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1 Berquist.Thomas{at}mayo.edu
The future of imaging is constantly scrutinized by local and national agencies and the insurance industry. In addition, we radiologists have been reminded of our responsibility to our patients and the public by leaders in medicine on numerous occasions. In 1977, Russell H. Morgan emphasized our role in working with our clinician colleagues to enhance patient care. Historically, it was also the beginning of a new era for state and local regulation for the purchase and utilization of imaging equipment [1]. The Eugene W. Caldwell Lecture presented by Robert W. Holden in 1998 emphasized "the absolute necessity for medical leadership to recognize the need for change; establish common professional values; create a vision; and provide courage, strength, and passion to make correct strategic choices to empower the success of medicine in the future" [2]. In 2004, Robert J. Stanley, AJR Editor Emeritus, issued a challenge when he said we must "develop a program to show measurable quality improvement and restore confidence in the American health care system" [3].
Quality health care is impacted by equipment vendors, regulatory agencies such as the Food and Drug Administration (FDA), insurers, physicians, medical physicists, and all allied heath care professionals. Bringing these people (THE TEAM) together to work in concert on health care issues may seem like a daunting task.
A recent New York Times article provides an excellent example of the work the above team needs to accomplish [4]. The story relates to a patient with an "uninterpretable" MRI study of the knee. The insurance company refused to pay for repeating the MR study, so the patient underwent an unnecessary operation for a meniscal tear that was suspected clinically, but found to be normal at surgery. The insurance did pay for the surgery and a poor imaging study. The article emphasized the overuse of imaging and unnecessary surgical procedures that are performed each day in the United States. Radiologists interviewed in the article commented on the issue of inadequate imaging studies, self referral, and the lack of regulation for most imaging studies except mammography.
The New York Times article on quality and this month's AJR focus on pediatric imaging serve as yet another reminder of our obligation to our patients and the public. This issue of AJR provides our readers with multiple articles on pediatric imaging. There are also two key commentaries. The first by Keith Strauss and colleagues is titled "Image Gently Vendor Summit: Working Together for Better Estimates of Pediatric Radiation Dose from CT Scans." The second by Dorothy I. Bulas and colleagues is titled "Image Gently: Why We Should Talk to Parents about CT in Children." Both address key issues in quality and safety when performing CT studies on children.
We should thank our colleagues in pediatric radiology for their efforts to "image gently." The "Image Gently" campaign began due to issues with the explosion of CT examinations being performed on children [5]. CT examinations on children increased 600% from 1985 to 1996 [6]. At the time, there were no consistently used guidelines for CT examinations performed on children [7]. The first conference on this topic was held in 2001 and has resulted in continued activity to improve patient safety and reduce radiation doses in children. These concerns led to the formation of the Alliance for Radiation Safety in Pediatric Imaging. The founding organizations were the Society for Pediatric Radiology, American Association of Physicists in Medicine, American College of Radiology (ACR), and the American Society of Radiologic Technologists. The alliance grew to a 13-member organization consisting of medical societies (including the American Roentgen Ray Society [ARRS]), agencies, and regulatory groups that work together to improve patient care. The ranks continue to grow and now include 31 national and international specialty societies (www.pedrad.org/associations). Our colleagues in pediatric radiology have accomplished a herculean effort by bringing all of the parties noted above to the table to continue to work on quality imaging and patient safety.
Recently, a strategic integration between the ARRS and the ACR was announced. Though the details have not been fully completed, this partnership should provide additional opportunities to improve quality and patient care. Our colleagues at the ACR have developed and promoted appropriateness criteria for years. These criteria provide evidence-based data and recommend the best imaging approach for specific clinical problems [8]. This information is available online (www.acr.org/ac) to all physicians and scientists.
Radiology departments may struggle with meeting state, local, or national regulatory requirements for safe and appropriate imaging. The ACR provides rigorous certification programs that ensure that radiology departments and their personnel meet national standards. Accreditation programs are available for mammography, ultrasound, CT, MRI, and nuclear medicine and PET. Every department should seek ACR accreditation for these modalities (www.acr.org).
How do we build upon what has been accomplished? For example, why have ACR appropriateness criteria not been fully incorporated into our practices? Medicine today has entered the electronic era. Therefore, should we not include the appropriateness criteria in our image ordering systems to reduce unneeded or inappropriate studies? We have a new Medical Physics and Informatics section in our journal. G. Donald Frey and his assistant editors see this as an opportunity to educate our readers about radiation dose reduction techniques and other technological advancements to improve patient care and safety. In January 2010, Howard P. Forman, AJR section editor for Health Care Policy and Quality, will begin regular panel discussions in AJR with his newly formed group termed the Masters of Radiology. These leaders in radiology will provide discussion and insight on key health care issues.
The AJR must continue to support and guide these endeavors by providing a forum for quality initiatives in radiology for all health care professionals. John K. Crowe, current President of the ARRS, said it well when he stated "we will need to teach ourselves and our trainees to lead teams that impact outcomes; see beyond the obvious; and better understand, manage, and influence our future [9]."
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