The specialty’s first champion was selected based on his focus on reducing unnecessary imaging for ICU patients.
Jeffrey P. Kanne, MD, was recently named radiology’s first champion in the American Board of Internal Medicine Foundation’s Choosing Wisely Champions program.
To select a champion, the ACR convened a group of patients under the Commission on Patient- and Family-Centered Care. The patients established the criteria and then selected the winner from the nominations. Kanne, a professor, chief of thoracic imaging and radiology, and vice chair of quality and safety at the University of Wisconsin (UW) School of Medicine and Public Health in Madison, spoke to the Bulletin about his efforts to reduce unnecessary imaging.
Q: What are some examples of what you’re doing at UW School of Medicine and Public Health to reduce unnecessary imaging and radiation exposure for patients?
A: We first worked on routine chest radiographs in the medical ICU. Studies have shown that “on-demand” chest radiography performed for a specific reason in the ICU (rather than routine chest radiographs) can reduce patient radiation exposure and costs without deleterious effects on care. To change the entrenched practice of ordering routine radiographs without consideration of the patient’s clinical status, I discussed the issue with our intensive-care physicians regularly. Once they agreed that the literature supported a change in practice, I met with the medical director of the ICU, the nurse manager, and an internal medicine resident interested in quality improvement. Together, we came up with a plan to alter the practice and ultimately stopped performing routine chest radiographs on medical ICU patients.
The other issue we worked on was inappropriate preoperative chest radiographs. Most patients undergoing surgery do not need this procedure in the absence of symptoms related to lung disease (as supported by the ACR Appropriateness Criteria®). After some investigation, I discovered these were being ordered because surgeons thought the anesthesiologist wanted them. The primary care physicians thought the surgeons wanted them. So again, I met with the appropriate stakeholders and we all agreed that most of the radiographs were indeed not necessary. Still, getting physician buy-in was not enough — many of the surgery clinics still had chest x-ray on their preoperative checklists, some of which had not been updated in years. Involving clinic managers and medical directors was key in reducing these unnecessary tests.
Q: Do you see your model as unique to UW, or could it be implemented elsewhere?
A: Our approach would work in any institution. The key is to ensure that all stakeholders are involved in the discussion. This means radiologists, radiology technologists (who do the lion’s share of the work related to these studies in the early hours of the morning), radiology managers (who are tasked with ensuring adequate staff and available equipment), referring clinicians, and nursing staff. Talking with nursing staff was particularly key because they must be aware that practices have changed and that a missing order for a daily chest radiograph is not, in fact, an oversight.
Q: How do you go about including other departments in your goals?
A: The best approach to involving other departments is to identify providers who share an interest in quality improvement. Each department at our institution has a physician leader responsible for heading up quality improvement activities. Involving midlevel providers and trainees is also important so that there is a clear understanding of, and broad support for, any new initiatives to reduce unnecessary imaging.
Q: What have been the most significant outcomes thus far, and what do you hope to accomplish down the road?
A: Reducing the number of routine ICU radiographs by about 20 per day has been our biggest success. In the future, I hope we can work with the surgical services to reduce their routine chest radiographs as well. We’ve had some resistance in that area, despite our success in the medical ICU.
Q: What’s your best advice to other radiologists looking to make a difference with their own efforts, similar to what you’ve accomplished?
A: Persistence is key. First, get support from your own team: colleagues, managers, and technologists. Second, open a dialogue with the relevant clinical services and provide them with current guidelines and relevant data. Then, keep moving forward. Follow up with clinical contacts. Ask what you can do to help — whether it is attending a small group meeting or presenting information during their departmental meetings. Try to provide baseline data whenever possible, so that your contacts understand the scope of the problem. Finally, share any successes with your partners so they feel like the whole team made a difference.
Q: What is your philosophy about patient-centered care?
A: My philosophy about medical imaging is very simple: If the results are going to alter how one cares for a patient, then imaging is appropriate — as long as you are sure to perform the most appropriate test for that reason. Otherwise, if care management will not change, the test should not be done. This can be applied to any diagnostic test in medicine.