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Noninterpretive skills for radiology residents |
1 Department of Radiology, The Albert Einstein College of Medicine and Montefiore Medical Center, 111 E. 210th St., Bronx, NY 10467.
Received July 6, 1999;
accepted after revision July 14, 1999.
Address correspondence to E. S. Amis, Jr.
Introduction
 Top Introduction ACR StandardsACR Accreditation ProgramsACR Appropriateness CriteriaReferences |
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In the early 1960s, ACR leaders realized that the government's involvement in medicine would probably continue. Initially addressing economic issues, government involvement was expected to extend to regulations governing the standards of medical practice. To preempt government imposition of specific and detailed standards, ACR leaders took the initiative in defining these standards. The ACR response was a series of programs and services designed to govern quality in all aspects of radiologic imaging and radiation oncology. These programs evolved into the current ACR Standards [1], ACR accreditation programs, and ACR appropriateness criteria. The Standards define how radiologic procedures should be performed to provide a high-quality and reproducible product, the accreditation programs use a survey instrument to determine whether standards are met for radiologic techniques, and the appropriateness criteria outline the best methods to diagnose or treat specific clinical conditions with diagnostic or interventional radiology. This triumvirate of programs is an invaluable tool for radiologists to maintain a high-quality practice. Currently, the cost to radiologists for these programs is approximately equal to the cost of development of the programs.
The responsibility for ACR programs is vested in the Commission on Standards and Accreditation, one of seven operational commissions in the ACR. Typically, members of the commission are individuals who also serve on one of the seven specialty commissions. Each of the specialty commissions has a committee on standards and accreditation, and the chairpersons of those committees are members of the Commission on Standards and Accreditation. This method of membership guarantees a broad spectrum of specialty representation (including members from private practice and academic medical centers) with a wide geographic distribution. Additionally, more than 500 volunteer radiologists are involved in creating additional programs and revising current programs on a regular basis. At ACR headquarters, a large contingent of dedicated personnel coordinate thousands of detailed activities, services, and publications designed to continually improve quality in radiology. The remainder of this article addresses each of the ACR programs in more detail.
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TopIntroductionACR StandardsACR Accreditation ProgramsACR Appropriateness CriteriaReferences |
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A rigid process is followed in developing standards [2]. New standards are proposed by specialty organizations, individual practicing radiologists, ACR state chapters, or other entities related to the specialty of radiology. Proposals are evaluated by the appropriate specialty commission, which can then accept, modify, or reject the proposed standard. Once accepted, a draft standard is circulated for comment to all state chapter presidents, councilors, alternate councilors, and members of the ACR Board of Chancellors and Council Steering Committee. Comments are collected, and then an ad hoc committee develops a version to submit to the ACR Council for final adoption or rejection. At the annual ACR meeting, the standard may be further revised by a reference committee. This complex approval process allows input from all sectors of radiology, and broad participation is invited in the interest of creating standards that are applicable to all types of radiology practices.
The purpose of ACR standards is not to mandate the operation of individual practices but rather to define reasonable principles of practice that, if followed, will produce highquality radiology care. In a review by the Physician Insurers Association of America, ACR standards have been shown to be good risk-management tools [3].
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TopIntroductionACR StandardsACR Accreditation ProgramsACR Appropriateness CriteriaReferences |
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Perhaps the best known ACR accreditation program is for mammography. In 1985, the United States Food and Drug Administration found significant image quality problems in mammography on the basis of data from the National Evaluation of X-Ray Trends studies [4]. At the same time, the American Cancer Society was encouraging ACR to develop an accreditation program for mammography facilities [5]. Radiologists were challenged to find ways to ensure quality and improve clinical results. A focused mail-in voluntary accreditation program was developed to evaluate personnel qualifications, equipment, radiation dose, phantom and clinical images, processor performance, and adherence to quality control and quality assurance procedures. This format was applied to all subsequent technique-specific accreditation programs. After receiving national media attention, the ACR mammography accreditation program became a standard by which women judged the quality of imaging centers. Subsequent National Evaluation of X-Ray Trends studies showed a marked improvement in mammographic image quality throughout the United States. In October 1992, President George Bush signed into law the Mammography Quality Standards Act, and in 1994, the ACR mammography accreditation program was adopted by the Food and Drug Administration. It is now illegal for an imaging center to offer mammography without certification from the Food and Drug Administration. Even though the Food and Drug Administration conducts annual site inspections, ACR continues to provide clinical and phantom image evaluations and to examine other quality control data.
In 1995, a sonography accreditation program was implemented covering antepartum obstetric sonography, general sonography, and a combination of the two. Noninvasive vascular sonography has since been added as a module. The positive response of radiologists to both accreditation programs highlighted the need for an encompassing accreditation program for all techniques in radiology practice. This concept is referred to as the umbrella program. Recently, accreditation programs for MR imaging and stereotactic or sonographically guided breast biopsy were implemented. Nuclear medicine, CT, radiography, fluoroscopy, and interventional radiology accreditation programs are in development and should undergo pilot-testing and be available in the next 2 years. Although each program currently requires a separate application, the long-term goal is a single simplified application for all accreditation programs with reaccreditation required every 3 years.
As with the ACR standards, the development of accreditation programs is a complex process. Furthermore, accreditation programs, to be valid, must adhere to recognized (and stringent) principles of accreditation law [6] (Appendix 1). An accreditation committee is formed on the basis of recommendations from the Commission on Standards and Accreditation. However, the development of an accreditation program is depoliticized as much as possible by keeping it separate from other committees and commissions of the ACR. Representation on accreditation committees comes from large and small practices, academia, and private practice. When the program is complete, it is pilot-tested in the field to ensure that it is realistic and performable by the full range of radiology practices. Before implementation, the completed accreditation program is reviewed and commented on by the ACR Council Steering Committee. ACR Council approval is required only for the development of accreditation programs, not for their final acceptance or implementation. After a program is fully operational, the chair of the accreditation committee becomes a member of the Commission on Standards and Accreditation.
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An ACR accreditation certificate indicates that an accredited technique or practice has completed a formal process and met stringent quality standards. Third-party payers are beginning to recognize that accreditation guarantees the quality of a technique, and some now require accreditation before reimbursement for various procedures.
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Because data available from existing scientific studies are usually insufficient for meta-analysis, it was necessary to use broad-based consensus techniques to reach agreement in the formulation of appropriateness criteria. The ACR used a modified Delphi technique to arrive at consensus [10]. Also, ACR leaders thought that the input of physicians from medical specialties other than radiology would be an important quality factor and a method for showing that the criteria were not self-serving. Specialty guidelines were developed by 10 expert consensus panels: eight diagnostic and two therapeutic. The diagnostic panels were organized along organ-system lines with exceptions for panels on pediatric radiology and women's imaging. Panel leaders and the chair of the task force acted as a steering committee to develop policy and provide direction. Each panel chair was responsible for selecting a broad representation of panel participants with expertise in the applicable imaging techniques. Major scientific societies representing medical specialty organizations outside radiology were contacted, and on the basis of their recommendations, nonradiologist physicians were selected to participate in the process.
Each panel selected clinical conditions to be addressed on the basis of the prevalence of the condition, the potential for morbidity or mortality, and the potential for improved care. Often, clinical conditions were separated into a number of variants. Once the clinical condition and its variants were defined, literature searches of peer-reviewed medical journals were conducted and major applicable articles were retrieved. Typically, one topic leader per panel was responsible for developing an evidence table based on the analysis of current literature. The valid literature was then used to develop a treatise for each clinical condition.
On the basis of the narrative and the accompanying literature evidence table, panelists, without outside influence, rated each applicable imaging examination or therapeutic procedure on a scale of 1-9 (least appropriate technique, 1; most appropriate technique, 9). The survey results were collected, tabulated, and redistributed for each subsequent round. Generally, three rounds were conducted and opinions unified to the highest degree possible; 80% agreement was considered consensus. The final outcome was an appropriateness rating for each potentially useful diagnostic or therapeutic procedure, considering medical evidence, professional expertise, and current practice patterns. As an example, the guidelines for staging clinically localized prostatic cancer in patients with a prostate-specific antigen of less than 10 ng/ml show ratings of 4 or less for all potentially useful staging techniques (including bone scanning). However, when the prostate-specific antigen is greater than 10 ng/ml (increasing the likelihood of tumor spread), bone scanning is rated 9 and is therefore a highly appropriate staging examination. Because the field of radiology is dynamic and constantly evolving, the appropriateness criteria are reviewed and revised (if necessary) every 3 years.
As noted in the introduction, appropriateness criteria are intended to serve as guidelines in selecting the best imaging or therapeutic procedure for a specific clinical condition. The uses of appropriateness criteria are multiple, and the criteria serve as a basis for treatment by retrospective or prospective review in working with managed care organizations.
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TopIntroductionACR StandardsACR Accreditation ProgramsACR Appropriateness CriteriaReferences |
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