Matthew D. Alvin

Eliminating Creatine Kinase–Myocardial Band Testing in Suspected Acute Coronary Syndrome: A Value-Based Quality Improvement

Cardiac biomarker testing is estimated to occur in nearly 30 million emergency department visits nationwide each year in the United States. The American College of Cardiology/European Society of Cardiology indicate that cardiac troponin is the biomarker of choice owing to its nearly absolute myocardial tissue specificity and high clinical sensitivity for myocardial injury. Multiple academic medical centers have implemented interventions to eliminate the routine ordering of creatine kinase–myocardial band tests, with published patient safety outcomes data; however, creatine kinase–myocardial band testing is still ordered in many hospitals and emergency departments. Eliminating a simple laboratory test that provides no incremental value to patient care can lead to millions of health care dollars saved without adversely affecting patient care quality, and in this case potentially improving patient care.

The USMLE Step 2 CS: Time for a change

Abstract The United States Medical Licensing Examination (USMLE®) Steps are a series of mandatory licensing assessments for all allopathic (MD degree) medical students in their transition from student to intern to resident physician. Steps 1, 2 Clinical Knowledge (CK), and 3 are daylong multiple-choice exams that quantify a medical student’s basic science and clinical knowledge as well as their application of that knowledge using a three-digit score. In doing so, these Steps provide a standardized assessment that residency programs use to differentiate applicants and evaluate their competitiveness. Step 2 Clinical Skills (CS), the only other Step exam and the second component of Step 2, was created in 2004 to test clinical reasoning and patient-centered skills. As a Pass/Fail exam without a numerical scoring component, Step 2 CS provides minimal differentiation among applicants for residency programs. In this personal view article, it is argued that the current Step 2 CS exam should be eliminated for US medical students and propose an alternative consistent with the mission and purpose of the exam that imposes less of a burden on medical students.

Training Radiology Residents to be Stewards in Healthcare Value

Medical imaging procedures have become a national target in the campaign to reduce wasteful practices. At a minimum, radiology residency programs must integrate high-value curricula and train residents to practice in accordance with value-based principles and new healthcare policy. A greater portion of radiology resident education needs to be devoted to appropriateness education and consultancy training. Ideally, radiology training programs will instill in residents the importance of embracing the movement and leading the change.

Cost-Effectiveness Analysis in Radiology: A Systematic Review

PURPOSE Cost-effectiveness analyses (CEAs) have become more prevalent in radiology. However, the lack of standard methodology may lead to conflicting conclusions on the cost-effectiveness of an imaging modality and hinder CEA-based policy recommendations. This study reviews recent CEAs to identify areas of methodological variation, explore their impact on interpretation, and discuss optimal strategies for performing CEAs in radiology. METHODS We performed a systematic review for cost-utility analyses in radiology from 2013 to 2017. Cost and quality-of-life methods were analyzed and compared using the Consolidated Health Economic Evaluation Reporting Standards checklist. RESULTS Eighty cost-utility studies met our inclusion criteria. A payer perspective was the most common (70%) and hospital perspective the least common (5%). Fourteen studies (17.5%) did not report perspective, and 12 (15%) reported a perspective inconsistent with their performed analysis. Cost inclusion varied greatly between studies; adverse effects of imaging (20.5%) and hospitalization (34.6%) were the least frequently included direct costs. Studies that measured their own utilities most commonly used the EuroQol-5D and Short Form-6D questionnaires; however, most studies (80%) cited utilities from previous literature. Seventy-two studies (90%) used willingness-to-pay thresholds, and 30 used cost-effectiveness acceptability curves (41.7%). CONCLUSION We observed statistically significant methodological variation indicating the need for a standardized, accurate means of performing and presenting CEAs within radiology. We make several recommendations to address key problems regarding study perspective, cost inclusion, and use of willingness-to-pay thresholds. Further work is required to ensure comparability and transparency between studies such that policymakers are properly informed when utilizing CEA results.

Cost-Effectiveness of Cervical Epidural Steroid Injections: A 3-Month Pilot Study

Study Design: Retrospective cohort. Objectives: There are conflicting reports on the short- and long-term quality of life (QOL) outcomes and cost-effectiveness of cervical epidural steroid injections (ESIs). The present study analyzes the cost-effectiveness analysis of ESIs versus conservative management for patients with radiculopathy or neck pain in the short term. Methods: Fifty patients who underwent cervical ESI and 29 patients who received physical therapy and pain medication alone for cervical radiculopathy and neck pain of <6 months duration were included. Three-month postoperative health outcomes were assessed based on EuroQol-5 Dimensions (EQ-5D; measured in quality-adjusted life years [QALYs]). Medical costs were estimated using Medicare national payment amounts. Cost/utility ratios and the incremental cost-effectiveness ratio (ICER) were calculated to assess for cost-effectiveness. Results: The ESI cohort experienced significant (P < .01) improvement in the EQ-5D score while the control cohort did not (0.13 vs 0.02 QALYs, respectively; P = .01). There were no significant differences in costs between the cohorts. The cost-utility ratio for the ESI cohort was significantly lower (

Spine Surgeon Treatment Variability: The Impact on Costs

21 884/QALY gained) than that for the control cohort (

Cervical spine surgery for tandem spinal stenosis: The impact on low back pain

176 412/QALY gained) (P < .01). The ICER for an ESI versus conservative management was negative, indicating that ESIs provide greater improvement in QOL at a lower cost. Conclusions: ESIs provide significant improvement in QOL within 3 months for patients with cervical radiculopathy and neck pain. ESIs are more cost-effective compared than conservative management alone in the shor -term. The durability of these results must be analyzed with longer term cost-utility analysis studies.

Transitioning to a High Value Health Care Model: Academic Accountability

Study Design: Cross-sectional analysis. Objectives: Given the lack of strong evidence/guidelines on appropriate treatment for lumbar spine disease, substantial variability exists among surgical treatments utilized, which is associated with differences in costs to treat a given pathology. Our goal was to investigate the variability in costs among spine surgeons nationally for the same pathology in similar patients. Methods: Four hundred forty-five spine surgeons completed a survey of clinical and radiographic case scenarios on patients with recurrent lumbar disc herniation, low back pain, and spondylolisthesis. Those surveyed were asked to provide various details including their geographical location, specialty, and fellowship training. Treatment options included no surgery, anterior lumbar interbody fusion, posterolateral fusion, and transforaminal/posterior lumbar interbody fusion. Costs were estimated via Medicare national payment amounts. Results: For recurrent lumbar disc herniation, no difference in costs existed for patients undergoing their first revision microdiscectomy. However, for patients undergoing another microdiscectomy, surgeons who operated <100 times/year had significantly lower costs than those who operated >200 times/year (P < .001) and those with 5-15 years of experience had significantly higher costs than those with >15 years (P < .001). For the treatment of low back pain, academic surgeons kept costs about 55% lower than private practice surgeons (P < .001). In the treatment of spondylolisthesis, there was significant treatment variability without significant differences in costs. Conclusions: Significant variability in surgical treatment paradigms exists for different pathologies. Understanding why variability in treatment selection exists in similar clinical contexts across practices is important to ensure the most cost-effective delivery of care among spine surgeons.

Clinical Access and Utilization of Reports and Images in Neuroradiology

STUDY DESIGN Retrospective Cohort. OBJECTIVE Tandem spinal stenosis (TSS) can present similarly to cervical myelopathy, but often has a worse prognosis. Few studies have investigated outcomes and compared treatment approaches for patients with TSS. We sought to determine the impact of cervical spine surgery on cervical and lumbar spine symptoms in patients with symptomatic tandem spinal stenosis. PATIENTS METHODS 84 patients with TSS were identified over 5 years. 48 underwent cervical spine surgery alone, 20 underwent both cervical and lumbar spine surgery, and 16 received conservative treatment alone (conservative cohort). Quality of life (QOL) measures included the Visual Analogue Scale (VAS) for arm, neck, and back pain, and EuroQOL-5 Dimensions (EQ-5D). QOL data were acquired at baseline (pre-operative) and 1 year postoperatively via an institutional prospectively collected database. RESULTS Both surgical cohorts showed significant (p < 0.01) pre- to postoperative improvement for VAS neck and arm scores at 1-year post-op and significantly (p < 0.01) greater improvements than the conservative cohort. In addition, the cohort undergoing cervical spine surgery alone experienced significant improvement in the EQ-5D score whereas those undergoing both cervical and lumbar spine surgery did not. CONCLUSIONS Cervical spine surgery with or without follow-up lumbar spine surgery significantly improves neck pain in patients with TSS. In contrast, cervical spine surgery in these patients does not improve lumbar symptoms. Lumbar surgery also did not improve low back pain or quality of life. Future prospective studies are necessary to examine the impact of lumbar decompression alone on cervical spine symptoms in patients with TSS.