Health services research fulfills ACGME requirements
Article Thumbnail ImageAugust 16, 2013 -- Radiology residents looking for unique and accessible research opportunities might want to consider health services research, according to a new article in the September issue of Academic Radiology.

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Accredited for radiology residents by the Accreditation Council for Graduate Medical Education (ACGME), HSR represents a novel way of addressing the organization's requirements for scholarly activity in academic radiology departments, while helping to demonstrate the value of imaging in patient care, the authors concluded.

HSR gives residents the chance to "study and demonstrate the value of imaging on patient outcomes today as well as discover the opportunity for further improvement and impact on patient outcomes from future iterations of imaging techniques," wrote Dr. Marta Heilbrun, Dr. James Rawson, and Dr. Manish Shah from the University of Utah School of Medicine and Georgia Health Sciences University.

Although the U.S. boasts some of the best physicians in the world and its healthcare costs are among the highest per capita, quality and care metrics show serious performance gaps that are being addressed as part of the nation's multiyear transformation from fee-for-service to outcomes-based healthcare, the authors explained (Acad Radiol, September 2013, Vol. 20:9 pp. 1077-1082).

"This spending is an obvious target when looking at the excesses in the U.S. medical system," they wrote. "Pressure is growing to identify and reward efficient quality care and penalize inappropriate, ineffective care, and excess resource utilization."

More accessible

A great thing about using HSR to fulfill ACGME's scholarly activities requirements is that it's more accessible than some other research topics, said Rawson, who is a professor and chair of radiology at the Medical College of Georgia.

"If you try and do a research project, you often have to get permission from an institutional review board, or human assurance committee, and to get that approval often takes several weeks or months," he told AuntMinnie.com. "If you had a week or a month of research, you could spend a lot of that time just going through the permission process, and not have the time to actually conduct the project."

But HSR relies on existing databases, which means the permissions process often falls into an exempt category that does not require institutional clearance. As a result, the resident can spend the time doing actual research rather than getting permission to do research, he said.

"Radiologists already work with large datasets, so being able to work with population data or other databases of patient health information is not a big leap for them," he said. Besides, research based on this data happens to be a great study topic, he added.

"Using health services research, we have an opportunity to study the impact of radiology on patient outcomes," Rawson said. Such work is useful for optimizing patient care, and it's very much in line with the American College of Radiology's Imaging 3.0 project, which deals with how to bring value beyond just the interpretation of the study.

"This is clearly an unmet need in radiology," he said. "If you design your project to look at datasets that link performing radiology exams to patient outcomes, then you can show an impact of radiology on patient outcomes."

One project at Rawson's institution used U.S. Food and Drug Administration (FDA) databases and cancer mortality data to determine the effect of having mammography facilities in a given county.

As reported on AuntMinnie.com in 2010, higher breast cancer rates in individual Georgia counties statewide were correlated with a lack of a mammography facility in the particular county.

"This was all publicly available data," Rawson said. "So I think the opportunity to do a meaningful project and show the value that radiology brings is tremendous."

Imaging utilization and outcomes

Advanced medical imaging has been identified as "the most important medical innovation in recent history," the authors of the Academic Radiology article noted. "Nevertheless, these technologic advances drive increasing healthcare costs and complexity."

Those additional costs will need to be justified, and without analysis it can simply look as though imaging's costs are rising without a corresponding patient benefit. For example, the Medicare Payment Advisory Commission (MedPAC) reported that the volume and complexity of imaging services grew at almost twice the rate of all physician services between 2002 and 2007, with some slowing between 2006 and 2007. "This spending is an obvious target when looking at the excesses in the U.S. medical system," the authors wrote.

Radiology is the best-positioned specialty to define how imaging should be used, while balancing the health and safety of patients in accountable care organizations (ACOs), where "all providers will have a role in shared risk and reward when containing costs of healthcare," Heilbrun and colleagues wrote.

For the specialty to ensure its validity in the healthcare reform process, "radiology as a profession must lead this transition," they wrote, in part by determining the most efficient use of imaging technology resources.

The range of potential HSR topics also includes safety, cost-effectiveness, patient preferences, and quality of life, the group wrote.

Technology assessment

An important type of analysis focuses on the technical performance of a diagnostic imaging test. A technology assessment (TA) program asks whether a technology works, for whom it works best, how much it costs, and what alternatives are available, the study team wrote.

A paper by Hollingsworth and Jarvik explained a TA hierarchy that encourages researchers to ask not only how well a test performs, "but also whether the test results are likely to change management and help a given patient," they wrote.

TA's lower levels focus on whether a test depicts anatomy and physiology, while its middle and higher levels probe its effects on health and disease. The questions at the middle assess the diagnostic impact of a test: for example, whether it leads to more tests. The next step up focuses on the test's effect on therapeutic and management decisions, and the highest level of a TA flowchart assesses a test's impact on overall health, including survival, morbidity, and quality of life.

Beyond the scope of TAs, the effects of a test on society can be evaluated, a task that often requires the incorporation of value equations in the assessment of cost-effectiveness, Heilbrun and colleagues wrote. Using the TA framework allows residents to answer these questions by examining practices in their own institutions, and then combine this knowledge with publicly available data.

"Based on the inquiries and results, it may be possible to address both the intended consequences of technologies as well as measure the unintended impacts on populations," the authors wrote. "With this evidence in hand, HSR will inform policymaking in healthcare and may change clinical practice."

Faculty members overseeing these projects are required to maintain an environment that encourages inquiry and scholarship, such as by authoring journal studies, presenting clinical research at meetings, and participating in national medical committees or organizations.

Several published studies have examined the applications and benefits of imaging tests. The critically appraised topic (CAT) provides a framework for performing a literature search related to specific clinical questions, and it can be completed in a short time frame, making it an excellent model that residents can use to fulfill research requirements.

"For example, a dilemma that many radiology residents taking call struggle with is the proper use of the computed tomography pulmonary angiogram (CTPA) in the emergency department," Heilbrun and colleagues wrote.

Beyond CTPA, "many of the imaging paradigms for care in emergency medicine are opportunities for study, especially when trying to include risks of resource overutilization in assessing the benefit of the test," the group wrote. "By framing questions about what would and should be the outcome if the disease is managed optimally, a resident can examine critically the actual practice in his or her institution."

Vast data troves and research opportunities

The availability of online data facilitates the study of a vast range of research topics, the team wrote.

"Within the 50 states, there are wide deviations in population, climate, employment, income, and other variables," they noted. "These variables can be correlated with health parameters such as breast cancer mortality and incidence of cancers or stage at time of diagnosis. When compared to mammography screening rates by state, an assessment of the imaging test's impact on health can be made and be deemed generalizable to the entire country."

Along with states, the 6,000 hospitals are also a natural source of study data, they wrote. The Hospital Compare database, for example, allows searches by ZIP code, city, and state. Researchers can look at data ranging from readmission and complications to surgical outcomes to outpatient imaging efficiency. And residents can combine data from several different databases to get the information they need, though they need to watch out for limitations, including whether or not different databases examining different aspects of a topic are actually looking at the same group of people.

"HSR provides radiology and radiologists the opportunity to study and demonstrate the value of imaging on patient outcomes today as well as discover the opportunity for further improvement and impact on patient outcomes from future iterations of imaging techniques," they wrote."These skills are critical in emerging healthcare paradigms."