This finding is good news for a specialty long considered to be behind the scenes in patient care, wrote researchers from Thomas Jefferson University in Philadelphia. Radiologists can take their rightful place in the healthcare enterprise by participating in utilization management programs.
"A critical part of the beginning [of the patient care continuum] is ensuring the appropriateness of the requested imaging study," lead author Dr. David P. Friedman and colleague Nancy Smith wrote. "[Utilization management] will not deter appropriate imaging or medical care but will truly reflect effective management."
In response to U.S. government efforts to curb healthcare costs, insurers have experimented with using utilization management programs for advanced imaging via radiology benefits management companies. But critics charge that these programs are too blunt of an instrument and may prevent patients from getting the imaging they need.
Dr. David P. Friedman of Thomas Jefferson University.
But when radiologists get involved -- and when RBMs use appropriateness guidelines established by medical organizations -- programs like these can be effective, according to Friedman and Smith. The program at Thomas Jefferson was established by the RBM firm HealthHelp, which developed detailed rule sets for a utilization management program for diagnostic radiology. Called RadConsult, the initiative offers peer-to-peer decision support for physicians ordering advanced outpatient imaging studies (AJR, July 2016, Vol. 207:1, pp. 121-125).
"Radiology benefit management companies often get a bad rap," Friedman told AuntMinnie.com. "But the premise of this program was different: It was designed to use evidence-based guidelines to evaluate the appropriateness of a particular imaging study."
Friedman and Smith evaluated the impact of the program, reviewing almost 170,000 studies that had been ordered between July 2009 and June 2014. Of these, 58.6% were approved by consensus (which was based on chart review or peer-to-peer consultation), 6.8% were changed by consensus, 13.5% were withdrawn by consensus, 6% were approved without consensus, and 15.2% were withdrawn, because the consulting radiologist did not receive a call back from the referring physician's office in response to a request for further information.
Overall, 20% of studies were changed or not performed as a result of a radiologist discussing the case with the referring provider, according to Friedman and Smith.
"These results were achieved without the use of denials," they wrote. "Such is the power of peer-to-peer collaboration."
Who benefited most?
The overall impact of the utilization management program was highest in family practice (42.7%), internal medicine (41.8%), and neurology (33.4%) -- specialties that are traditionally heavier users of radiology -- with impact measured as the combined rate of withdrawn orders and no callback to the radiologist from the referring doctor, Friedman and Smith found. This impact was greater than the researchers expected.
"We believe that this is related to the evidence-based, educational nature of this [utilization management] program and the expertise of the ... participating radiologists," they wrote.
Finally, a further benefit to programs like this one is a downstream change in ordering patterns due to the education referring physicians receive from interacting with radiologists, as well as a sentinel effect -- that is, the tendency for people's behavior to improve when they know they're being scrutinized, according to the researchers.
"When a neuroradiologist reviews the clinical guidelines of the American College of Physicians for diagnosis and treatment of low back pain with a family practitioner, it is reasonable to assume that the latter will consider these guidelines when assessing future patients," Friedman and Smith wrote.
In any case, radiologists are not only a valuable part of a patient's healthcare experience, but also a key factor in reducing inappropriate imaging, according to Friedman.
"Traditionally, radiologists have been at the back end of patient care," he said. "But utilization management programs like this one puts them at the front end, allowing them to apply their expertise when a study is first being ordered."
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