Use the Best Option First

Cheryl ProvalEight years ago, I sent an email to Barry Pressman, MD, FACR, radiology chair at Cedars-Sinai Medical Center (West Hollywood, California). My 75–year-old mother, a lifelong nonsmoker whose primary-care physician had diagnosed lung cancer (based on a chest radiograph), needed a referral to a surgeon. Pressman recommended Robert McKenna, MD, who had helped pioneer video-assisted thoracic (VAT) surgery in this country.

VAT surgery, which is recommended for patients with lung cancer at stages I through IIIA, was not new in 2005, but it was far from being the standard of care. At the time, McKenna had performed nearly 1,000 VAT surgeries, but for my mother, having the surgery in California would mean traveling across the country with my father, who was struggling with Parkinson disease and was none too steady on his feet.

The nearest academic medical center to my parents’ home that offered the surgery was 2.5 hours away by car, however, making transportation a major issue. Aside from that, the only surgeon there who performed VAT surgery had been recently recruited and was very young.

My mother made the fortuitous decision to have surgery to remove half of her left lung at Cedars-Sinai Medical Center. McKenna made three small incisions and inserted a videoscope; a stapling device; and a tool used to capture and remove the explant (in a plastic bag, to prevent cell tracking). If my mother had undergone lobectomy via traditional thoracotomy, the tools used would have been quite different: scalpels, retractors, and other devices that would have caused a longer hospital stay and a more difficult recovery.

Instead, my mother was discharged after two nights in the hospital, although McKenna suggested that she could leave after just one. Within a week, she was walking the hills in my neighborhood.
Eight years later, she is being followed with an annual radiograph and subsequent visit to an oncologist (in addition to completing an annual Cedars-Sinai research form). Knock wood: Hers was an excellent and wholly unexpected outcome.

More Than 17 Years

How does this relate to radiology? A window has opened, and radiology now has a unique (and perhaps unprecedented) opportunity to create widespread implementation of evidence-based medicine across the health-care delivery system. A commonly held figure for the time that it takes for medical research to translate into practice is 17 years; how long, after that, is the lag between reaching practice and becoming the standard of care?

In a draft version of policy, the House Ways and Means Committee and Senate Finance Committee jointly crafted a remedy for the sustainable growth rate (SGR) formula that includes language promoting the use of appropriateness criteria in ordering advanced imaging. Those who fail to use appropriateness criteria would be penalized, and prior authorization would be mandated for those providers found to be outliers. Furthermore, the DHHS secretary would be asked to identify the appropriateness criteria to be used (and mechanisms through which they could be disseminated).

Whether this language will survive in whatever solution is brought forth to fix the SGR cannot be predicted. What is known is that the ACR® has made the appropriateness criteria Web based—and therefore, highly available (and updatable). In this digital era, in the highly digital specialty of radiology, imaging professionals have the tools (and therefore, the potential) to begin widespread implementation of the best evidence-based medicine that the specialty can provide. What might be lacking is the will, as the responsibility is formidable.

The second way that my personal anecdote relates to radiology could be a bit naive, but it is well intended. It also is in line with the theme of value-added radiology, on which we expend a good many words in this issue of Radiology Business Journal.

One reason that VAT surgery is not widespread is likely to be that it is conducted under image guidance, which is not, for many surgeons, an area of competence. This is, however, a skill of interventional radiologists, who also are adept at navigating instruments into the human body under fluoroscopic guidance. Could there be a partnership here that would accelerate the availability of VAT surgery, which appears to be taking a languorous route toward becoming the standard of care?

As radiology works to add value to the health-care experience, it will strive to create different value propositions for different health-care stakeholders, including referring physicians, hospitals, payors, employers, and (most important) patients. With 2014 around the corner, let’s make getting it right the first time our New Year’s resolution.

Let’s put an end to poorly selected and unnecessary imaging. If the referring physician doesn’t get it right from the outset, at the point of diagnosis, then the meter starts running on waste—in time, money, morbidity, and mortality. That’s one boatload of value that radiology can provide to patients (and the entire health-care system).