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Nonradiologist Utilization of American College of Radiology Appropriateness Criteria in a Preauthorization Center for MRI Requests: Applicability and Effects

¹ Surgeon General Headquarters, Israel Air Force, Tel-Hashomer, Israel.
² Department of Radiology, Tel-Aviv Sourasky Medical Center, 6 Weitzman St., Tel-Aviv, Israel 30500.
³ Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
⁴ Department of Radiology, Rabin Medical Center, Golda Campus, Petach-Tikva, Israel.
⁵ Department of Health Systems Management, Faculty of Health Sciences, Ben-Gurion University, Beer-Sheva, Israel.
⁶ Chief Medical Officer Headquarters, Israel Defense Forces, Home Front Command, Ramla, Israel.

Received June 20, 2005; accepted after revision August 23, 2005.

 
Address correspondence to G. Levy (gad.levy{at}gmail.com).

Abstract

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OBJECTIVE. The purpose of this study was to evaluate the effects and applicability of use of the American College of Radiology (ACR) Appropriateness Criteria by nonradiologist physicians in an MRI preauthorization center.

MATERIALS AND METHODS. All MRI requests received at our preauthorization center during a 19-month period were included in the study. The study period was divided into preintervention and postintervention phases, indicating before and after introduction of the ACR criteria to the general practitioners staffing our center. ACR appropriateness values were classified into three groups: appropriate, indeterminate, and inappropriate. Requests for which a matching ACR value could not be assigned were labeled ACR-noncodable. Multiple parameters evaluated and compared for the two phases included rate of request receipt, total approval and denial rates, and approval and denial rates according to the ACR Appropriateness Criteria and by anatomic region to be evaluated.

RESULTS. There was no significant change in rate of request receipt and total approval and denial rates. However, there was an increase in the rate of approval of appropriate requests (phase 1, 71/96 [74%]; phase 2, 74/76 [97%]; p < 0.001) and the rate of denial of inappropriate requests (phase 1, 0/12 [0%]; phase 2, 9/13 [69%]; p < 0.001). More than 40% of requests were marked "ACR-noncodable" because of a lack of a matching clinical condition or variant.

CONCLUSION. Introduction of the ACR Appropriateness Criteria resulted in an increase in the rate of performance of appropriate MRI examinations and a decrease in the rate of performance of inappropriate MRI examinations. ACR Appropriateness Criteria were applicable to approximately 50% of MRI requests.

Keywords: American College of Radiology • Appropriateness Criteria • MRI

Introduction

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In the last decade, imaging technology has rapidly developed with the introduction and improvement of new, sophisticated, and expensive procedures. The use of diagnostic imaging studies, particularly CT and MRI, among many medical specialties has increased dramatically and continues to grow [1]. In addition, the increasing complexity of cross-sectional imaging was accompanied by inefficient use of diagnostic facilities, which led to inappropriate patient management, unnecessary radiation exposure, and costs. The limited resources available for the health care system and the increased expenditure on high-cost imaging examinations have motivated health systems and medical insurers worldwide to implement control mechanisms aimed at appropriate utilization of imaging examinations. This economically driven trend along with an increasing tendency toward evidence-based medicine [2, 3] and large variability among radiologists and clinicians about appropriate utilization of imaging techniques for a given clinical scenario [4] were recognized by the American College of Radiology (ACR) leaders in 1993 with the development of the detailed guidelines known as the ACR Appropriateness Criteria [5].

Although more than a decade has passed since work on the ACR guidelines began, the body of evidence on the use and impact of the criteria is small and inconclusive. Martin et al. [6] retrospectively studied the applicability of the ACR criteria in an internal medicine clinic setting and found that the criteria could be applied to about three fourths of imaging examination requests in that setting. Tigges et al. [7] studied the proportion of radiologists who declared having used the criteria and found it to be as low as one third. To the best of our knowledge, no other studies aimed at studying the impact of ACR criteria utilization by nonradiologist physicians staffing a preauthorization center for MRI have been published. We evaluated a model of preauthorization of MRI requests by nonradiologists using the ACR guidelines and analyzed the effect of the guidelines on imaging utilization.

Materials and Methods

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Preauthorization Model
Our Air Force health system is a primary care system of general practitioner-based infirmaries at bases supervised and regulated by the Air Force Surgeon General headquarters. Secondary and tertiary medical care services are generally out-sourced. The Air Force health system serves as both the insurer and provider of medical services to Air Force personnel. Among the cost-containment mechanisms in our health care system is an MRI preauthorization center aimed at controlling MRI utilization. The center is located at the medical services section of the Air Force Surgeon General headquarters. The center is staffed by two medical officers who are general practitioners by profession (3 years of experience) and not by radiologists. All MRI requests are faxed to the preauthorization center by the referring physicians, who are stationed at various Air Force bases. The request is written on a designated form that includes demographic information, relevant clinical history, previous imaging examinations, and clinical indication for the MRI examination. A document showing that the examination has been recommended by a board-certified specialist in a relevant clinical discipline must be attached to the request form. The medical officers staffing the preauthorization center may approve or defer the imaging requests. If clinical information is insufficient, the referring physician may be contacted and a telephone or written consultation is conducted. When necessary, the preauthorization center medical officers can consult with board-certified specialists of all clinical fields regarding approval or denial of specific MRI examination requests. If the referring physician disagrees with the preauthorization decision, the preauthorization staff is available for a telephonic debate.

Study Design
We divided the study into two phases: an initial preintervention phase and a second postintervention phase, defined, respectively, as the time before and after introduction of the ACR guidelines to the preauthorization center. The first phase of the study was conducted between February 1, 2002, and December 31, 2002. During this phase, retrospective evaluation of all MRI requests sent for preauthorization was performed by a radiologist familiar with the ACR guidelines. After completion of this phase, an intervention was performed at the end of March 2003. The same radiologist gave a 2-hour teaching session to the preauthorization center medical staff and followed it with a week of personal tutoring of the medical officers during routine work at the center. The intervention did not formally include the referring primary care physicians, although it is likely they became aware of the procedural changes at the preauthorization center during the study period. We believe that because of the unique structure of our Air Force health system, no significant influence on initiation of MRI requests by the referring physicians could have existed. The primary care physicians in the infirmaries are not authorized to request MRI examinations without a specific clinical specialist recommendation. MRI requests are therefore initiated by board-certified specialists in the various clinical fields, who are independent and not directly used by our system. These specialists were not aware of the procedural changes at the preauthorization center during the study period.

During the second phase of the study, April 1, 2003, through December 31, 2003, a retrospective evaluation of all MRI requests sent for preauthorization after introduction of the ACR guidelines was performed. The decision to use the ACR guidelines for evaluation of each MRI request was left to the medical officers' discretion; use of the guidelines was not obligatory. This design allowed us to investigate, among other parameters, the extent of self-initiated criteria utilization by the medical officers, more closely simulating the real-life environment in the preauthorization center. The ACR guidelines were available to the medical officers through the ACR site on the World Wide Web. The officers were asked to fill out a designated form for every MRI request evaluated. The form included the following data: ACR criteria used or not, reason for not using the ACR criteria if not used, ACR clinical variant used for approval or denial of the request, and ACR appropriateness value assigned to the request. Information regarding the anatomic system of the MRI request and the preauthorization outcome (approved or denied) also were evaluated. For statistical analysis of the data we devised a classification of ACR guidelines referred to as "ACR label." All imaging requests with an ACR value of 1-3 were labeled inappropriate, imaging requests with an ACR value of 4-6 were labeled indeterminate, and imaging requests with an ACR value of 7-9 were labeled appropriate. Requests for which an ACR value could not be assigned were labeled ACR-noncodable. We also compared the following parameters between the two study phases: monthly number of MRI requests, distribution of requests according to ACR label, total request approval and denial rate, and approval and denial rate according to ACR label and according to anatomic system (head, spine, shoulder, knee, etc.).

Statistical analysis included descriptive statistics and a modified chi-square statistic for assessment of significance of differences in parameters between the two phases of the study. Statistical analysis was performed with statistical analysis software.

The first phase of the study lasted 11 months and the second phase lasted 9 months. Rather than being a predetermined issue, the difference in lengths of the study phases was the result of organizational constraints intrinsic to our health system. However, because the study was focused not on utilization patterns of MRI but on the decision-making process and results inside the preauthorization center, we believe no bias was introduced by this variation.

Results

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A total of 374 MRI examination requests were received for consideration at the preauthorization center during the study period. Sixteen MRI examination requests were excluded from the study because of incomplete data. The other 358 requests were enrolled in the study. Out of these requests, 194 were received during the first (preintervention) phase of the study and 164 requests were received during the second (postintervention) phase. All the requests received during the first phase of the study were retrospectively evaluated according to the ACR Appropriateness Criteria (Fig. 1). During the second phase of the study, 121 imaging requests of the total 164 requests were evaluated by nonradiologist physicians using the ACR guidelines, and 43 (26.2%) of the imaging requests were evaluated without reference to the ACR guidelines (Fig. 2). Out of these imaging requests, 33 were approved and 10 were denied. The reasons given by our preauthorization staff for not using the ACR guidelines for the 33 approved requests were follow-up of a known pathologic condition and routine postoperative evaluation. The reasons for not using the ACR guidelines for the requests that were denied were senior consultant recommendation to defer the request and technically insufficient data.

View larger version (17K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1 —Flow chart shows phase 1 (preintervention) MRI requests received at preauthorization center during study period.

View larger version (17K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2 —Flow chart shows phase 2 (postintervention) MRI requests received at preauthorization center during study period.

In evaluation of the approval and denial rates of the imaging requests by ACR label, a statistically significant increase in the percentage of approval of ACR appropriate requests (from 74% to 97%) and decrease in the rate of approval of ACR inappropriate requests (from 100% to 30%) was seen (Table 1).

Evaluation of the approval rate of MRI requests by anatomic region examined (Table 2) showed a statistically significant decrease in the rate of approval of spinal MRI examination requests from 97% in the first phase of the study to 71%. There was no statistically significant change in approval rate for the other main anatomic areas evaluated. There was no statistically significant difference in average monthly rate of request receipts or in total rate of request approval.

Discussion

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Health systems in the Western world are dealing with the issue of maintaining and promoting the quality of medical care while containing expenditures. Radiology is one of the most rapidly growing specialties in medicine, and with the advent of new and expensive technologies, the costs of imaging are growing faster then the costs of prescription drugs. The increasingly expensive and often inefficient use of diagnostic imaging leads to unnecessary radiation exposure and puts the patients at needless risk of contrast reaction and of further invasive procedures when a false-positive result is obtained.

With the emergence of credible guidelines such as the ACR Appropriateness Criteria and the Royal College of Radiology guidelines, implementation of preauthorization programs for expensive imaging examinations may be a solution for improvement of patient care and reduction of imaging costs. Implementation of such programs may encourage physician education and may allow dissemination of information regarding the appropriate use of imaging techniques. Preauthorization of imaging requests commits the referring physician to consider each case rationally before ordering an examination.

Our data show a statistically significant increase in the rate of approval of appropriate MRI requests and in the rate of denial of inappropriate requests. Thus use of the ACR criteria improved utilization of MRI by the general practitioner medical officers. Use of an MRI preauthorization center staffed with general practitioners using the ACR criteria can significantly improve MRI utilization. However, use of radiologists as reviewers may have an advantage over use of general practitioners because radiologists have hands-on familiarity with imaging techniques, especially those that are alternatives to MRI. Implementation of the preauthorization process also resulted in a significant decrease in the rate of performance of spinal MRI imaging, showing that inappropriate imaging of the spine may be common.

The ACR criteria are invaluable and can be used by both clinicians and radiologists for better imaging utilization and improvement in patient management. We believe radiologists should serve as ambassadors for the distribution of these guidelines within the medical community. Mainiero et al. [8] suggested educating radiology residents to use the ACR guidelines to augment their ability to provide radiologic consultation to clinicians. Education efforts should also target clinicians. Taragin et al. [9] found that knowledge is lacking on the part of internal medicine residents choosing imaging examinations. Simplifying access methods to the criteria and making use of electronic databases with advanced user-friendly search engines may facilitate attainment of these goals, as results of several studies have suggested [10, 11].

We found a considerable number of imaging requests for which an ACR label could not be assigned: 41.2% in the first phase of the study and 24% in the second phase of the study. However, most requests for which ACR criteria were not consulted in the second phase of the study (26.2% of requests) corresponded to the ACR-noncodable group, leading to a total of approximately 50% of imaging requests that could not be assigned an ACR label. The rate of ACR-noncodable requests in both phases of the study was therefore similarly high, indicating a possible need for broadening of the ACR criteria.

There were a few limitations to our study. The study population, composed of active-duty Air Force personnel, did not necessarily represent other primary health care populations. Our data show that the preauthorization center did not have an effect on the number of MRI requests received. This result is in accordance with our study design: The intervention in our study was performed at the level of the decision-making mechanism (preauthorization center) and did not formally include the referring physicians. The lack of effect on the number of MRI requests received is also a result of the structure of our health system, in which the physicians who initiate the requests are not intrinsic to the system. Thus we were not able to examine the effect of the preauthorization center on possible cost savings resulting from a possible decrease in the number of imaging requests generated by the referring physicians.

Another limitation stemmed from the relatively small annual volume of MRI requests received in our preauthorization center compared with that in larger health organizations worldwide. In our study, no significant difference was detected in the rate of MRI examination request initiation and total rate of MRI request approval, which are major parameters in evaluation of the economic consequences of the intervention. In larger health systems in a different milieu, these parameters might behave differently. This supposition is particularly true considering that in our system the insurer and the provider are the same. In systems in which the provider differs from the insurer, one may expect a larger percentage of inappropriate imaging requests.

Despite the limitations, we believe that the major influence shown in the current study, significant qualitative improvement in utilization of MRI, is likely to be valid for other health systems and therefore should serve as a drive to incorporate established criteria such as the ACR Appropriateness Criteria to the decision-making process in imaging preauthorization centers. In conclusion, use of a preauthorization center staffed by general practitioners using the ACR criteria led to better utilization of MRI and an increase in the rate of performance of appropriate MRI examinations and a decrease in the rate of performance of inappropriate MRI examinations.

References

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