How one key phrase significantly improved best practices and clinical value.
- Physicians at RadPartners recognized that referring clinicians were ordering unnecessary imaging follow-up when it wasn’t specified as extraneous.
- The team decided to combat this problem by incorporating into their best practice guidelines that radiologists include the phrase, “No follow-up imaging is recommended” directly in their reports.
- Since implementation of best practice guidelines created by RadPartners, including the no follow-up statement, adherence to the guidelines has improved by as much as 81 percent.
Several years ago, leaders at Radiology Partners (RadPartners), a multisite radiology practice serving more than 400 hospitals and facilities across the U.S., noticed that referring clinicians often defaulted to
ordering follow-up imaging if the radiologist did not specifically state not to do so. “Reviewing thousands of interpretive reports taught us that being silent to the next step frequently resulted in unnecessary follow up of benign or physiologic findings,” says Jay A. Bronner, MD, president and chief medical officer at RadPartners. This finding set the practice off on a journey to rein in inappropriate imaging and improve patient care.
A team of physicians from across RadPartners gathered with a shared interest in making sure they provide the best recommendations for imaging findings. They came to a simple, but forward-thinking conclusion: Why not ask radiologists to specifically state “No follow-up is recommended” in their reports to referring clinicians? Now, this phrase is being added via template or freehand to the “impression” section of imaging reports whenever it’s warranted.
As RadPartners began rolling out this concept, however, referring physicians initially pushed back a bit, concerned that radiologists may not have the total picture of the patient’s health, Bronner says. This feedback impelled RadPartners to state, “No follow-up imaging is recommended,” adding an important keyword concerning their area of expertise. This small change allowed for the big impact of making highly specific recommendations to referring clinicians. “We are consultants just like cardiologists or surgeons,” says Bronner. “Sometimes telling your referring physician that no action is necessary is the right thing to do — just as other subspecialists do in the course of evaluating patients.”
But what if radiologists specified no follow-up for a benign finding that later developed into a malignancy? RadPartners worked diligently to ensure that the best practices they developed for each area, such as for ovarian cysts and incidental thyroid nodules, were evidence based, providing their radiologists with support to specify no follow-up where appropriate. (Read the Imaging 3.0 case study about RadPartners’ best practices for incidental thyroid nodules.)
Following these best practices which incorporate recommendations from ACR whitepapers, Appropriateness Criteria®, and other expert guidelines, greatly reduces the likelihood of liability because the care provided is consistent with well-established, published guidelines and with the standard of care. In addition, patient care is improved and liability is reduced when patients are not exposed to potential complications from unnecessary follow-up procedures, Bronner says.
One factor that surprised Bronner was how quickly a large practice, with locations in multiple states with hundreds of physicians, was able to incorporate internal best practices, including adding “no follow-up imaging is recommended” to their reports. To facilitate adoption, RadPartners created teaching videos about their best practices, and around 90 percent of staff watched the videos.
But the implementation primarily relied on local leadership, says Upma Rawal, MD, a diagnostic radiologist and director of clinical quality at RadPartners who was also integral in setting up this new “no follow-up” procedure. She notes that many physician leaders shared data on their practice’s performance at departmental meetings and with their local physician board, and some tied adoption of best practices, including “no follow-up” statements, into year-end bonuses.
In terms of success, the results truly speak for themselves. Since implementation in 2016, the adherence to best practices for simple ovarian cysts, which started at 4 percent, has increased to 75 percent. For abdominal aortic aneurysm, the practices went from 4 percent to 85 percent adherence. Finally, for incidental thyroid nodules follow-up, they started in 2014 at 50 percent adherence and are now up to 90 percent, meeting their practice goal. “Overall, we have been able to significantly reduce variability in what our radiologists recommend and how they describe that recommendation,” Bronner says.
This project also reduced costs, which is critical as many payers are moving to value-based payment systems. “Our practice has already entered into its first contract with a payer in Ohio that rewards the practice with a premium for meeting agreed-upon targets of adherence to our own clinical best practices,” Bronner says. Although, he adds, contracting was not their reason for developing best practices. “Mainly, it’s the right thing to do for our patients. There’s also a lot of personal satisfaction that our physicians gained by doing this.”
- Use ACR whitepapers and other expert guidelines to adopt best practices across various areas like ovarian cysts and incidental thyroid nodules.
- Encourage radiologists to specify when “no follow-up imaging is recommended” directly in their reports, providing training materials and education to increase adoption rates of best practices.
- Track adherence to best practices to identify overall results, including the impact on possible premium payment or value-based care models.
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Alyssa Martino is a freelance writer