ACR Issues New Choosing Wisely Recommendations

Nov choosingwisely

New guidelines for radiologists include recommendations on overuse of abdominal CT with and without IV contrast and how to responsibly address incidental findings.

The ACR recently renewed its continuing commitment to the national Choosing Wisely® initiative by issuing five new recommendations designed to help radiologists improve their interpretations and recommendations based on the latest evidence-based findings.

The ACR was one of the first of nine specialty societies to join the initiative when it was formed in 2012 by the American Board of Internal Medicine (ABIM) Foundation in Philadelphia. The initiative was designed to spark conversations between patients and physicians about how best to avoid unnecessary medical tests, treatments, and procedures. At that time, ACR issued five recommendations.

“I call them the nine courageous and bold,” says Daniel B. Wolfson, executive vice president and chief operating officer of the ABIM Foundation, of the first members. “It was a bold move. I just can’t tell you what a wonderful collaboration it is with Choosing Wisely and ACR.”

The current expert workgroup that developed the second set of recommendations was chaired by Pamela T. Johnson, MD, vice chair of quality and safety in the department of radiology at Johns Hopkins Medicine in Baltimore, Md. Johnson, who specializes in diagnostic radiology, was interested in reducing the use of multiphase abdominal computed tomography (CT) protocols. Additionally, she wanted to address the role that a radiologist’s interpretation of images plays in a patient’s future management — reducing the possibility of sending patients down a pathway to unnecessary biopsy, surgery, or further consultations.

Many of the recommendations of other groups provide guidance about when to order imaging and what imaging to order, as the College does with its ACR Appropriateness Criteria®. “But what the American College of Radiology wanted to do with this ... was craft recommendations that would improve how radiologists themselves were practicing their protocol selection and the recommendations they were making in their interpretations,” Johnson says.

The workgroup is comprised of highly experienced radiologists from academic centers around the country who brainstormed and discussed clinical situations in which they agreed that radiology practice could be improved, Johnson says.

Two of the new recommendations pertain to abdominal CT protocol selection. The other three relate to recommendations radiologists should make to guide management of incidental findings. These new recommendations are founded on years of work by the ACR, as represented in a series of white papers on such findings.

For instance, “a patient goes for CT scan of the chest, and it turns out they have a thyroid nodule they didn’t know they had. The odds are that it’s benign. We want radiologists to follow the ACR’s evidence-based management algorithms that dictate which patients require further imaging and potential biopsy, so we don’t subject patients to these procedures unnecessarily,” Johnson says.

Another of the new recommendations addresses when to perform an abdominal CT with contrast. Research indicates that using this protocol, which doubles the patient’s radiation exposure and increases the cost, is used unnecessarily in 10 percent of cases in which it is ordered. Johnson calculates that addressing this one situation could save millions of dollars annually in health care costs and reduce patients’ radiation exposure.

The expert workgroup drafted the five recommendations, revised them based on internal comments, and then sought outside experts for further input. Thyroid specialist Jenny K. Hoang, MBBS, an associate professorin the department of radiology at the Duke University School of Medicine, in Durham, N.C., was consulted for the thyroid nodule recommendation, for example. Later the recommendation was reviewed by a separate panel of experts in thyroid imaging.

“What the American College of Radiology wanted to do...was craft recommendations that would improve how radiologists 
themselves were practicing — their protocol selection and the recommendations they were making in their interpretations.”
— Pamela T. Johnson, MD.


The workgroup also consulted experts in ACR’s Appropriateness Criteria to make sure that the new recommendations were consistent with evidence-based guidelines about appropriate imaging and treatment decisions. Finally, the ACR Board of Chancellors reviewed the recommendations, offered comments, and approved them. The recommendations were then submitted to the ABIM Foundation, which conducted a separate review.

Johnson encourages ACR members to look at the Choosing Wisely recommendations and incorporate them into their practice. “Everybody wants to keep improving the quality of their practice, and here we have society-backed recommendations — evidence-based — that radiologists can implement to improve the value of the care they deliver. We’ve done it ourselves here at Hopkins,” Johnson says. “We have taken other Choosing Wisely recommendations and made them into quality improvement projects spearheaded collaboratively by faculty and residents from multiple departments.”

The recommendations are designed to guide judicious use of multiphase abdominal CT protocols and follow-up recommendations for incidental findings. Johnson says it is part of a radiologist’s responsibility to protect patients from the experience of unnecessary tests, costs, and radiation. “We want to reduce unnecessary imaging, unnecessary biopsies, and unnecessary surgeries. And we can do that if we use evidence-based recommendations in our reports,” Johnson says.

The Choosing Wisely initiative has grown dramatically since ACR participated in the initial round of recommendations in 2012. The initiative now has more than 80 specialty societies, and the number of recommendations continues to grow as new groups become partners and early participants add new information.

This continuing momentum encourages Wolfson, who notes the campaign is just five years old and has already normalized and socialized physicians to the notion that they have a responsibility to address overuse. “That’s been very important, and I think we have, by focusing on quality, safety, and doing no harm, made physicians feel like this istheir ... professional responsibility. I think they feel more comfortable about talking to patients about overuse.”

“We want to reduce unnecessary imaging, unnecessary biopsies, and
unnecessary surgeries. And we can do that if we use evidence-based
recommendations in our reports.”
— Pamela T. Johnson, MD.


The key challenge that remains is spreading the message, but Wolfson is confident that the initiative can affect large scale change in the next five years.

Because one of the initiative’s goals is for informed patients to discuss treatment options with their physicians, Consumer Reports will distribute a simplified version of the new recommendations to the public through a series of partners that includes the AARP and Wikipedia.

By Kevin Wilcox, freelance writer, ACR Press

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