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Shaping Change From Within

Using R-SCAN®, a radiology group reduced inappropriate follow-up imaging by nearly 55 percent for patients with ovarian masses.

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When the radiology team at Carle Foundation Hospital in Urbana, Ill., began receiving feedback from referring clinicians — primarily OB/GYN and family medicine providers — about the possibility of inappropriate follow-up imaging recommendations for ovarian masses, they knew they needed immediate action. The solution came in the form of R-SCAN®, a collaborative action plan bringing radiologists and referring clinicians together to improve imaging appropriateness and streamline image ordering (

The Carle team recognized an immediate opportunity to leverage R-SCAN’s educational resources and the ACR Select® clinical decision support system with its internal team of radiologists and technologists. Since completing its initial intervention in August of 2015, the team’s inappropriate imaging recommendations have decreased by nearly 55 percent. At the same time, appropriate follow-up imaging recommendations climbed from 68.75 percent to more than 85 percent.

A Multiphase Action Plan

Radiologists at Carle Foundation Hospital selected the ovarian cyst topic to resolve inconsistencies in how their pelvic ultrasound reports were being generated and variabilities in recommendations for follow-up care. The team began by collecting three months’ worth of studies — some 300 exams that had the words “ovarian cyst” listed in the report — eliminating those reports that did not have all the necessary documentation (such as detailed information about a specific cyst).

Juan J. Jimenez, MD, associate medical director of radiology at Carle Foundation Hospital and Carle Physician Group, says identifying high-quality retrospective finding reports for the project was imperative. “If your reports aren’t hitting those key pieces of information, such as the size of the lesion and the degree of complexity, then it becomes impossible to accurately characterize for the purposes of tracking compliance with the Choosing Wisely® recommendations,” he says. The team wound up with a total of 64 cases, which they entered into ACR Select in the pre-intervention phase of the project.

The Dig for Data

Jimenez and his team discovered inconsistencies in how the technologists measured ovarian cysts and variances in how they characterized the complexity of the cases. “We found that our technologists were putting in measurements and describing a lot of findings on the scans that weren’t necessarily clinically relevant,” Jimenez says. “As a result, our radiologists were compelled to discuss those measurements and findings within the report and make follow-up recommendations for CTs based on this irrelevant information.”

Realizing how heavily they were relying on their technologists’ judgment, the radiologists knew they had to get the entire radiology team on the same page to achieve the necessary congruence with standard imaging guidelines. To that end, Jimenez says his first objective was to develop an educational intervention for both radiologists and ultrasound technologists.

“My goal was to educate our radiologists and our technologists about the ACR’s evidence-based recommendations not to image clinically inconsequential adnexal cysts,” Jimenez explains. “We wanted to achieve improved compliance with these recommendations.” Jimenez and his team implemented the intervention by presenting the recommendations at a departmental meeting for radiologists and a staff meeting for technologists.

Radiology imaging manager Anne Finfrock, RT(R)(N)(CT), CNMT, and the practice’s informatics department used data mining and keyword searches to identify cases for the project. The group learned how to better identify the ovarian cysts, observe their documented size, and determine whether the image order follow-up recommendations aligned with the ACR Appropriateness Criteria® and other evidence-based guidelines, such as the “Management of Asymptomatic Ovarian and Other Adnexal Cysts Imaged at US: Society of Radiologists in Ultrasound Consensus Conference Statement.”

Education and Engagement

Jimenez and his team also developed an educational presentation and posted it on the radiology department’s website. The presentation provides answers to questions at the point of care, mainly for technologists. It also links to clear-cut visual examples of what constitutes different cysts, as well as recommendations for varying premenopausal versus post menopausal ovarian cysts. “Our technologists now understand that while scanning, for example, they don’t have to put calipers on something and draw attention to normal follicles,” Jimenez says.

The sonographers now have a more standardized set of follow-up criteria, Finfrock adds. “It allows them to confidently report measurements and findings, knowing they will be in line with the radiologist’s recommendation,” she says. By educating their own team and amending their approach to reporting on adnexal cystic masses, the radiologists succeeded in reducing their inappropriate follow-up imaging recommendations from 31 to 14 percent and increasing their appropriate follow-up imaging recommendations by nearly 24 percent. The Strength of R-SCAN

“R-SCAN is probably the best thing that could have happened to radiology quality,” Jimenez contends. “You don’t have to be a high-end academic institution to improve outcomes with R-SCAN. It’s essentially turnkey; all you need to do is collect your cases and enter them.”

Jimenez adds that patients also benefit from less repeat and follow-up imaging when practices improve imaging appropriateness through R-SCAN. “It lowers the cost and diminishes the inconvenience to the patient. It also frees up resources within the system to accommodate patients who really need imaging,” he notes. “In addition, it reduces anxiety, a less-easily measured benefit.”

Jimenez states that his group’s success with R-SCAN and the impact on the practice is multi-factorial. “We had contributions from both the radiologists and the technologists, and the quality of our reporting has improved because we’re now more cognizant of it,” he says. “Working with the technologists to achieve this goal was rewarding because it gave us results that we can all take pride in.”

By participating in R-SCAN®, you will gain access to ACR Select®, a comprehensive clinical decision support tool based on national standards. The database comprises more than 3,000 clinical scenarios and 15,000 criteria. Find out more about ACR Select at

By Amena Hassan, freelance writer, ACR Press