Joseph R. Steele

The Joint Commission Practice Performance Evaluation: A Primer for Radiologists

As health care quality continues to move into the limelight, so do physicians. The new Joint Commission requirements (Ongoing Professional Practice Evaluation and Focused Professional Practice Evaluation) mandate continuous data-based evaluation and monitoring of physician practice performance. This task could be seen as cumbersome, but it may provide opportunities to develop quality improvement programs that demonstrate the value provided by hospital-based radiologists.

Continuous Quality Improvement Programs Provide New Opportunities to Drive Value Innovation Initiatives in Hospital-Based Radiology Practices

Imaging services constitute a huge portion of the of the total dollar investment within the health care enterprise. Accordingly, this generates competition among medical specialties organized along service lines for their pieces of the pie and increased scrutiny from third-party payers and government regulators. These market and political forces create challenge and opportunity for a hospital-based radiology practice. Clearly, change that creates or builds greater value for patients also creates sustainable competitive advantage for a radiology practice. The somewhat amorphous concept of quality constitutes a significant value driver for innovation in this scenario. Quality initiatives and programs seek to define and manage this amorphous concept and provide tools for a radiology practice to create or build more value. Leadership and the early adoption of these inevitable programs by a radiology practice strengthens relationships with hospital partners and slows the attrition of imaging service lines to competitors.

Guidelines for Establishing a Quality Improvement Program in Interventional Radiology

THE membership of the Society of Interventional Radiology (SIR) Standards of Practice Committee represents experts in a broad spectrum of interventional procedures from both the private and academic sectors of medicine. Generally Standards of Practice Committee members dedicate the vast majority of their professional time to performing interventional procedures; as such they represent a valid broad expert constit-

Quality Initiatives: Establishing an Interventional Radiology Patient Radiation Safety Program

The Interventional Radiology Patient Radiation Safety Program was created to better educate patients who are scheduled to undergo high-dose interventional radiologic procedures about the risks of radiation, better monitor the delivered doses, and reduce the risk for deterministic effects. The program combines preprocedure evaluation and counseling, intraprocedure monitoring, and postprocedure documentation and counseling with the guidelines of the National Cancer Institute and the Society of Interventional Radiology. Between July 2009, when the program was implemented, and September 2010, over 3500 interventional radiologic procedures were monitored and documented, and 63 procedures with an adjusted cumulative dose of more than 3 Gy were identified and further analyzed; four procedures were found to be outside the control limits. Additional review of these four procedures resulted in practice modifications. Anecdotal feedback from physician assistants and attending physicians indicated that the program had another positive effect: Patients who required postprocedure counseling about the potential for radiation-induced skin injuries were no longer surprised by this information. Implementation of this program is straightforward, requires little infrastructure and few resources, and may be applied in most interventional radiology practices. Supplemental material available at http://radiographics.rsna.org/lookup/suppl/doi:10.1148/rg.321115002/-/DC1.

Monte Carlo Simulation to Analyze the Cost-Benefit of Radioactive Seed Localization Versus Wire Localization for Breast-Conserving Surgery in Fee-for-Service Health Care Systems Compared With Accountable Care Organizations

OBJECTIVE In breast-conserving surgery for nonpalpable breast cancers, surgical reexcision rates are lower with radioactive seed localization (RSL) than wire localization. We evaluated the cost-benefit of switching from wire localization to RSL in two competing payment systems: a fee-for-service (FFS) system and a bundled payment system, which is typical for accountable care organizations. MATERIALS AND METHODS A Monte Carlo simulation was developed to compare the cost-benefit of RSL and wire localization. Equipment utilization, procedural workflows, and regulatory overhead differentiate the cost between RSL and wire localization. To define a distribution of possible cost scenarios, the simulation randomly varied cost drivers within fixed ranges determined by hospital data, published literature, and expert input. Each scenario was replicated 1000 times using the pseudorandom number generator within Microsoft Excel, and results were analyzed for convergence. RESULTS In a bundled payment system, RSL reduced total health care cost per patient relative to wire localization by an average of

Bundled Payments: Bundled Risk or Bundled Reward?

115, translating into increased facility margin. In an FFS system, RSL reduced total health care cost per patient relative to wire localization by an average of

Optimizing radiation use during fluoroscopic procedures: proceedings from a multidisciplinary consensus panel.

595 but resulted in decreased facility margin because of fewer surgeries. CONCLUSION In a bundled payment system, RSL results in a modest reduction of cost per patient over wire localization and slightly increased margin. A fee-for-service system suffers moderate loss of revenue per patient with RSL, largely due to lower reexcision rates. The fee-for-service system creates a significant financial disincentive for providers to use RSL, although it improves clinical outcomes and reduces total health care costs.

Quality and Value of Subspecialty Reinterpretation of Thoracic CT Scans of Patients Referred to a Tertiary Cancer Center

One potential option of President Obamas proposed health care plan is to change from fee-for-service to episode-of-care payments. These global payments would combine physician and hospital reimbursement from admission to discharge. In an effort to further evaluate this strategy, CMS has initiated a pilot study called the Acute Care Episode (ACE) Demonstration. Five hospitals in the United States have been chosen to participate. The authors review the history of bundled payments, the current ACE Demonstration, and the opinions of those radiologists involved and attempt to outline a plan for hospital-based practices to prepare for this possible scenario.

The Role of RADPEER™ in the Joint Commission Ongoing Practice Performance Evaluation

James R. Duncan, MD, PhD, Stephen Balter, PhD, Gary J. Becker, MD, Jeffrey Brady, MD, MPH, James A. Brink, MD, Dorothy Bulas, MD, Mythreyi B. Chatfield, PhD, Simon Choi, PhD, MPH, Bairbre L. Connolly, MB, Robert G. Dixon, MD, Joel E. Gray, PhD, Stephen T. Kee, MD, Donald L. Miller, MD, Donald W. Robinson, LTC, MD, Mark J. Sands, MD, David A. Schauer, DSc, Joseph R. Steele, MD, Mandie Street, RT, Raymond H. Thornton, MD, and Robert A. Wise, MD

Quality Improvement in Interventional Radiology: An Opportunity to Demonstrate Value and Improve Patient-centered Care

INTRODUCTION Patients referred to tertiary cancer centers often present with imaging studies performed and interpreted at other health care institutions. Although reinterpretation of imaging performed at another health care institution can reduce repeat imaging, unnecessary radiation dose, and cost, the benefit is uncertain. The purpose of this study is to evaluate the quality of initial imaging studies of patients seeking a second opinion at a tertiary cancer center, to compare the accuracy of initial interpretations to reinterpretations performed by subspecialty trained radiologists at a tertiary oncologic center, and to determine the potential impact on patient management. METHODS An institutional review board-approved retrospective, single-institution database review was performed in 120 new patients presenting to the thoracic surgery clinics at our institution from 2010 through 2013, with initial chest CTs performed at another institution. Two thoracic radiologists blinded to the interpretation independently assessed the quality and performed a reinterpretation of 52 CTs. Fishers exact tests were used to compare the frequency with which clinically important staging parameters appeared in the reinterpretations and initial reports. Discrepancies between the reinterpretations and initial interpretations were adjudicated independently by two thoracic radiologists at different tertiary cancer institutions to determine which interpretations were more accurate. The impact of discrepancies on clinical management was evaluated based on National Comprehensive Cancer Network guidelines. RESULTS Of the 52 CTs, 32 (62%) were of inadequate image quality for staging. In 17 of 52 (33%), discrepancies were identified between reinterpretations and initial interpretations. For discrepancies, the reinterpretation was judged to be more accurate for staging than the initial interpretation. In nine of these patients, staging parameters were omitted in the initial interpretations that precluded adequate staging. In the remaining eight patients, six were upstaged, one was downstaged, and one was unchanged by the reinterpretation. CONCLUSIONS Imaging studies from outside institutions are of variable image quality and often not adequate for appropriate staging of thoracic malignancies. Reinterpretation can decrease repeat imaging and associated technical costs. Additionally, the accuracy of staging is improved by reinterpretation of CTs by subspecialty trained radiologists and can significantly impact clinical management.