Adding a second review of inpatient MRI orders at two healthcare centers has helped cut hundreds of avoidable hospital days while saving $200,000, according to research published Friday.
Magnetic resonance imaging volumes have swelled in recent years, driven partly by the delivery of unnecessary exams that add no value for the patient. But radiologists grappling with heavy workloads sometimes have inadequate time to carefully review orders and ensure appropriateness.
Two large New York City medical centers have faced this concern in recent years, experiencing “lengthy” delays in completing inpatient MRI orders, experts detailed in Clinical Imaging. However, revising workflows and harnessing an automated platform to flag exams ordered within 24 hours before discharge has produced dramatic improvements.
“This streamlined process can reduce the number of inpatient MRI orders, avoidable hospital days, [length of stay] and hospital costs,” N. Bryce Robinson, MD, with the Department of Surgery at New York-Presbyterian/Weill Cornell Medicine, and co-authors wrote Nov. 19. “Such a workflow can be adopted by other medical institutions to reduce inappropriate imaging orders and more effectively use inpatient imaging resources,” they added.
For their study, scientists evaluated all inpatient radiology orders at unnamed “Institution X” that contributed to any delays in 2017. They also manually reviewed radiology notes for 59 delayed MRI orders and found that 66% were due to systemic, nonmedical causes. Reasons included incomplete screening forms, poorly coordinated transport or diet status, and orders getting pushed aside for urgent cases. About 19% of postponed MRIs were “medically appropriate” to be conducted in the outpatient setting, while 9% required inpatient delivery.
Robinson et al. focused on that 19% number, setting the goal of converting 15% of all inpatient MRIs at the two institutions into outpatient exams over a nine-month period. They mapped out the imaging workflow and found no standardized process for escalating MRI orders, nor a system to coordinate with the outpatient side (i.e., obtaining prior authorization, scheduling the exam and transitioning from one setting to the other). Those involved implemented a commercial patient-flow platform, addressing such deficiencies by automatically identifying which orders to cancel, prioritize or shift to outpatient. Members of the care team were then emailed to conduct a second review.
During the nine-month study, the platform flagged 618 MRI requests, with providers reviewing 54%. Altogether, about 13% were either switched to outpatient or canceled (short of their initial 15% goal). Robinson and colleagues estimated that the two unnamed institutions eliminated 267 avoidable hospital days for a cost savings of $199,194. Researchers flagged their low response rate—with only about 52% of clinicians initially responding to the prompt urging them to reconsider an order—as one possible area for improvement. Lack of buy-in and heavy email burdens may be reasons for the low number.
“Future initiatives should assess methods to further improve the clinician response rate,” the authors advised. “For example, sending emails after morning rounds but before attending rounds could help the team make a more expeditious and informed decision. Using a more readily accessible medium, such as text messages to providers, could also improve the response rate.”
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.