Drs. Cronin and Rawson would like to welcome you to the 2012 edition of the annual Radiology Alliance for Health Services Research (RAHSR) issue. This is the first RAHSR edition for these co-editors, and it is a great honor and privilege to put together this edition. We would like to express our deepest appreciation of the ground-breaking contributions of the two previous RAHSR editors, Dr. Blackmore and Dr. Carlos, and we hope we will continue the great work!
It is a measure of the contributions of Drs. Blackmore and Carlos to see how far health services research (HSR) in radiology has come. Previous RAHSR editions have educated the radiology community about HSR, discussed methodology for clinical trials in radiology, technology assessment and diffusion and quality improvement, and developing critical thinking skills for practicing radiologists and for radiology residents (ie, the next generation of practicing radiologists). Previous editions have also increased understanding of evidence-based radiology (ie, how evidence-based practice is specifically applies to radiology), and evaluating the progress and challenges of implementing new (or established) technologies into clinical practice. The RAHSR editions have provided a forum for education, research, an understanding of HSR, and the encouragement of careers in HSR.
Still the fundamental question remains of how can imaging contribute to health care. Big questions are still unanswered. Should we test? Do tests improve patient outcomes? Do new tests improve patient outcomes? Which test should be used first? Do we need multiple tests? If so, what is the best order of testing? How do we evaluate the cost (not just financial cost) of incorporating new or established tests into clinical practice?
The goal of HSR in radiology is still to support best practices. As evidence-based radiology has gained mainstream acceptance, our clinical colleagues look to us to provide the evidence. Future directions for radiology HSR include generating the evidence that informs policy decisions using evidence-based techniques broadly applied to clinical questions in imaging as well as develop new research methods to assess patient-centered outcomes that fully reflect our contribution to clinical care. As researchers, we need to systematically review all existing evidence about the benefits (and harms) of each imaging modality (for different groups of people) from existing clinical trials, clinical studies, and other research. We also need to conduct studies that generate new evidence of effectiveness or comparative effectiveness of a diagnostic test, treatment, procedure, or health care service. Comparative effectiveness research (CER) requires the development, expansion, and use of a variety of data sources and methods to conduct timely and relevant research and disseminate the results in a form that is quickly usable by clinicians, patients, policymakers, and health plans and other payers. The main steps for radiology involved in conducting this research and in ensuring continued development of the research infrastructure to sustain and advance these efforts are: Identifying new and emerging clinical interventions; reviewing and synthesizing current medical research; identifying gaps between existing medical research and the needs of clinical practice; promoting and generating new scientific evidence and analytic tools; training and developing clinical researchers, and translating and disseminating research findings to diverse stakeholders. Examples of CER in diagnostic imaging illustrate the potential range of research studies that CER encompasses.
Another import area is patient-centered care, which has been divided into six general domains. Areas for patient-centered care specific to radiology include the radiologist–patient relationship; structure and process of care and delivery of imaging services; needs anticipation and patient preferences; communication and shared decision-making; and patient-centered outcomes, with communicating with patients representing the biggest challenge to imagers in the provision of patient-centered imaging care. The diagnostic test has different properties including but not limited to test performance. For patients (and their health care providers) important issues are invasiveness, pretest preparation, administration of contrast agents, radiation, cost (not limited to financial cost) and level of anxiety induced leading to preferences for certain tests. Patients and physicians make tradeoffs leading to preferences for different test properties such minimizing false-positive results or maximizing disease detection or minimizing invasiveness or maximizing test performance. Arguably, these preferences could be included in decision algorithms for imaging, incorporated into analyses of cost (whether formal cost-effectiveness analyses or not), and clinical decision rules in the practice of radiology.
This RAHSR issue of Academic Radiology encapsulates the best of the RAHSR program at the 2011 Association for University Radiologists annual meeting. Utilization of diagnostic imaging tests and development of evidence-based guidelines and reviews have both undergone substantial growth in recent years. However, the proliferation of evidence-based information has not translated into universal deployment of evidence-based medical and coverage policy decisions in diagnostic imaging, possibly because of the failure of the institutions generating evidence-based information formatting findings in an accessible manner for all relevant stakeholders. A simple and transparent method for rating evidence that is accessible to clinicians, patients, payers, and other policymakers is required. Ollendorf et al describe a process in relation to three imaging-based examples . To address the high cost, insufficient quality, and overutilization of specific medical technologies, the Washington State Health Technology Assessment Program was founded in 2007. Using the Washington State Health Technology Assessment Program experience, Blackmore describes how evidence-based policy can provide a valuable contribution to improving the quality of medical care through limiting public resources to those interventions of proven effectiveness . Otero et al systematically review and summarize the Center for Medicare and Medicaid Services National Coverage Determination pertaining diagnostic imaging technologies from 1999 through 2010 . Sanelli et al perform an outcomes-based assessment of a new reference standard for delayed cerebral ischemia related to vasospasm . This builds on prior work in which the authors developed and internally validated a reference standard using a composite criterion incorporating the most relevant clinical and imaging criteria for vasospasm.
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References
1. Ollendorf D., Blackmore C.C., Lee J.M.: Toward evidence-based decisions in diagnostic radiology: a research and rating process for multiple decision-makers. Acad Radiol 2012; 19: pp. 1049-1054.
2. Blackmore C.C.: Using evidence to inform coverage decisions: the Washington State experience. Acad Radiol 2012; 19: pp. 1055-1059.
3. Otero H.J., Chambers J.D., Bresnahan B.W., et. al.: Medicare’s national coverage determinations in diagnostic radiology: examining evidence and setting limits. Acad Radiol 2012; 19: pp. 1060-1065.
4. Sanelli P., Anumula N., Gold R., et. al.: Outcomes-based assessment of a new reference standard for delayed cerebral ischemia related to vasospasm in aneurysmal subarachnoid hemorrhage. Acad Radiol 2012; 19: pp. 1066-1074.
5. Reichman M., Gold R., Greenberg E., et. al.: Validation of a new reference standard for the diagnosis of vasospasm. Acad Radiol 2010; 17: pp. 1083-1089.
6. Reichman M.B., Greenberg E.D., Gold R.L., et. al.: Developing patient-centered outcome measures for evaluating vasospasm in aneurysmal subarachnoid hemorrhage. Acad Radiol 2009; 16: pp. 541-545.
7. Foerster B.R., Dwamena B.A., Petrou M., et. al.: Diagnostic accuracy using diffusion tensor imaging in the diagnosis of ALS: a meta-analysis. Acad Radiol 2012; 19: pp. 1075-1086.
8. Hansen N., Weadock W., Morani A., et. al.: Liver lesions discovered incidentally on ultrasound: evaluation of reader ability to characterize lesions on MRI without intravenous contrast. Acad Radiol 2012; 19: pp. 1087-1093.
9. Liu Y.I., Rubin D.L.: The role of informatics in health care reform. Acad Radiol 2012; 19: pp. 1094-1099.
10. Kelly A.M.: Evaluating and writing education papers compared with non-education papers. Acad Radiol 2012; 19: pp. 1100-1109.
11. Sundgren P.C.: Mentoring radiology residents in clinical and translational research. Acad Radiol 2012; 19: pp. 1110-1113.