Radiologists and emergency room physicians with Southern Delaware’s largest health care system have joined forces using elements of both the American College of Radiology’s (ACR’s) Radiology Support Communication and Alignment Network (R-SCAN) and the American College of Emergency Physicians’ (ACEP’s) E-QUAL (Emergency Quality Network) programs to improve the ordering of imaging exams for non-traumatic low back pain.
Funded by the Centers for Medicare and Medicaid Services’ (CMS’) Transforming Clinical Practice Initiative, both the R-SCAN and E-QUAL programs focus on improving the ordering of imaging related to several Choosing Wisely® recommendations — including low back pain. This shared focus created an opportunity for collaboration between radiologists and emergency physicians with Bayhealth.
To achieve success with their low back pain initiative, long-time colleagues Craig Hochstein, MD, medical director at Bayhealth’s Smyrna campus, and Thomas Vaughan, MD, a radiologist and chief wellness officer at Bayhealth, applied several R-SCAN-inspired strategies to aid discussions with patients and provide insight to clinicians about the most appropriate use of imaging for low back pain.
Hochstein and Vaughan described their experiences while implementing the program at three Bayhealth emergency departments (EDs) during a recent webinar and podcast for the E-QUAL Network’s Reducing Avoidable Imaging Collaborative.
The Kent campus is largest of the three facilities. Based in Dover, the state capital, its emergency department serves about 55,000 patients annually. About 32,000 ED visits were recorded in 2018 at the new Bayhealth Hospital, Sussex Campus in Milford, DE, and another 18,000 patients were treated at Bayhealth’s freestanding emergency service at Smyrna, DE.
Success for the Reducing Avoidable Imaging Initiative was measured by comparing lumbar spine CT and X-ray imaging volumes at the three facilities before and after an extensive educational program was carried out. The educational efforts for clinicians included presentations at departmental meetings, information displayed in prominent locations in the ED and regular chart reviews.
Posters for patients were displayed in the ED waiting area that described when imaging is necessary for managing low back pain. Individual facility results also were compared with data collected from hospitals across the nation participating in ACEP’s Low Back Initiative.
At Kent, for example, Hochstein and Vaughan measured a 30 percent reduction in low back CT imaging from January to March 2018. This change may have been offset by a 15 percent increase in low back X-ray use. National lumbar CT and X-ray utilization data for the three-month period from ACEP found two percent declines for lumbar CT and X-ray imaging.
The second phase from July to September 2018 revealed the staying power of the Reducing Avoidable Imaging Initiative. Hochstein reported the Kent emergency department saw a zero percent change in lumbar CT from the earlier period, while lower back X-ray procedures declined another six percent. Similar utilization reductions were seen at Sussex and Smyrna.
But realizing these improvements was not easy. Hochstein and Vaughan noted successful implementation required numerous staff meetings and educational sessions to empower ED physicians to say no to patient requests for imaging to find the source of their lower back pain. It took well-designed posters and their intelligent display in the ED to inform patients that their conditions probably do not require an X-ray or advanced imaging. It also involved reliance on ACR Appropriateness Criteria® to identify specific symptoms that should lead to immediate diagnostic imaging. And, it required various R-SCAN tools to measure and monitor the new policies’ effects.
The education of new ED physicians was addressed during departmental meetings and sometimes with individual attention to help them become accustomed and committed to the new imaging ordering policies.
“The project was designed in various ways to maintain high physician and patient compliance to assure continuing success,” Hochstein said. “This proved possible by continuing to teach new providers how to avoid unnecessary low back imaging. We want to provide ongoing data for the group. We do that at our monthly meetings and with information and consultations down to the individual provider level.”
Vaughan credited R-SCAN for providing tools that encourage different clinical specialties, such as ER and radiology, to collaborate to reduce their dependence upon low-yield, high-cost imaging for emergency studies.
“R-SCAN has many advantages,” Vaughan said. “Having clear guidelines about when to image moves patients through the ED quicker. It also allows radiologists to address imaging cases where the results will have an impact on patient care. There is less patient exposure to radiation and certainly decreased cost.”