Quality Measurements in Radiology: A Systematic Review of the Literature and Survey of Radiology Benefit Management Groups

Disparities in Ultrasound Use for Diagnosing Pediatric Appendicitis Across United States Emergency Departments

INTRODUCTION

An ultrasound (US)-first approach for evaluating appendicitis is recommended by the American College of Radiology. We sought to assess the access to and utilization of an US-first approach for children with acute appendicitis in United States Emergency Departments.

METHODS

Utilizing the 2019 Nationwide Emergency Department Sample, we performed a retrospective cohort study of patients <18 y with a primary diagnosis of acute appendicitis based on International Classification of Disease 10th Edition Diagnosis codes. Our primary outcome was the presentation to a hospital that does not perform US for children with acute appendicitis. Our secondary outcome was the receipt of a US at US-capable hospital. We developed generalized linear models with inverse-probability weighting to determine the association between patient characteristics and outcomes.

RESULTS

Of 49,703 total children, 24,102 (48%) received a US evaluation. The odds of presenting at a hospital with no US use were significantly higher for patients aged 11-17 compared to patients <6 y (adjusted odds ratio [aOR] [95% confidence interval (CI)]: 1.59, [1.19- 2.13], P = 0.002); lowest median household income quartile compared to highest (aOR [95% CI]: 2.50, [1.52-4.10], P < 0.001); rural locations compared to metropolitan (aOR [95% CI]: 8.36 [5.54-12.6], P < 0.001), and Hispanic compared to non-Hispanic White (aOR [95% CI]: 0.63 [0.45-0.90], P = 0.01). The odds of receiving a US at US-capable hospitals were significantly lower for patients >6 y, lowest median household income quartiles, and rural locations (P < 0.05).

CONCLUSIONS

Rural, older, and poorer children are more likely to present to hospitals that do not utilize US in the diagnosis of acute appendicitis and are less likely to undergo US at US-capable hospitals.

A National Quality Improvement Program on Ultrasound Department in China: A Controlled Cohort Study of 1297 Public Hospitals

Providing high-quality medical services is of great importance in the imaging department, as there is a growing focus on personal health, and high-quality services can lead to improved patient outcomes. Many quality improvement (QI) programs with good guidance and fine measurement for improvement have been reported to be effective. In order to improve the quality of ultrasound departments in China, we conducted this study of a national quality improvement program. A total of 1297 public hospitals were included in this QI program on ultrasound departments in China from 2017 to 2019. The effect of this QI program was investigated, and potential factors, including hospital level and local economic development, were considered. The outcome indicators, the positive rate and diagnostic accuracy, were improved significantly between the two phases (positive rate, 2017 vs. 2019: 66.21% vs. 73.91%, p < 0.001; diagnostic accuracy, 2017 vs. 2019: 85.37% vs. 89.74%; p < 0.001). Additionally, they were improved in secondary and tertiary hospitals, with the improvement in secondary hospitals being greater. Notably, the enhancement of diagnostic accuracy in low-GDP provinces was almost 20%, which was more significant than the enhancement in high-GDP provinces. However, the important structural indicator, the doctor-to-patient ratio, decreased from 1.05:10,000 to 0.96:10,000 (p = 0.026). This study suggests that the national ultrasound QI program improved the outcome indicators, with secondary-level hospitals improving more than tertiary hospitals and low-GDP provinces improving more than high-GDP regions. Additionally, as there is a growing need for ultrasound examinations, more ultrasound doctors are needed in China.

Predictors of Clinical Outcomes in Pediatric Appendicitis: Role of the Individual Sonographer and Radiologist When Using a First-Line Ultrasound Approach

OBJECTIVE

To determine if differences between individual sonographers and radiologists performing and interpreting appendix ultrasound affect clinically important outcomes in children with suspected acute appendicitis.

METHODS

Patients <18 years of age who presented to our emergency department (ED) with suspected acute appendicitis and underwent an appendix ultrasound were identified. Sonographers who performed fewer than 100 examinations and radiologists who interpreted fewer than 100 examinations during the study period were excluded. Multivariable logistic regression was performed to assess the effect of sonographer, radiologist, clinical variables, and system factors on key clinical outcomes, including hospital admission and appendectomy.

RESULTS

In all, 9,283 appendix ultrasounds (mean age, 9.9 ± 4.2 years; 5,400 [58.2%] boys) performed by 31 sonographers (mean number of examinations, 299 ± 140 [range, 115-610]) and interpreted by 31 radiologists (mean number of examinations, 299 ± 157 [range, 101-845]) were included. Mean admission frequency per sonographer was 34.0% ± 3.3% (range, 27.8%-42.6%) and per radiologist was 33.5% ± 3.9% (range, 23.7%-41.6%). Mean appendectomy frequency per sonographer was 20.3% ± 2.6% (range, 14.9%-27.0%) and per radiologist was 20.3% ± 3.1% (range, 15.2%-28.7%). Significant multivariable predictors of hospital admission included temperature (P < .0001), white blood cell count (P < .0001), male sex (P = .002), imaging performed at the main hospital (versus satellite hospital) (P = .001), abdominal tenderness with ultrasound transducer compression (P < .0001), presence of rebound tenderness (P = .001), and presence of acute appendicitis by ultrasound (P < .0001), but not sonographer or radiologist. Predictors of appendectomy included weight (P < .0001), white blood cell count (P < .0001), male sex (P = .0004), abdominal tenderness with ultrasound transducer compression (P < .0001), and the presence of acute appendicitis by ultrasound (P < .0001), but not sonographer or radiologist.

CONCLUSION

Differences in individual sonographers and radiologists did not predict clinically important outcomes in children undergoing ultrasound in the ED for suspected acute appendicitis.

Radiology Patient Outcome Measures: Impact of a Departmental Pay-for-Performance Initiative on Key Quality and Safety Measures

OBJECTIVE

Assess impact of a multifaceted pay-for-performance (PFP) initiative on radiologists' behavior regarding key quality and safety measures.

METHODS

This institutional review board-approved prospective study was performed at a large, 12-division urban academic radiology department. Radiology patient outcome measures were implemented October 1, 2017, measuring report signature timeliness, critical results communication, and generation of peer-learning communications between radiologists. Subspecialty division-wide and individual radiologist targets were specified, performance was transparently communicated on an intranet dashboard updated daily, and performance was financially incentivized (5% of salary) quarterly. We compared outcomes 12 months pre- versus 12 months post-PFP implementation. Primary outcome was monthly 90th percentile time from scan completion to final report signature (CtoF). Secondary outcomes were percentage timely closed-loop communication of critical results and number of division-wide peer-learning communications. Statistical process control analysis and parallel coordinates charts were used to assess for temporal trends.

RESULTS

In all, 144 radiologists generated 1,255,771 reports (613,273 pre-PFP) during the study period. Monthly 90th percentile CtoF exhibited an absolute decrease of 4.4 hours (from 21.1 to 16.7 hours) and a 20.9% relative decrease post-PFP. Statistical process control analysis demonstrated significant decreases in 90th percentile CtoF post-PFP, sustained throughout the study period (P < .003). Between 95% (119 of 125, July 1, 2018, to September 30, 2018) and 98.4% (126 of 128, October 1, 2017, to December 31, 2017) of radiologists achieved >90% timely closure of critical alerts; all divisions exceeded the target of 90 peer-learning communications each quarter (range: 97-472) after January 1, 2018.

DISCUSSION

Implementation of a multifaceted PFP initiative using well-defined radiology patient outcome measures correlated with measurable improvements in radiologist behavior regarding key quality and safety parameters.

Subspecialization in radiology: effects on the diagnostic spectrum of radiologists and report turnaround time in a Swiss university hospital

PURPOSE

To analyze the changes in the work profiles of radiologists and the reporting time after the implementation of professional subspecialization in the radiology department of a Swiss university hospital.

METHODS

In a retrospective analysis, the overall number of different radiologic examinations performed in the department of radiology of the largest Swiss university hospital was documented for 2014 and 2016 before and after the implementation of subspecialized reporting (subspecialities: abdominal, musculoskeletal, cardiothoracic, emergency, and pediatric imaging) in May 2015. For six selected radiologists, the number and types of reported examinations as well as the related radiology report turnaround times (RTATs) were analyzed in detail and compared between the two 1-year periods.

RESULTS

Overall, there was a significant increase of 10.3% in the total number of examinations performed in the whole department in 2016 compared with 2014. For four of the six radiologists, the range of different types of examinations significantly decreased with the introduction of subspecialized reporting (p < 0.05). Furthermore, there was a significant change in the subset of the ten most commonly reported types of examinations reported by each of the six radiologists. Mean overall RTATs significantly increased for five of the six radiologists (p < 0.05).

CONCLUSIONS

Implementation of subspecialized reporting led to a change in the structure and a decrease in the range of different examination types reported by each radiologist. Mean RTAT increased for most radiologists. Subspecialized reporting allows the individual radiologist to focus on a special field of professional competence but can result in longer overall RTAT.

A Call to Improve the Visibility and Access of the American College of Radiology Practice Parameters in Neuroradiology: A Powerful Value Stream Enhancer for Both Neuroradiologists and Patients

Clinical practice guidelines and clinical practice parameters are among the tools that clinicians and radiologists use to inform decision making in the diagnosis and treatment of patients. Radiologists have been urged to objectively establish their value and measurable contributions to patient care. Radiology's contribution to the health care value stream can be established in the development of sound clinical practice guidelines. Neuroradiologists have been quite active in developing clinical guidelines, particularly in collaboration with the American College of Radiology, but there is a need to increase the visibility and accessibility of such documents. Increasing access and visibility can contribute to improved patient outcomes and an improved overall quality of care.

Improvement of radiology reporting in a clinical cancer network: impact of an optimised multidisciplinary workflow

PURPOSE

To assess the effectiveness of implementing a quality improvement project in a clinical cancer network directed at the response assessment of oncology patients according to RECIST-criteria.

METHODS

Requests and reports of computed tomography (CT) studies from before (n = 103) and after (n = 112) implementation of interventions were compared. The interventions consisted of: a multidisciplinary working agreement with a clearly described workflow; subspecialisation of radiologists; adaptation of the Picture Archiving and Communication System (PACS); structured reporting.

RESULTS

The essential information included in the requests and the reports improved significantly after implementation of the interventions. In the requests, mentioning start date increased from 2% to 49%; date of baseline CT from 7% to 64%; nadir date from 1% to 41%. In the reports, structured layout increased from 14% to 86%; mentioning target lesions from 18% to 80% and non-target lesions from 11% to 80%; measurements stored in PACS increased from 76% to 97%; labelled key images from 38% to 95%; all p values < 0.001.

CONCLUSION

The combination of implementation of an optimised workflow, subspecialisation and structured reporting led to significantly better quality radiology reporting for oncology patients receiving chemotherapy. The applied multifactorial approach can be used within other radiology subspeciality areas as well.

KEY POINTS

• Undeveloped subspecialisation makes adherence to RECIST guidelines difficult in general hospitals. • A clinical cancer network provides opportunities to improve healthcare. • Optimised workflow, subspecialisation and structured reporting substantially improve request and report quality. • Good interdisciplinary communication between oncologists, radiologists and others contributes to quality improvement.

Quality measures and pediatric radiology: suggestions for the transition to value-based payment

Recent political and economic factors have contributed to a meaningful change in the way that quality in health care, and by extension value, are viewed. While quality is often evaluated on the basis of subjective criteria, pay-for-performance programs that link reimbursement to various measures of quality require use of objective and quantifiable measures. This evolution to value-based payment was accelerated by the 2015 passage of the Medicare Access and CHIP (Children's Health Insurance Program) Reauthorization Act (MACRA). While many of the drivers of these changes are rooted in federal policy and programs such as Medicare and aimed at adult patients, the practice of pediatrics and pediatric radiology will be increasingly impacted. This article addresses issues related to the use of quantitative measures to evaluate the quality of services provided by the pediatric radiology department or sub-specialty section, particularly as seen from the viewpoint of a payer that may be considering ways to link payment to performance. The paper concludes by suggesting a metric categorization strategy to frame future work on the subject.

Categorization of National Pediatric Quality Measures

BACKGROUND AND OBJECTIVE

The number of quality measures has grown dramatically in recent years. This growth has outpaced research characterizing content and impact of these metrics. Our study aimed to identify and classify nationally promoted quality metrics applicable to children, both by type and by content, and to analyze the representation of common pediatric issues among available measures.

METHODS

We identified nationally applicable quality measure collections from organizational databases or clearinghouses, federal Web sites, and key informant interviews and then screened each measure for pediatric applicability. We classified measures as structure, process, or outcome using a Donabedian framework. Additionally, we classified process measures as targeting underuse, overuse, or misuse of health services. We then classified measures by content area and compared disease-specific metrics to frequency of diagnoses observed among children.

RESULTS

A total of 386 identified measures were relevant to pediatric patients; exclusion of duplicates left 257 unique measures. The majority of pediatric measures were process measures (59%), most of which target underuse of health services (77%). Among disease-specific measures, those related to depression and asthma were the most common, reflecting the prevalence and importance of these conditions in pediatrics. Conditions such as respiratory infection and otitis media had fewer associated measures despite their prevalence. Other notable pediatric issues lacking associated measures included care of medically complex children and injuries.

CONCLUSIONS

Pediatric quality measures are predominated by process measures targeting underuse of health care services. The content represented among these measures is broad, although there remain important gaps.

Radiology Research in Quality and Safety: Current Trends and Future Needs

Promoting quality and safety research is now essential for radiology as reimbursement is increasingly tied to measures of quality, patient safety, efficiency, and appropriateness of imaging. This article provides an overview of key features necessary to promote successful quality improvement efforts in radiology. Emphasis is given to current trends and future opportunities for directing research. Establishing and maintaining a culture of safety is paramount to organizations wishing to improve patient care. The correct culture must be in place to support quality initiatives and create accountability for patient care. Focused educational curricula are necessary to teach quality and safety-related skills and behaviors to trainees, staff members, and physicians. The increasingly complex healthcare landscape requires that organizations build effective data infrastructures to support quality and safety research. Incident reporting systems designed specifically for medical imaging will benefit quality improvement initiatives by identifying and learning from system errors, enhancing knowledge about safety, and creating safer systems through the implementation of standardized practices and standards. Finally, validated performance measures must be developed to accurately reflect the value of the care we provide for our patients and referring providers. Common metrics used in radiology are reviewed with focus on current and future opportunities for investigation.