project Topic—The goal was to increase appropriate use of screening cervical spinal CT in the emergency department after blunt trauma. Rationale—Although inappropriate use of health care resources, including imaging, occurs throughout medicine, this project focused on the use of screening cervical spinal CT in the emergency department after blunt trauma, a frequent reason for patient presentation to emergency departments across the country. Evidence-based clinical guidelines have been established to assist clinicians in determining which patients are most likely to benefit from cervical spinal imaging. Despite these guidelines, physicians often have a low threshold for ordering imaging of the cervical spine, likely in part because of fear of disastrous consequences associated with delayed diagnosis. This, in turn, leads to a high number of cervical spinal CT scans with normal findings in this setting and unnecessary radiation exposure to a substantial number of patients. The goal of phase 1 was to assess the degree of cliAJR:202, April 2014
Practice Quality Improvement
Phase 1
Phase 2
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PLAN ACT
Cycle 1
Phase 3
PLAN DO
ACT
STUDY
PLAN
Cycle 2
DO
ACT
Cycle 3
STUDY
2009
STUDY
2011 Survey Introduction
DO
2012 Clinical Education Program
Fig. 1—Flowchart shows overall process of multiphase practice quality improvement project including plando-study-act cycles.
nician adherence to evidence-based guidelines when ordering imaging of the cervical spine after blunt trauma. Designing a metric for inappropriate use— In establishing a metric for assessing potentially inappropriate studies, regardless of the modality or the indication, clinical criteria used by clinicians to determine the appropriateness of a study must be ascertained. In the current study of the use of cervical spinal CT after blunt trauma, we focused on the National Emergency X-Radiography Utilization Study (NEXUS) low-risk criteria [16]. The NEXUS criteria, which were established in 2000, are used along with the Canadian Cervical Spine Rule (CCR) as part of the American College of Radiology (ACR) Appropriateness Criteria for determining the need for imaging of the cervical spine in patients who have sustained trauma [17]. To meet the NEXUS criteria, a patient must have the following: no tenderness at the posterior midline of the cervical spine, no focal neurologic deficit, normal level of alertness, no evidence of intoxication, and no clinically apparent, painful injury that might distract the patient from the pain of a cervical spinal injury [16]. Patients meeting these criteria are considered to be at low risk of cervical spinal injury, and therefore, imaging of the cervical spine is not considered indicated. Thus for the purposes of this study, CT was considered not appropriate if performed despite the patient’s meeting the NEXUS criteria for not undergoing imaging. Study design—The next step is establishing a method of identifying potentially inappropriate studies, which can be performed either prospectively or retrospectively by reviewing medical records after study completion. Phase 1 was designed as a retrospective review of all cervical spinal CT studies performed for blunt trauma within a 1-year period at our institution’s level I trauma center [18]. The medical records of all eligible pa-
tients, identified through a search of radiology information systems, were reviewed to identify the presence of cervical spinal injury and to document the five NEXUS criteria. Step 2: Do—Baseline Measurement Summary Using the previously determined metric (i.e., meeting the NEXUS criteria for low risk of injury), we assessed the number of potentially inappropriate studies and calculated the degree of overuse (Fig. 2). In addition, the rate of positive findings (cervical spinal injury in the current study) can be measured, providing an additional metric for assessing changes in utilization practices after implementation of an improvement plan. In this phase of the project, only 41 of 1589 (2.6%) cervical spinal CT examinations performed on eligi-
ble patients showed signs of acute cervical spine injury [16]. Of the remaining CT examinations, 1524 (95.9%) patients had negative findings for acute injury and 24 (1.5%) had indeterminate findings, although they were not found to have acute injury at subsequent imaging and clinical follow-up [16]. Of the 1524 patients without acute injury, 364 (23.9%) had no documentation of any of the five NEXUS criteria and therefore could have potentially avoided imaging [18]. Although phase 1 was not designed to test the actual performance of the NEXUS criteria, we did find that among the CT studies performed on patients meeting the NEXUS criteria for not undergoing imaging (372 studies), four (1.1%) had positive findings of acute injury and four had indeterminate findings [18]. However, none of these injuries were unstable or required surgical intervention [18]. Step 3: Study—Data Analysis The purpose of evidence-based guidelines, such as those in the ACR Appropriateness Criteria, is to assist providers in “making the most appropriate imaging or treatment decision for a specific clinical condition” [19]. Although the ultimate goal is to have as few inappropriate studies as possible, situations arise in which imaging studies are ordered on the basis of clinician judgment even though they do not meet the appropriate guidelines.
Total studies 2224
419 Performed at satellite facility
Level I trauma center studies
1805
216 Excluded as a result of additional criteria
1589
Included studies
Documented NEXUS criteria
+ 1217
− 372
CT results 37
1160
20
4
364
4
+
−
Indeterminate
+
−
Indeterminate
Fig. 2—Flowchart shows breakdown of study subjects in phase 1 according to National Emergency X-Radiography Utilization Study (NEXUS) low-risk criteria and CT results. (Reprinted from [18])
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Griffith et al. In phase 1, results of the retrospective review [18] showed that approximately 24% (364/1524) of screening cervical spinal CT examinations were potentially inappropriate according to strict application of the NEXUS criteria as documented. Those results also showed the sensitivity of the NEXUS criteria to be only 90.2%, which is significantly less than the 99% sensitivity cited in the NEXUS study itself [16, 18]. However, a number of limitations were also identified, foremost being those attributable to the retrospective nature of the study, which limited data to the information recorded by medical personnel at the patient’s presentation. Step 4: Act—Improvement Plan Given the limitations of the study and a desire to establish a prospective baseline for overuse before implementing an improvement plan, a collaborative study (phase 2) was planned between the departments of radiology and emergency medicine [20]. These results would be used to assess the degree of improvement after a planned intervention. In addition, the information obtained in phase 2 would help identify potential root causes of overuse. Phase 2: Investigating the Issues Step 5: Plan—Cycle 2 Phase 2 was designed to prospectively determine the number of potentially avoidable cervical spinal CT studies based on proper application of established clinical guidelines and to assess clinician reasons for ordering studies in the absence of these criteria. During this phase, which occurred over a 9-month period, all patients presenting to the emergency department after blunt trauma who underwent screening CT of the cervical spine and met the appropriate inclusion criteria were eligible [20]. For each patient, ordering clinicians completed a survey (Fig. 3) documenting mechanism of injury, indication for ordering the study, and clinical suspicion of cervical spine injury. Indications available on the survey included the five NEXUS criteria and abbreviated CCR criteria, among other indications. CT images were then interpreted by a board-certified radiologist blinded to the survey information [20]. Step 6: Do—Repeat Measurement Summary During Phase 2, 1391 eligible patients were identified, 507 (36.4%) of whom were enrolled during the 9-month study period [20]. Surveys were not completed for the other 63.5% of patients, likely because of the setting in which
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BLUNT TRAUMA CERVICAL SPINE CT PROSPECTIVE STUDY Evaluator (please circle): Staff Date: Patient MRN:
/
Resident
/
PA
/
Other:
Exclusion Criteria: (Circle all that apply; if “yes” to any, do not complete remaining questions) Age < 18 yrs Penetrating injury Known C-spine fracture or dislocation/subluxation Transfer patient Remote injury (> 48 hrs) Mechanism of Injury (please circle): Fall
MVA
Assault
Pedestrian vs Motor vehicle
Other (specify):
Reason for Study (please circle number of all that apply): 1 2 3 4 5 6
7 8 9 10 11 12 13 14 15 16
Posterior midline cervical spine tenderness Suspected intoxication Altered level of consciousness/alertness Focal neurologic deficit Distracting injury Dangerous mechanism by Canadian Cervical Spine Rule (include: Fall from height > 3 ft or 5 stairs; Axial load to head; MVA at speed > 100 km/hr or 62 mph or with rollover or ejection; Collision involving motorized recreational vehicle; or Bicycle injury) Dangerous Mechanism (Other: ) Age > 65 yrs Paresthesias in extremities Inability to actively rotate neck (limited or painful range of motion) Paravertebral tenderness Suspicious C-spine radiographs Intracranial injury on Head CT Complains of neck pain Study requested by consulting service (Name of Service: ) Other (please specify):
Clinical Suspicion for Cervical Spine Injury (1 − very unlikely; 5 − very likely) 1
2
3
4
5
Fig. 3—Survey completed by clinicians for each enrolled patient in phases 2 and 3. (Used with permission from B. Griffith, et al. Screening cervical spine CT in the emergency department, phase 2: a prospective assessment of use. AJNR 34(4): 899–903, 2013 © by American Society of Neuroradiology)
the study was performed, a busy level I trauma center, where clinicians may not have the time or do not remember to fill out a survey [20]. A subset analysis was performed to analyze characteristics of enrolled and nonenrolled patients to ensure no selection bias [20]. As in phase 1, the rate of positive findings of injury and the number of potentially inappropriate studies according to strict application of evidence-based guidelines (NEXUS criteria) were determined. Of the 507 cervical spinal CT examinations performed on enrolled patients, five (1.0%) had positive findings of acute cervical spine injury [20]. Of the examinations with negative findings, 81 met all five NEXUS criteria for patients not requiring imaging. Of the 416 patients eligible for evaluation according to the CCR criteria (normal level of alertness), 119 had none of the abbreviated criteria and should
not have undergone imaging. In addition, 38 patients without acute injury were deemed not to need imaging when both the NEXUS and the abbreviated CCR criteria were appropriately applied [20]. Step 7: Study—Remeasurement Data Analysis The phase 2 findings confirmed those of phase 1: A large number of patients could have been spared cervical spinal CT if appropriate clinical guidelines had been followed (16% by NEXUS; 29% by abbreviated CCR; 8% by application of either criteria). In addition, there was a significant decrease in overuse from 24% to 16% (p < 0.001) between phases 1 and 2 after institution of the clinician survey, suggesting that the survey may have acted as a reminder for ordering clinicians [20]. Further analysis showed that of all studies ordered by staff physicians, only 9.6% did not require imaging by
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Practice Quality Improvement NEXUS criteria versus 17.3% for residents and physician assistants. These findings were consistent with staff physicians’ stricter adherence to clinical guidelines [20]. This finding suggested that further education, especially of residents and midlevel providers, may improve adherence to clinical guidelines and in doing so decrease overuse. In addition, although four patients with cervical spinal injury would not have undergone imaging in phase 1 if the NEXUS criteria had been strictly followed, all cases of cervical spinal injury in phase 2 were found through proper application of both the NEXUS and abbreviated CCR criteria [20]. Possible root causes of inappropriate use were then considered. These included lack of knowledge or awareness of guidelines or failure to remember the guidelines, lack of trust in the guidelines, complex guidelines that are difficult to apply or interpret, failure to accurately document the appropriate criteria, and clinical judgment based on patient- or scenario-specific factors. Step 8: Act—Project Decision Point Using the results of phases 1 and 2 (two PDSA cycles) as guides, radiologists and their collaborators in the department of emergency medicine developed an improvement plan. The goal of the plan was to address the possible root causes of overuse, focusing specifically on the causes suggested by the phase 2 findings. Phase 3: Implementing a Plan for Improvement Given the possible root causes identified in phase 2, it was decided to initiate a clinical education program for clinicians in the emergency department regarding appropriate use of screening cervical spinal CT in the setting of blunt trauma. This clinical education program included a 45-minute lecture discussing both the findings of the phase 1 and phase 2 studies and current clinical guidelines for ordering cervical spinal imaging in the setting of blunt trauma with specific emphasis on the ACR Appropriateness Criteria (CCR and NEXUS) [21]. Although the intention was to educate all clinicians ordering cervical spinal CT examinations in the emergency department, attendance was not tracked. We were also unable to control for clinicians newly entering the system, in part because of the educational setting in which the study was performed. However, reminders of the study and the ACR Appropriateness Criteria were posted throughout the emergency department.
After the intervention, prospective assessment of utilization was repeated with the same method as in phase 2. Results in phase 3 showed that the rate of potentially inappropriate studies (according to strict application of the NEXUS criteria) decreased to 13%, from 16% in phase 2 and 24% in phase 1 [21]. In addition, of the 388 cervical spinal CT examinations performed, 12 (3.1%) had positive findings of acute cervical spinal injury. This rate increased from 1% before implementation of the clinical education program, suggesting improved clinical effectiveness of the imaging studies being performed, an expected result of stricter adherence to evidence-based criteria [21]. The improvement in utilization after implementation of the clinical education program, although modest, did suggest clinician education may help address issues of inappropriate imaging. More importantly, however, it appears that the greatest improvement in utilization occurred between phases 1 and 2. Although the decrease in inappropriate imaging was likely due in part to improved documentation, we believe it also suggests that simply engaging clinicians and raising awareness through something as simple as a survey can alter ordering practices [21]. It also emphasizes the importance of involving other departments and clinicians in this process as part of a collaborative effort to address issues of imaging utilization. Finally, given the continued overuse in phase 3 (13%) despite the survey and clinical education program, the findings suggest that other root causes, including physician trust in the guidelines and complexity of the guidelines, must be addressed. Steps 9 and 10: Participant’s Narrative Self-Reflection Statement and Attestation After completion of the PQI project, a short narrative must be completed discussing the project’s effect on the participant’s practice or patients, including any improvements resulting from the project [13]. Finally, participants must complete an attestation of project completion on their ABR personal database [13]. Conclusions PQI is essential to the practice of medicine and is an important aspect of quality patient care. In addition, shifts toward quality-based reimbursement and changes to the MOC process have increased emphasis on practice quality improvement. Active involvement in practice quality improvement, particular-
ly collaborative efforts focusing on the quality and safety of patient care, is important to the future of radiology. Given the essential role that imaging plays in health care, issues of appropriate utilization will only increase, particularly as efforts to contain health care costs continue. Radiologists must assert their expertise in imaging to address utilization issues, thereby ensuring patients continue to receive the most appropriate and effective care. This project shows the potential influence of active radiologist involvement in issues of imaging utilization and offers a guide for implementing similar measures addressing utilization of imaging services across the health care spectrum. Acknowledgment We thank Stephanie Stebens, Sladen Library Henry Ford Hospital, for assistance in manuscript preparation. References 1. Centers for Medicare and Medicaid website. Quality initiatives: general information. www. cms.gov/Medicare/Quality-Initiatives-PatientAssessment-Instruments/QualityInitiativesGenInfo/index.html?redirect=/qualityinitiativesgeninfo. Published 2013. Accessed June 28, 2013 2. Thrall JH. The emerging role of pay-for-performance contracting for health care services. Radiology 2004; 233:637–640 3. Shaller D, Sofaer S, Findlay SD, Hibbard JH, Lansky D, Delbanco S. Consumers and quality-driven health care: a call to action. Health Aff (Millwood) 2003; 22:95–101 4. Bipartisan Policy Center Health Information Technology Initiative. Improving quality and reducing costs in health care: engaging consumers using electronic tools. Washington, DC: Bipartisan Policy Center, 2012 5. Hobson C. Adapting to change: in a time of declining reimbursements and increasing government regulations, radiologists evolve to remain integral members of the health-care community. ACR Bulletin 2013; 2013:10–13 6. Medical Group Management Association. MGMA physician compensation and production 2013 report based on 2012 data. Englewood, CO: MGMA, 2013 7. Centers for Medicare and Medicaid Services website. Physician quality reporting system. www.cms. gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html?redirect=/ PQRS. Published 2013. Accessed June 28, 2013 8. Centers for Medicare and Medicaid Services website. Maintenance of certification program incentive. www.cms.gov/Medicare/Quality-Initiatives-PatientAssessment-Instruments/PQRS/Maintenance_of_
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Griffith et al. Certification_Program_Incentive.html. Published 2013. Accessed June 28, 2013 9. Centers for Medicare and Medicaid Services website. The physician quality reporting system maintenance of certification program incentive requirements for 2013. www.cms.gov/Medicare/Quality-InitiativesPatient-Assessment-Instruments/PQRS/Downloads/ 2013-MOC_Qualification_Requirements.pdf. Published December 11, 2012. Accessed June 28, 2013 10. Strife JL, Kun LE, Becker GJ, et al. The American Board of Radiology perspective on maintenance of certification, part IV: practice quality improvement for diagnostic radiology. Radiology 2007; 243:309–313 11. American Board of Medical Specialties website. Fact sheet: American Board of Medical Specialties (ABMS) and the ABMS maintenance of certification (ABMS MOC) program. www.abms.org/ News_and_Events/Media_Newsroom/pdf/ABMS _Fact_sheet.pdf. Published March 29, 2013. Ac-
cessed June 28, 2013 12. American Board of Radiology website. Guidelines for practice quality improvement (PQI) projects. www. theabr.org/moc-dr-pqiguides. Accessed June 28, 2013 13. American Board of Radiology website. Maintenance of certification Part IV: ABR guide to practice quality improvement 2012. www.theabr.org/ sites/all/themes/abr-media/PQI_2012.pdf. Published March 6, 2012. Accessed June 28, 2013 14. American Board of Radiology website. MOC: maintenance of certification. www.theabr.org/moc-landing. Published June 2013. Accessed June 28, 2013 15. Hendee WR, Becker GJ, Borgstede JP, et al. Addressing overutilization in medical imaging. Radiology 2010; 257:240–245 16. Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. N Engl J Med
2000; 343:94–99 17. Daffner RH, Hackney DB. ACR Appropriateness Criteria on suspected spine trauma. J Am Coll Radiol 2007; 4:762–775 18. Griffith B, Bolton C, Goyal N, Brown ML, Jain R. Screening cervical spine CT in a level I trauma center: overutilization? AJR 2011; 197:463–467 19. American College of Radiology website. ACR appropriateness criteria. www.acr.org/Quality-Safety/Appropriateness-Criteria. Published 2013. Accessed June 28, 2013 20. Griffith B, Kelly M, Vallee P, et al. Screening cervical spine CT in the emergency department, phase 2: a prospective assessment of use. AJNR 2013; 34:899–903 21. Griffith B, Vallee P, Krupp S, et al. Screening cervical spine CT in the emergency department, phase 3: increasing effectiveness of imaging through improved adherence to appropriateness criteria. J Am Coll Radiol 2013 Sep 10 [Epub ahead of print]
F O R YO U R I N F O R M AT I O N
This article is available for CME and Self-Assessment (SA-CME) credit that satisfies Part II requirements for maintenance of certification (MOC). To access the examination for this article, follow the prompts associated with the online version of the article.
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Griffith et al. Practice Quality Improvement Health Care Policy and Quality Review
Improving Imaging Utilization Through Practice Quality Improvement (Maintenance of Certification Part IV): A Review of Requirements and Approach to Implementation
Brent Griffith1 Manuel L. Brown1 Rajan Jain2
OBJECTIVE. The purposes of this article are to review the American Board of Radiology requirements for practice quality improvement and to describe our approach to improving imaging utilization while offering a guide to implementing similar projects at other institutions, emphasizing the plan-do-study-act approach. CONCLUSION. There is increased emphasis on improving quality in health care. Our institution has undertaken a multiphase practice quality improvement project addressing the appropriate utilization of screening cervical spinal CT in an emergency department.
Griffith B, Brown ML, Jain R
I
Keywords: imaging utilization, maintenance of certification, practice quality improvement DOI:10.2214/AJR.13.11607 Received July 23, 2013; accepted after revision September 20, 2013. 1 Department of Radiology, Henry Ford Health System, 2799 W Grand Blvd, Detroit, MI 48202. Address correspondence to B. Griffith ([email protected]). 2 Department of Radiology, New York University Langone Medical Center, New York, NY.
mproving quality and safety remains a major focus in health care. In 2001, the Department of Health and Human Services and the Centers for Medicare and Medicaid Services began quality initiatives for assuring quality health care “through accountability and public disclosures” [1]. Insurance companies, too, have become more actively involved in quality assurance measures with the institution of programs specifically aimed at improving quality and service [2]. More importantly, however, patients themselves now bear a greater share of their own health care costs and are increasingly encouraged to become engaged in their health care choices and, in doing so, compel providers to improve the quality of care [3, 4]. This new emphasis on quality improvement could not have come at a better time for radiology, which has struggled in recent years with a push toward commoditization of imaging [5]. Although radiology offers many opportunities to improve quality, one area of particular importance is addressing the appropriate use of imaging. The dependence of health care on imaging and the growing need to reduce health care costs have positioned radiology to take a central role in addressing these issues.
This article is available for credit. AJR 2014; 202:797–802 0361–803X/14/2024–797 © American Roentgen Ray Society
Value-Added Reimbursement: A Change in Thinking Beyond the demands for improved quality, reimbursement itself is increasingly linked to performance and quality metrics rather than
payment for simple delivery of a service [2]. According to a 2013 report by the Medical Group Management Association, in 2012, 2% of total compensation for specialists was based on quality metrics [6]. An example of this quality-based reimbursement is the federally mandated Physician Quality Reporting System (PQRS), which uses a combination of incentive payments and payment adjustments to promote the reporting of quality information [7]. Beginning in 2015, a payment adjustment will be applied to those failing to satisfactorily report data on quality measures for covered professional services [7]. In addition to the PQRS incentive, the Centers for Medicare and Medicaid Services allows physicians to earn an additional 0.5% incentive payment between 2011 and 2014 for reporting quality metric data through a maintenance of certification (MOC) program [8]. Qualification for this extra incentive requires successful participation in PQRS for 1 calendar year; participation in an MOC program; and successful completion of a qualified MOC program practice assessment [8]. Regarding this final requirement, a qualified MOC program practice assessment is defined as one that includes an initial assessment of the practice showing use of evidence-based medicine; a survey of patient experience with care; implementation of a quality improvement intervention to address a practice weakness identified in the initial assessment; and reassessment of performance improvement after the intervention [9].
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Griffith et al. Maintenance of Certification: The New Standard To address the many new challenges facing health care providers, particularly given the increased demands for accountability and public disclosures, the American Board of Medical Specialties mandated the institution of specialty-specific MOC programs. The MOC program for diagnostic radiology was initiated in 2007 and greatly influenced the way the American Board of Radiology (ABR) and those it certifies interact—moving away from a system based on limited interactions during residency toward one characterized by a continuous relationship throughout one’s professional career [10]. The objective of the new MOC process was to “improve the quality of health care through diplomate-initiated learning and quality improvement” [10]. Through the MOC process, participating physicians show a commitment to lifelong learning and ongoing self-assessment in six core competencies: professionalism, patient care and procedural skills, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, and systems-based practice [11]. Although the criteria for MOC vary by specialty, the MOC process itself is standard and includes the following four parts: I, professional standing; II, lifelong learning and periodic self-assessment; III, cognitive expertise; and IV, evaluation of practice performance [11]. Part IV: Evaluation of Practice Performance Shifts toward quality-based reimbursement have compelled medical professionals, including radiologists, to justify their contributions to improving the quality of patient care. Documenting this influence on quality of care is central to maintaining the integral role of radiology in health care delivery. With its emphasis on critical evaluation of one’s own performance in practice, part IV of the MOC process, referred to as practice quality improvement (PQI), provides a means by which the aforementioned goals can be achieved. Through part IV, radiologists “demonstrate commitment to practice quality improvement and competence in clinical practice” and are required to select projects that can “improve the quality of the diplomate’s practice and enhance quality of care” [10]. PQI projects may be completed individually or by groups, institutions, or societies. Regardless of the number of participants, to satisfy the ABR part IV requirements, a project must be relevant to one’s practice, be achievable in 798
one’s practice setting, produce results suited for repeat measurement during an MOC cycle, and be reasonably expected to result in quality improvement [12]. To meet the needs of a diverse group of radiology practices, the ABR identified five PQI topic categories: patient safety, accuracy of interpretation, report turnaround time, practice guidelines and technical standards, and referring physician surveys [10]. Although the number of PQI projects to be completed once was defined for a specific 10year MOC cycle and depended on one’s cycle starting date and discipline [13], the ABR implemented a new process, known as continuous certification, beginning with certificates issued in 2012 [14]. In this new system, progress is evaluated annually in March with a rolling calendar year look-back. To obtain the status of meeting requirements, candidates must have completed at least one PQI project in the previous 3 years [14]. Pathway to Success: Plan-DoStudy-Act Plan-do-study-act (PDSA) is a four-step process used for continuous quality improvement and is an important tool used to link repeated PQI cycles [13]. After an initial cycle to obtain baseline data, repeated cycles are performed to assess the effects of the quality improvement initiatives [13]. Because of the importance of each PDSA step in successful completion of PQI projects, understanding the components of a step is essential. Initially, participants should identify a practice area in need of improvement and devise a measurement to assess the degree of change needed, develop a plan to implement the measure and obtain the required data, and set a target or goal to reach the measure (plan) [13]. The plan should then be implemented and the data collected (do) [13]. The measurements are then compared with the desired goal, and possible causes of failing to achieve the goal are evaluated (study) [13]. Finally, means of addressing the causes of failing to achieve the goal are considered, and an improvement plan for the next PDSA cycle is developed (act) [13]. After implementation of the improvement plan, the next PDSA cycle should be started and the degree of improvement assessed [13]. This process can be repeated until the goal is met or be performed periodically to assess the stability of the improvement [13]. Practice Quality Improvement in Action: Addressing Utilization of Imaging An example of using the principles of PDSA to improve the quality of care in a spe-
cific clinical scenario is utilization of imaging. Inappropriate use of imaging (i.e., overuse) has become a topic of great interest in recent years, particularly given the increased focus on reducing health care costs. In addition, heightened awareness of medical radiation exposure has led to further scrutiny of imaging modalities, such as CT, that are associated with higher levels of radiation. Although inappropriate use of imaging, or overuse, is often loosely applied, it is generally considered use of an imaging procedure that is unlikely to improve patient outcome [15]. For the purposes of this discussion, however, inappropriate imaging studies are considered those ordered despite the presence of guidelines or criteria suggesting that imaging is not warranted. In 2009 at our institution, a collaborative group composed of neuroradiologists and emergency department physicians undertook a multiphase PQI project aimed at decreasing the inappropriate use of screening cervical spinal CT in the emergency department after blunt trauma (Fig. 1). All phases of the project were HIPAA compliant and approved by our institutional review board. The following sections describe the step-by-step approach taken to complete this project and serve as a template for implementing similar PQI projects aimed at improving utilization of imaging services. They emphasize our use of the PDSA approach. Phase 1: Identifying the Problem Step 1: Plan—Identifying and Describing the Project Topic—The goal was to increase appropriate use of screening cervical spinal CT in the emergency department after blunt trauma. Rationale—Although inappropriate use of health care resources, including imaging, occurs throughout medicine, this project focused on the use of screening cervical spinal CT in the emergency department after blunt trauma, a frequent reason for patient presentation to emergency departments across the country. Evidence-based clinical guidelines have been established to assist clinicians in determining which patients are most likely to benefit from cervical spinal imaging. Despite these guidelines, physicians often have a low threshold for ordering imaging of the cervical spine, likely in part because of fear of disastrous consequences associated with delayed diagnosis. This, in turn, leads to a high number of cervical spinal CT scans with normal findings in this setting and unnecessary radiation exposure to a substantial number of patients. The goal of phase 1 was to assess the degree of cliAJR:202, April 2014
Practice Quality Improvement
Phase 1
Phase 2
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PLAN ACT
Cycle 1
Phase 3
PLAN DO
ACT
STUDY
PLAN
Cycle 2
DO
ACT
Cycle 3
STUDY
2009
STUDY
2011 Survey Introduction
DO
2012 Clinical Education Program
Fig. 1—Flowchart shows overall process of multiphase practice quality improvement project including plando-study-act cycles.
nician adherence to evidence-based guidelines when ordering imaging of the cervical spine after blunt trauma. Designing a metric for inappropriate use— In establishing a metric for assessing potentially inappropriate studies, regardless of the modality or the indication, clinical criteria used by clinicians to determine the appropriateness of a study must be ascertained. In the current study of the use of cervical spinal CT after blunt trauma, we focused on the National Emergency X-Radiography Utilization Study (NEXUS) low-risk criteria [16]. The NEXUS criteria, which were established in 2000, are used along with the Canadian Cervical Spine Rule (CCR) as part of the American College of Radiology (ACR) Appropriateness Criteria for determining the need for imaging of the cervical spine in patients who have sustained trauma [17]. To meet the NEXUS criteria, a patient must have the following: no tenderness at the posterior midline of the cervical spine, no focal neurologic deficit, normal level of alertness, no evidence of intoxication, and no clinically apparent, painful injury that might distract the patient from the pain of a cervical spinal injury [16]. Patients meeting these criteria are considered to be at low risk of cervical spinal injury, and therefore, imaging of the cervical spine is not considered indicated. Thus for the purposes of this study, CT was considered not appropriate if performed despite the patient’s meeting the NEXUS criteria for not undergoing imaging. Study design—The next step is establishing a method of identifying potentially inappropriate studies, which can be performed either prospectively or retrospectively by reviewing medical records after study completion. Phase 1 was designed as a retrospective review of all cervical spinal CT studies performed for blunt trauma within a 1-year period at our institution’s level I trauma center [18]. The medical records of all eligible pa-
tients, identified through a search of radiology information systems, were reviewed to identify the presence of cervical spinal injury and to document the five NEXUS criteria. Step 2: Do—Baseline Measurement Summary Using the previously determined metric (i.e., meeting the NEXUS criteria for low risk of injury), we assessed the number of potentially inappropriate studies and calculated the degree of overuse (Fig. 2). In addition, the rate of positive findings (cervical spinal injury in the current study) can be measured, providing an additional metric for assessing changes in utilization practices after implementation of an improvement plan. In this phase of the project, only 41 of 1589 (2.6%) cervical spinal CT examinations performed on eligi-
ble patients showed signs of acute cervical spine injury [16]. Of the remaining CT examinations, 1524 (95.9%) patients had negative findings for acute injury and 24 (1.5%) had indeterminate findings, although they were not found to have acute injury at subsequent imaging and clinical follow-up [16]. Of the 1524 patients without acute injury, 364 (23.9%) had no documentation of any of the five NEXUS criteria and therefore could have potentially avoided imaging [18]. Although phase 1 was not designed to test the actual performance of the NEXUS criteria, we did find that among the CT studies performed on patients meeting the NEXUS criteria for not undergoing imaging (372 studies), four (1.1%) had positive findings of acute injury and four had indeterminate findings [18]. However, none of these injuries were unstable or required surgical intervention [18]. Step 3: Study—Data Analysis The purpose of evidence-based guidelines, such as those in the ACR Appropriateness Criteria, is to assist providers in “making the most appropriate imaging or treatment decision for a specific clinical condition” [19]. Although the ultimate goal is to have as few inappropriate studies as possible, situations arise in which imaging studies are ordered on the basis of clinician judgment even though they do not meet the appropriate guidelines.
Total studies 2224
419 Performed at satellite facility
Level I trauma center studies
1805
216 Excluded as a result of additional criteria
1589
Included studies
Documented NEXUS criteria
+ 1217
− 372
CT results 37
1160
20
4
364
4
+
−
Indeterminate
+
−
Indeterminate
Fig. 2—Flowchart shows breakdown of study subjects in phase 1 according to National Emergency X-Radiography Utilization Study (NEXUS) low-risk criteria and CT results. (Reprinted from [18])
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Griffith et al. In phase 1, results of the retrospective review [18] showed that approximately 24% (364/1524) of screening cervical spinal CT examinations were potentially inappropriate according to strict application of the NEXUS criteria as documented. Those results also showed the sensitivity of the NEXUS criteria to be only 90.2%, which is significantly less than the 99% sensitivity cited in the NEXUS study itself [16, 18]. However, a number of limitations were also identified, foremost being those attributable to the retrospective nature of the study, which limited data to the information recorded by medical personnel at the patient’s presentation. Step 4: Act—Improvement Plan Given the limitations of the study and a desire to establish a prospective baseline for overuse before implementing an improvement plan, a collaborative study (phase 2) was planned between the departments of radiology and emergency medicine [20]. These results would be used to assess the degree of improvement after a planned intervention. In addition, the information obtained in phase 2 would help identify potential root causes of overuse. Phase 2: Investigating the Issues Step 5: Plan—Cycle 2 Phase 2 was designed to prospectively determine the number of potentially avoidable cervical spinal CT studies based on proper application of established clinical guidelines and to assess clinician reasons for ordering studies in the absence of these criteria. During this phase, which occurred over a 9-month period, all patients presenting to the emergency department after blunt trauma who underwent screening CT of the cervical spine and met the appropriate inclusion criteria were eligible [20]. For each patient, ordering clinicians completed a survey (Fig. 3) documenting mechanism of injury, indication for ordering the study, and clinical suspicion of cervical spine injury. Indications available on the survey included the five NEXUS criteria and abbreviated CCR criteria, among other indications. CT images were then interpreted by a board-certified radiologist blinded to the survey information [20]. Step 6: Do—Repeat Measurement Summary During Phase 2, 1391 eligible patients were identified, 507 (36.4%) of whom were enrolled during the 9-month study period [20]. Surveys were not completed for the other 63.5% of patients, likely because of the setting in which
800
BLUNT TRAUMA CERVICAL SPINE CT PROSPECTIVE STUDY Evaluator (please circle): Staff Date: Patient MRN:
/
Resident
/
PA
/
Other:
Exclusion Criteria: (Circle all that apply; if “yes” to any, do not complete remaining questions) Age < 18 yrs Penetrating injury Known C-spine fracture or dislocation/subluxation Transfer patient Remote injury (> 48 hrs) Mechanism of Injury (please circle): Fall
MVA
Assault
Pedestrian vs Motor vehicle
Other (specify):
Reason for Study (please circle number of all that apply): 1 2 3 4 5 6
7 8 9 10 11 12 13 14 15 16
Posterior midline cervical spine tenderness Suspected intoxication Altered level of consciousness/alertness Focal neurologic deficit Distracting injury Dangerous mechanism by Canadian Cervical Spine Rule (include: Fall from height > 3 ft or 5 stairs; Axial load to head; MVA at speed > 100 km/hr or 62 mph or with rollover or ejection; Collision involving motorized recreational vehicle; or Bicycle injury) Dangerous Mechanism (Other: ) Age > 65 yrs Paresthesias in extremities Inability to actively rotate neck (limited or painful range of motion) Paravertebral tenderness Suspicious C-spine radiographs Intracranial injury on Head CT Complains of neck pain Study requested by consulting service (Name of Service: ) Other (please specify):
Clinical Suspicion for Cervical Spine Injury (1 − very unlikely; 5 − very likely) 1
2
3
4
5
Fig. 3—Survey completed by clinicians for each enrolled patient in phases 2 and 3. (Used with permission from B. Griffith, et al. Screening cervical spine CT in the emergency department, phase 2: a prospective assessment of use. AJNR 34(4): 899–903, 2013 © by American Society of Neuroradiology)
the study was performed, a busy level I trauma center, where clinicians may not have the time or do not remember to fill out a survey [20]. A subset analysis was performed to analyze characteristics of enrolled and nonenrolled patients to ensure no selection bias [20]. As in phase 1, the rate of positive findings of injury and the number of potentially inappropriate studies according to strict application of evidence-based guidelines (NEXUS criteria) were determined. Of the 507 cervical spinal CT examinations performed on enrolled patients, five (1.0%) had positive findings of acute cervical spine injury [20]. Of the examinations with negative findings, 81 met all five NEXUS criteria for patients not requiring imaging. Of the 416 patients eligible for evaluation according to the CCR criteria (normal level of alertness), 119 had none of the abbreviated criteria and should
not have undergone imaging. In addition, 38 patients without acute injury were deemed not to need imaging when both the NEXUS and the abbreviated CCR criteria were appropriately applied [20]. Step 7: Study—Remeasurement Data Analysis The phase 2 findings confirmed those of phase 1: A large number of patients could have been spared cervical spinal CT if appropriate clinical guidelines had been followed (16% by NEXUS; 29% by abbreviated CCR; 8% by application of either criteria). In addition, there was a significant decrease in overuse from 24% to 16% (p < 0.001) between phases 1 and 2 after institution of the clinician survey, suggesting that the survey may have acted as a reminder for ordering clinicians [20]. Further analysis showed that of all studies ordered by staff physicians, only 9.6% did not require imaging by
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Practice Quality Improvement NEXUS criteria versus 17.3% for residents and physician assistants. These findings were consistent with staff physicians’ stricter adherence to clinical guidelines [20]. This finding suggested that further education, especially of residents and midlevel providers, may improve adherence to clinical guidelines and in doing so decrease overuse. In addition, although four patients with cervical spinal injury would not have undergone imaging in phase 1 if the NEXUS criteria had been strictly followed, all cases of cervical spinal injury in phase 2 were found through proper application of both the NEXUS and abbreviated CCR criteria [20]. Possible root causes of inappropriate use were then considered. These included lack of knowledge or awareness of guidelines or failure to remember the guidelines, lack of trust in the guidelines, complex guidelines that are difficult to apply or interpret, failure to accurately document the appropriate criteria, and clinical judgment based on patient- or scenario-specific factors. Step 8: Act—Project Decision Point Using the results of phases 1 and 2 (two PDSA cycles) as guides, radiologists and their collaborators in the department of emergency medicine developed an improvement plan. The goal of the plan was to address the possible root causes of overuse, focusing specifically on the causes suggested by the phase 2 findings. Phase 3: Implementing a Plan for Improvement Given the possible root causes identified in phase 2, it was decided to initiate a clinical education program for clinicians in the emergency department regarding appropriate use of screening cervical spinal CT in the setting of blunt trauma. This clinical education program included a 45-minute lecture discussing both the findings of the phase 1 and phase 2 studies and current clinical guidelines for ordering cervical spinal imaging in the setting of blunt trauma with specific emphasis on the ACR Appropriateness Criteria (CCR and NEXUS) [21]. Although the intention was to educate all clinicians ordering cervical spinal CT examinations in the emergency department, attendance was not tracked. We were also unable to control for clinicians newly entering the system, in part because of the educational setting in which the study was performed. However, reminders of the study and the ACR Appropriateness Criteria were posted throughout the emergency department.
After the intervention, prospective assessment of utilization was repeated with the same method as in phase 2. Results in phase 3 showed that the rate of potentially inappropriate studies (according to strict application of the NEXUS criteria) decreased to 13%, from 16% in phase 2 and 24% in phase 1 [21]. In addition, of the 388 cervical spinal CT examinations performed, 12 (3.1%) had positive findings of acute cervical spinal injury. This rate increased from 1% before implementation of the clinical education program, suggesting improved clinical effectiveness of the imaging studies being performed, an expected result of stricter adherence to evidence-based criteria [21]. The improvement in utilization after implementation of the clinical education program, although modest, did suggest clinician education may help address issues of inappropriate imaging. More importantly, however, it appears that the greatest improvement in utilization occurred between phases 1 and 2. Although the decrease in inappropriate imaging was likely due in part to improved documentation, we believe it also suggests that simply engaging clinicians and raising awareness through something as simple as a survey can alter ordering practices [21]. It also emphasizes the importance of involving other departments and clinicians in this process as part of a collaborative effort to address issues of imaging utilization. Finally, given the continued overuse in phase 3 (13%) despite the survey and clinical education program, the findings suggest that other root causes, including physician trust in the guidelines and complexity of the guidelines, must be addressed. Steps 9 and 10: Participant’s Narrative Self-Reflection Statement and Attestation After completion of the PQI project, a short narrative must be completed discussing the project’s effect on the participant’s practice or patients, including any improvements resulting from the project [13]. Finally, participants must complete an attestation of project completion on their ABR personal database [13]. Conclusions PQI is essential to the practice of medicine and is an important aspect of quality patient care. In addition, shifts toward quality-based reimbursement and changes to the MOC process have increased emphasis on practice quality improvement. Active involvement in practice quality improvement, particular-
ly collaborative efforts focusing on the quality and safety of patient care, is important to the future of radiology. Given the essential role that imaging plays in health care, issues of appropriate utilization will only increase, particularly as efforts to contain health care costs continue. Radiologists must assert their expertise in imaging to address utilization issues, thereby ensuring patients continue to receive the most appropriate and effective care. This project shows the potential influence of active radiologist involvement in issues of imaging utilization and offers a guide for implementing similar measures addressing utilization of imaging services across the health care spectrum. Acknowledgment We thank Stephanie Stebens, Sladen Library Henry Ford Hospital, for assistance in manuscript preparation. References 1. Centers for Medicare and Medicaid website. Quality initiatives: general information. www. cms.gov/Medicare/Quality-Initiatives-PatientAssessment-Instruments/QualityInitiativesGenInfo/index.html?redirect=/qualityinitiativesgeninfo. Published 2013. Accessed June 28, 2013 2. Thrall JH. The emerging role of pay-for-performance contracting for health care services. Radiology 2004; 233:637–640 3. Shaller D, Sofaer S, Findlay SD, Hibbard JH, Lansky D, Delbanco S. Consumers and quality-driven health care: a call to action. Health Aff (Millwood) 2003; 22:95–101 4. Bipartisan Policy Center Health Information Technology Initiative. Improving quality and reducing costs in health care: engaging consumers using electronic tools. Washington, DC: Bipartisan Policy Center, 2012 5. Hobson C. Adapting to change: in a time of declining reimbursements and increasing government regulations, radiologists evolve to remain integral members of the health-care community. ACR Bulletin 2013; 2013:10–13 6. Medical Group Management Association. MGMA physician compensation and production 2013 report based on 2012 data. Englewood, CO: MGMA, 2013 7. Centers for Medicare and Medicaid Services website. Physician quality reporting system. www.cms. gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html?redirect=/ PQRS. Published 2013. Accessed June 28, 2013 8. Centers for Medicare and Medicaid Services website. Maintenance of certification program incentive. www.cms.gov/Medicare/Quality-Initiatives-PatientAssessment-Instruments/PQRS/Maintenance_of_
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Griffith et al. Certification_Program_Incentive.html. Published 2013. Accessed June 28, 2013 9. Centers for Medicare and Medicaid Services website. The physician quality reporting system maintenance of certification program incentive requirements for 2013. www.cms.gov/Medicare/Quality-InitiativesPatient-Assessment-Instruments/PQRS/Downloads/ 2013-MOC_Qualification_Requirements.pdf. Published December 11, 2012. Accessed June 28, 2013 10. Strife JL, Kun LE, Becker GJ, et al. The American Board of Radiology perspective on maintenance of certification, part IV: practice quality improvement for diagnostic radiology. Radiology 2007; 243:309–313 11. American Board of Medical Specialties website. Fact sheet: American Board of Medical Specialties (ABMS) and the ABMS maintenance of certification (ABMS MOC) program. www.abms.org/ News_and_Events/Media_Newsroom/pdf/ABMS _Fact_sheet.pdf. Published March 29, 2013. Ac-
cessed June 28, 2013 12. American Board of Radiology website. Guidelines for practice quality improvement (PQI) projects. www. theabr.org/moc-dr-pqiguides. Accessed June 28, 2013 13. American Board of Radiology website. Maintenance of certification Part IV: ABR guide to practice quality improvement 2012. www.theabr.org/ sites/all/themes/abr-media/PQI_2012.pdf. Published March 6, 2012. Accessed June 28, 2013 14. American Board of Radiology website. MOC: maintenance of certification. www.theabr.org/moc-landing. Published June 2013. Accessed June 28, 2013 15. Hendee WR, Becker GJ, Borgstede JP, et al. Addressing overutilization in medical imaging. Radiology 2010; 257:240–245 16. Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. N Engl J Med
2000; 343:94–99 17. Daffner RH, Hackney DB. ACR Appropriateness Criteria on suspected spine trauma. J Am Coll Radiol 2007; 4:762–775 18. Griffith B, Bolton C, Goyal N, Brown ML, Jain R. Screening cervical spine CT in a level I trauma center: overutilization? AJR 2011; 197:463–467 19. American College of Radiology website. ACR appropriateness criteria. www.acr.org/Quality-Safety/Appropriateness-Criteria. Published 2013. Accessed June 28, 2013 20. Griffith B, Kelly M, Vallee P, et al. Screening cervical spine CT in the emergency department, phase 2: a prospective assessment of use. AJNR 2013; 34:899–903 21. Griffith B, Vallee P, Krupp S, et al. Screening cervical spine CT in the emergency department, phase 3: increasing effectiveness of imaging through improved adherence to appropriateness criteria. J Am Coll Radiol 2013 Sep 10 [Epub ahead of print]
F O R YO U R I N F O R M AT I O N
This article is available for CME and Self-Assessment (SA-CME) credit that satisfies Part II requirements for maintenance of certification (MOC). To access the examination for this article, follow the prompts associated with the online version of the article.
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