Analysis of appropriateness of outpatient CT and MRI referred from primary care clinics at an academic medical center: how critical is the need for improved decision support?

PURPOSE: The aim of this study was to retrospectively analyze a large group of CT and MRI examinations for appropriateness using evidence-based guidelines. METHODS: The authors reviewed medical records from 459 elective outpatient CT and MR examinations from primary care physicians. Evidence-based appropriateness criteria from a radiology benefit management company were used to determine if the examination would have met criteria for approval. Submitted clinical history at the time of interpretation and clinic notes and laboratory results preceding the date of the imaging study were examined to simulate a real-time consultation with the referring provider. The radiology reports and subsequent clinic visits were analyzed for outcomes. RESULTS: Of the 459 examinations reviewed, 284 (62%) were CT and 175 (38%) were MRI. Three hundred forty-one (74%) were considered appropriate, and 118 (26%) were not considered appropriate. Examples of inappropriate examinations included brain CT for chronic headache, lumbar spine MR for acute back pain, knee or shoulder MRI in patients with osteoarthritis, and CT for hematuria during a urinary tract infection. Fifty-eight percent of the appropriate studies had positive results and affected subsequent management, whereas only thirteen percent [corrected] of inappropriate studies had positive results and affected management. CONCLUSION: A high percentage of examinations not meeting appropriateness criteria and subsequently yielding negative results suggests a need for tools to help primary care physicians improve the quality of their imaging decision requests. In the current environment, which stresses cost containment and comparative effectiveness, traditional radiology benefit management tools are being challenged by clinical decision support, with an emphasis on provider education coupled with electronic order entry systems.

A prior authorization program of a radiology benefits management company and how it has affected utilization of advanced diagnostic imaging.

Radiology benefits management companies have evolved in recent years to meet the need to control the rapid growth in advanced diagnostic imaging. The Obama administration and other key policymakers have proposed using them as a cost-control mechanism, but little is known about how they operate or what results they have produced. The main tool they use is prior authorization. The authors describe the inner workings of the call center of one radiology benefits management company and how its prior authorization program seems to have slowed the growth in the utilization of MRI, CT, and PET in the large markets of one commercial payer.

Experience of an academic neuroradiology division participating in a utilization management program.

BACKGROUND AND PURPOSE: There has been a steady increase in the utilization of expensive outpatient imaging studies, with a resultant increase in health care costs. To reduce unnecessary and inappropriate studies, the authors' department has participated in a utilization management (UM) program; in this article, the authors report the experience of the division of neuroradiology. METHODS: Using evidence-based guidelines, a commercial UM program provides real-time decision support for physicians ordering expensive outpatient imaging studies. After consultation between UM personnel and a referring physician's staff, studies not meeting appropriateness criteria are referred to an academic radiologist for review. The radiologist can approve the study after reviewing the electronic chart or call the referring physician for further information. Studies are not denied by radiologists. RESULTS: For health plans of one large payer, 2,032 neuroradiologic studies were reviewed by 7 neuroradiologists during a 1-year period, of which 1,622 (80%) were approved. The remaining 410 studies (20%) were initially withdrawn by consensus or by no callback. Overall, 293 of the 410 (71%) studies (208 magnetic resonance, 85 computed tomography) initially not performed were not reordered (duration of follow-up, 3-15 months). Hence, 293 of 2,032 (14%) of all studies reviewed were not performed. The estimated cost of scans not performed was about $150,000. Approximately 6% of requests were changed to more appropriate studies. CONCLUSION: The participation of academic neuroradiologists in a UM program affected the performance of many expensive outpatient imaging studies. There was a durable reduction in unnecessary and inappropriate studies. These results demonstrate the utility of evidence-based appropriateness criteria in radiology UM programs and the power of the sentinel effect.

Computed tomography appearances of hypervascular hepatic tumors after percutaneous radiofrequency ablation therapy.

A retrospective review of the computed tomography (CT) findings of patients with hypervascular liver tumors (26 hepatocellular carcinomas and 2 metastases [1 periampullary carcinoma and 1 neuroendocrine tumor]) who underwent percutaneous ultrasound-guided radiofrequency ablation (RFA) was performed. CT images consisted of nonenhanced and dual-phase contrast-enhanced helical CT images performed on a multidetector CT scan. Findings indicative of adequate tumor ablation on multidetector CT scanwere complete nonenhancement of the treated tumor with or without faint, thin, peripheral rim enhancement. Ablated lesions that showed complete nonenhancement on initial and subsequent follow-up CT examinations either remained stable or became progressively smaller. Thick rim or nodular peripheral enhancement was indicative of tumor residual or recurrence.