In 2015, healthcare expenditures consumed nearly 17% of the gross domestic product in the United States—substantially higher than any other industrialized nation . As the cost of care in the United States continues to rise, the questions of value and appropriateness will continue to be both scientific and political. Regardless of political environment, the need for comparative effectiveness research will continue to increase. In 2014, Section 218(b) of the Protecting Access to Medicare Act of 2014 directed Center for Medicare and Medicaid Services (CMS) to establish a program for the use of appropriate use criteria for advanced diagnostic imaging services . As Medicare continues to incorporate clinical decision making into the computed order entry process, there is likely to be an increased expectation by physicians in both the robustness of evidence and the granularity and specify to unique aspects of the clinical scenario they are dealing with. Previous Radiology Alliance for Health Services Research (RAHSR) issues have highlighted challenges in clinical decision support. In this issue, we look at methods and communication.
A 2015 National Academy of Medicine report focused on the challenges of diagnostic tests and diagnostic errors . Questions such as what diagnostic test is the best next step based on your working diagnosis can be approached from many different directions. Carrol et al. present a critical appraisal analysis of the diagnostic performance of different imaging modalities in the diagnosis of intussusception, and methods used in the treatment . In this review of the best available evidence, ultrasound is the diagnostic modality of choice for the diagnosis of ileocolic intussusception in children. In stable children without signs of peritonitis, nonoperative reduction is the treatment of choice, with pneumatic (gas) reduction enema superior to hydrostatic (liquid) enema reduction . Agapova and Bresnahan review multicriteria decision analysis methods and specifically study the relative imaging appropriateness of contrast-enhanced computed tomography, magnetic resonance imaging, and ultrasound in suspected appendicitis by conducting a mock appropriateness criteria panel using the analytic hierarchy process . While the conclusions parallel the American College of Radiology’s Appropriateness Criteria (ACR AC), the preferences of emergency medicine physicians and radiologists differ. Their research suggests that the analytic hierarchy process for prioritizing imaging tests may benefit the guideline development process such as the ACR AC in identifying the relative appropriateness of imaging tests. With additional development, this process may improve appropriateness when expert opinion is used in clinical guideline development. In a second paper, Agapova et al. describe the initial steps toward the building of a benefit-risk assessment framework in diagnostic radiology. It studies the possibility of creating a benefit risk for four specific clinical use scenarios and highlights the need for multidisciplinary teams.
Cronin and Dwamena reanalyzed Prospective Investigation of Pulmonary Embolism Diagnosis data using potential scoring systems for likelihood of pulmonary emboli; calculate likelihood ratios (LRs) and posttest probabilities for multiple-level test result for scintigraphy imaging studies . Much information is sacrificed by reducing scores to a dichotomy. Developments in evidence-based practice address this loss of information with a technique known as multiple-level LRs. Multiple-level LRs convey more information by increasing the number of useful scores. These data are presented in this study . As clinical decision support rolls out, the use of guidelines and algorithms will increase. This type of modeling demonstrates the feasibility and value of comparison of competing strategies for optimizing imaging ordering.
These questions are being asked in a time of increased transparency and connectivity. More healthcare data are on line ranging from information for patients such as RadiologyInfo.org and webMD to profiles of hospitals and physicians. In a 2016 study, the Pew determined that nearly 8 of 10 Americans use the social network Facebook whereas 24% use Twitter . The ability to friend your physician on Facebook or Tweet your health questions was not available just a few years ago. Patel et al. present survey results studying radiologists on social media . The study looks at both who are on social media and what they are doing. It compares the characteristics, habits, and attitudes of radiologists who use social networking for professional purposes to those who do not . Some researchers now release their conclusions or links to their papers on social media. The authors found that over half of radiologist respondents use social networking for professional purposes. Therefore, the authors concluded that radiology is likely to see growth in the role of social networking in the future as nearly half of professional users are radiology trainees. The authors also found that Twitter use was disproportionately male. Knowing this gender imbalance may enable the improved visibility of female leaders on social networking.
Kelly et al. discuss the role of professionalism in the practice of radiology . This article summarizes the justifications and expectations for teaching professionalism to our residents. The authors also discuss best practices on how to teach professionalism that can be shared with busy radiology faculty in their everyday practice supervising radiology residents . This article is a follow-up to article on professionalism published in the last RAHSR edition . That article defined what professionalism is, and outlined what professionalism looks like in practice. The article concluded with a summary with examples of the opportunities within radiology practice, for the radiology community to exhibit professional actions, values, and ideas.
Some of the health service research methods are beyond the understanding of the practicing clinician. As educators, the complexity of the questions and research methods as well as the increased transparency and electronic access available to patients suggest radiologists may need to expand their skills. While medical school and residency training is expected to include basic biostatistics, there is an opportunity for radiology educators to improve access to health services research methods in radiology residency. For radiology researchers, the needs for both new methods and applications of health services research methods to complex clinical questions are an unmet need. Health services research offers the opportunity to improve patient outcomes by optimizing the choices we make about diagnostic imaging. In this issue of Academic Radiology , we highlight some of the issues and skills required by radiology professionals and health services researchers.
References
1. Organization for Economic Co-operation and Development (OECD) : Health expenditure and financing. Available at: http://stats.oecd.org/Index.aspx?DataSetCode=SHA Accessed February 12, 2017
2. Appropriate Use Criteria Program. Available at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Appropriate-Use-Criteria-Program/index.html
3. National Academies of Sciences, Engineering, and Medicine : Improving diagnosis in health care.2015.The National Academies PressWashington, DC Available at: https://www.nap.edu/catalog/21794/improving-diagnosis-in-health-care
4. Carrol A.G., Kavanagh R.G., Leidhin C.N., et. al.: Comparative effectiveness of imaging modalities for the diagnosis and treatment of intussusception: a critically appraised topic. Acad Radiol 2017; pp. 16-186. in press
5. Agapova M., Bresnahan B.: Using the analytic hierarchy process for prioritizing imaging tests in diagnosis of suspected appendicitis. Acad Radiol 2017; pp. 16-188. in press
6. Agapova M., Bresnahan B., Linnau K.F., et. al.: Toward a framework for benefit risk assessment in diagnostic imaging: identifying scenario-specific criteria. Acad Radiol 2017; pp. 16-152. in press
7. Cronin P., Dwamena B.A.: A clinically meaningful interpretation of the prospective investigation of pulmonary embolism diagnosis (PIOPED) scintigraphic data. Acad Radiol 2017; pp. 17-21. in press
8. Greenwood S., Perrin A., Duggan M.: Social media update.2016.Pew Research Center Available at: http://www.pewinternet.org/2016/11/11/social-media-update-2016/ Accessed February 12, 2017
9. Patel S.S., Hawkins M., Rawson J.V., et. al.: Professional social networking in radiology: who is there and what are they doing?. Acad Radiol 2017; pp. 16-459. in press
10. Kelly A.M., Mullan P.B., Gruppen L.D.: Professionalism in medicine and radiology. Acad Radiol 2017; in press
11. Kelly A.M., Mullan P.B., Gruppen L.D.: The evolution of professionalism in medicine and radiology. Acad Radiol 2016; 23: pp. 531-536.