Reducing Unnecessary Imaging

1. Producing Value
through Imaging
A Quality Improvement Initiative

2. Negative Trends in Medical Imaging
• There is evidence that supports the fact that the more tests you order
the less likely you are to be charged with malpractice or negligence.
• Providers want to provide assurances to their patients that they have
not missed anything.
Defensive Medicine
• Providers are under pressure from patients to give tangible results
and assurances. Many patients already know what test they want
before their visit.
Patient Pressures

3. CT, fluoroscopy, and
Nuclear medicine account
for 26% of imaging orders
•These modalities
account for 89% of
annual dose
Population Exposure
•The annual dose in the
U.S. has increased seven
times the dose in the
1980s.
Pediatric Risk
•Pediatric patients that
receive CT scans are 24%
more at risk for cancer
later in life.
Radiation Exposure

4. Expense
• Cost of non-contrast head CT
• $3190.12
• Value
• It is estimated that 20% to 50% of
exams hold no value to patients
• Incindental findings occur 26.3% of
the time
• Frequency of follow up was
64.5%(Lombreras, Donat et al,2010)

5. Greater Expense & Worse Outcomes
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Category 1 Category 2 Category 3 Category 4
Series 1 Series 2 Series 3

6. Change is Coming
CMS
• Appropriate Use Criterea
Program
• PAMA (Protecting Access to
Medicare Act)
• Goes into effect January 2022
• Requires use of CDSM(clinical
decision support mechanism)
prior to ordering advanced
imaging
FDA
• Initiative to Reduce Unnecessary
Radiation Exposure from Medical
Imaging
• Focused on the types of imaging
procedures that are associated with
the highest radiation doses: CT,
fluoroscopy, and nuclear medicine.

7. What Can We Do to Help
We have selected 5 aims
to reduce unnecessary
exams
1. Imaging for low
back pain
2. Daily chest x-rays
3. Perioperative testing
4. Head CT
5. CTA for PE

8. Steps to Achieve 50% Reduction
Education
Patient
Engagement
Appropriate
Use Criteria
CDSM

9. Low Back Pain
ACR Appropriate Use Criteria
Low Back Pain
• No red flags and no prior
management does
not warrant imaging in any
modality.
Lumbar Radiculopathy
• No red flags and no prior
management does not
typically warrant imaging in any
modality.
This Photo by Unknown author is licensed under CC BY-ND.

10. Daily Chest X-Rays
ACR Appropriate Use Criteria
Avoid Standing Orders
• A portable chest radiograph is
appropriate for clinical
indications only
Appropriate Use
• After placement of an
endotracheal tube,
central venous line, Swan-
Ganz catheter, nasogastric tube,
feeding tube, or chest tube.
This Photo by Unknown author is licensed under CC BY-SA.

11. Perioperative Testing
ACR Appropriate Use Criteria
American Society of Anesthesiologists
• The role of preoperative cardiac
stress testing has been reduced to
the identification of extremely high-
risk patients.
American College of Physicians
• In the absence of cardiopulmonary
symptoms, preoperative chest
radiography rarely provides any
meaningful changes in management
or improved patient outcomes
This Photo by Unknown author is licensed under CC BY.

12. CT Head
ACR Appropriate Use Criteria
When to Avoid CT
• In the absence of head injury or signs of a stroke, a CT scan of
the brain should not be routinely ordered
Appropriate Use
•High risk factors
•GCS <15 two hours post injury
•suspected open skull fracture
•sign of base of skull fracture
•vomiting more than twice
•age >65 years
• Medium risk factors
•amnesia post event >30 min
•dangerous mechanism of injury
•pedestrian struck by motor vehicle
•occupant ejected from motor vehicle
•fall from >3 feet or 5 stairs((Dempsey)
This Photo by Unknown author is licensed under CC BY-SA-NC.

13. CT Pulmonary Angiograms
ACR Appropriate Use Criteria
The American College of Emergency
Physicians
• "If patient historical factors and physical
examination findings are negative,
along with a negative D-dimer (if the
physician chooses to order it), evidence
shows that the risk of an undiagnosed
blood clot is the same as if the patient
had a negative CTPA"(ABIM
Foundation, 2014)
Benefits
• "Such a strategy saves the risk of
radiation, kidney injury and the
high cost of a CTPA" (ABIM
Foundation, 2014)
This Photo by Unknown author is licensed under CC BY.

14. Outcomes
Why Change?

15. Patient Benefits
Decreased LOS (length
of stay)
Decreased cost
Stronger engagement
Less risk
This Photo by Unknown author is licensed under CC BY.

16. Financial Benefits
Millions in potential
savings
Higher efficiency
CMS compliance
Improvement oriented
culture

17. Patient Benefits
• Reduce patient dose
• Reduce potential for allergic reaction
• Save money
• Save time
This Photo by Unknown author is licensed
under CC BY-SA-NC.
This Photo by Unknown author is licensed under CC BY-SA.

18. Resources
ABIM Foundation. (2014, October). ACEP - Avoid head CT for asymptomatic adults with syncope: Choosing Wisely. Choosing Wisely | Promoting conversations between
providers and patients. https://www.choosingwisely.org/clinician-lists/acep-avoid-head-ct-for-asymptomatic-adults-with-syncope/.
ABIM Foundation. (2013, October 13). ASA - Pre-op baseline diagnostic cardiac testing: Choosing Wisely. Choosing Wisely | Promoting conversations between providers and
patients. https://www.choosingwisely.org/clinician-lists/american-society-anesthesiologists-preop-baseline-diagnostic-cardiac-testing/.
ABIM Foundation. (2012, April 4). ACP - Avoid pre-op chest radiography: Choosing Wisely. Choosing Wisely | Promoting conversations between providers and
patients. https://www.choosingwisely.org/clinician-lists/american-college-physicians-preop-chest-radiography/.
ABIM Foundation. (2014, October 27). ACEP - CT pulmonary angiography in ED patients: Choosing Wisely. Choosing Wisely | Promoting conversations between providers and
patients. https://www.choosingwisely.org/clinician-lists/acep-ct-pulmonary-angiography-in-ed-patients/.
Dempsey, P. (n.d.). Canadian CT head rule: Radiology Reference Article. Radiopaedia Blog RSS. https://radiopaedia.org/articles/canadian-ct-head-rule?lang=us.
Lumbreras B, Donat L, Hernández-Aguado I. Incidental findings in imaging diagnostic tests: a systematic review. Br J Radiol. 2010;83(988):276-289. doi:10.1259/bjr/98067945