Medical-Imaging Stewardship in the Accountable Care Era.

M technology plays an essential role in the timely diagnosis and manage­ ment of many conditions. Lately, however, it’s become equally well known for its low­value uses and as the single largest source of per capita radiation exposure. Imaging is by far the most com­ mon service on the lists of un­ necessary tests and procedures of the Choosing Wisely campaign, and an estimated 20 to 50% of imaging is unnecessary.1 Medi­ cal imaging is thus a valuable resource in dire need of better stewardship. Because of concerns about overuse, private insurers have increasingly delegated imaging utilization management to radiol­ ogy benefit management firms (RBMs), inserting into the value chain a third party whose cre­ dentials are unfamiliar to both patients and physicians. RBMs evaluate the medical necessity of imaging services and approve or deny physician requests. Although they help control overuse, RBMs fragment the ordering process. The time that physicians and their staff spend gathering and trans­ mitting information and engaging with RBMs reduces their produc­ tivity and results in cost shifting rather than value creation. Two recent policy changes have created a more favorable en­ vironment for provider­led imag­ ing stewardship. The first is the movement toward payment re­ form, as exemplified by the goal of transitioning 50% of all Med­ icare payments to alternative models by 2018.2 The second is a little­known section of the Pro­ tecting Access to Medicare Act of 2014, which mandates that, be­ ginning in 2017, physicians refer­ ence appropriateness guidelines from provider organizations when ordering advanced imaging for Medicare beneficiaries.3 Although practical aspects of implementa­ tion of the law have yet to be clarified, in the context of the shift toward value­based care many health systems are implementing clinical decision support (CDS) sys­ tems to help providers select the most appropriate form of imag­ ing while limiting overutilization. We believe we’ve reached an inflection point for provider­led imaging stewardship nationwide. To understand the approach to stewardship that may emerge, it’s helpful to consider the framework that infectious­disease specialists have used over the past two de­ cades to systematically educate and persuade referring providers to use antimicrobial agents prop­ erly. There’s growing evidence that these interventions both im­ prove quality — by reducing the spread of resistant nosocomial infections, for example — and reduce costs.4 The Centers for Disease Control and Prevention lists seven core elements of ef­ fective antimicrobial stewardship (see table).5 Its recipe for success involves securing leadership com­ mitment, putting experts in charge of stewardship, implementing pro­ cess interventions that curb inap­ propriate utilization, and proper­ ly educating ordering physicians. We believe an analogous frame­ work can be used in transition­ ing to imaging stewardship. Alternative payment models are creating financial incentives for reducing overutilization, allow­ ing health care leaders to com­ mit themselves more deeply to imaging stewardship. Protecting time for physician champions to lead change­management efforts and investing in infrastructure to support them are necessary but not sufficient; leaders must also publicly signal a cultural transi­ tion away from easy imaging ac­ cess and toward stewardship. This message will be most effective if it’s framed as an essential com­ ponent of a larger quality­improve­ ment strategy. Public endorsement of specific Choosing Wisely rec­ ommendations related to imaging is an excellent first step. Since keeping up with the evi­ dence on appropriate imaging is a full­time endeavor, stewardship programs should be led by prac­ ticing imaging specialists such as radiologists, cardiologists, and nuclear­medicine physicians. Al­ though it’s important for refer­ ring physicians to play a role in shaping local concepts of appro­ priate imaging within their care pathways, stewardship should be a central function within each provider organization, and dedi­ cated leaders with common goals are required. CDS can be an enabling tool, but stewardship interventions don’t necessarily require it. By making relatively minor adjustments to workflow, organizations can en­ courage physicians to seek con­ sultation for types of exams that have a high potential for over­ use. Several years ago, our institu­ tion began requiring radiologist approval for all nonemergency pediatric computed tomographic (CT) scans. We subsequently ob­ served a spillover effect: requiring