• Suboptimal Utilization of Imaging Studies

  • Answer to Question 1

    As is true with all physicians, radiologists have a duty to ensure that only the appropriate and optimum level of care is provided to patients. Achieving this level of care is likely to require continual oversight and review by members of the radiology practice. Although the practice of medicine is associated with varying levels of diagnostic uncertainty, many clinical problems have been studied extensively, with generally accepted ways of arriving at the best diagnosis and treatment. Physicians who follow the tenets of evidence-based medicine will tend to be aware and conscientious about the need to ensure appropriate utilization of health care services, including the use of expensive imaging technology.

    In this vignette, you have already identified at least one physician whose test-ordering practice appears to lead to overutilization of imaging services, including expensive MR imaging studies. However, sudden confrontation of that referring physician about his or her test-ordering practice may be highly counterproductive, especially in the absence of evidence. Therefore, answer B is incorrect.

    Clinical decision support has been shown to reduce the frequency of inappropriate utilization of advanced imaging tests (1). While the introduction of a computerized physician order entry system may prove to be a wise investment over the long term and can be accepted clinically (2), it will represent a sizable short-term cost and may be associated with initial difficulties by the end users. The system also does not directly deal with the specific short-term issue of overutilization of imaging technology by a single provider. Therefore, answer E is incorrect.

    Upgrading the skills and knowledge of administrative staff about the intricacies and complexity of coding and billing may often be helpful to the welfare of the radiology practice. However, such upgrading likely would not address the specific issue of inappropriate utilization. Answer A is incorrect.

    On the other hand, warning the insurers about the possibility of legal action if they refuse payment for imaging studies deemed to be clinically appropriate is likely to go nowhere and could be counterproductive. Answer D is incorrect.

    Since you are aware of a set of imaging studies that are at risk for being deemed medically unnecessary and therefore not reimbursed, your practice is likely to benefit from discovering key pieces of information. This information includes the percentage of imaging studies that fall into this category, the identity of the referring physicians who request the majority of these studies, and the kinds of operational processes that allow these imaging studies to be scheduled without a high likelihood of reimbursement. In discussion with the referring clinician, you may be able to use published guidelines to arrive at a better evidence-based approach, including the appropriateness guidelines of the American College of Radiology (ACR) (3–6).

    The correct answer is C (review the previous month’s MR imaging orders, tally the potentially problematic cases, and arrange a discussion with the local physician about the upcoming changes and these potential “problem” cases). 

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