In a recent New England Journal of Medicine (NEJM) perspective, Durand and colleagues propose “medical-imaging stewardship.” They believe that imaging can be more appropriately used through “provider-led imaging stewardship,” based on the model of antimicrobial stewardship.
Antimicrobial stewardship is a hospital program composed of an expert pharmacist and infectious disease physician. Its goal is to improve appropriateness of antimicrobial use through restriction of antibiotics, post-prescription review, and education. Clinician-led stewardship could limit overuse and improve care beyond antimicrobial use or imaging and should be considered for all areas of medicine.
The comparison of imaging to antimicrobials is appropriate. Both imaging and antimicrobials are heavily overused; up to 50 percent of both are unnecessary. Likewise, both have objective harms to patients, with imaging leading to false-positive results such as incidentalomas, contrast, and radiation exposure and antimicrobials increasing risk for Clostridium difficile infection, drug side effects, and promotion of resistance. Both imaging and antimicrobials are often the response to uncertainty in clinical decisions: just to be safe let’s get a CT scan; just to be safe, take a week of ciprofloxacin.
Imaging Stewardship
Durand and colleagues imagine an Imaging Steward would (1) implement Choosing Wisely items related to imaging; (2) allocate resources towards information technology such as clinical-decision support systems; (3) intervene to ensure review for appropriateness of image ordering through dialogue with physicians; (4) gather and share data on ordering appropriateness that could show performance by physician; and (5) provide education on imaging knowledge gaps.
Where antimicrobial stewardship has an advantage over imaging is that antimicrobials are costly for hospitals, especially for newer antimicrobials such as daptomycin or linezolid. Antimicrobial stewardship programs have often justified their existence through a business argument that stewardship would lessen inappropriate use of expensive antimicrobials and reduce costs to the system. Imaging, on the other hand, typically generates income for a hospital through direct billing. Antimicrobial stewardship has developed over the past 15 years and now is a key part of the President’s National Action Plan for Combating Antimicrobial-Resistant Bacteria and stewardship programs may become a requirement to receive Medicare payments.
Policymakers and The Joint Commission should realize the potential benefit of expert stewardship outside of antimicrobial use. Imaging is a natural place to start, but hardly the only area in which overuse of medical care could be improved. Overuse has been estimated to account for up to 30 percent of all medical care and the majority of patients receive more care than is needed. Such overuse includes inappropriate use of antimicrobials and imaging but also cancer screening tests, diagnostic tests, invasive procedures, major operations, blood transfusions, and medication use. Clinician-led stewardship could intelligently lessen overuse in many environments.
Medical Stewardship Beyond Imaging And Antibiotics
How might this appear? It is easy to imagine having stewards responsible for areas of medicine including antimicrobial use and imaging as well as surgery and procedures that have a great deal of variation in use (and therefore likely overuse). This would include interventional cardiology, orthopedics, vascular surgery, endocrine and cancer surgery, among others. Medical areas such as oncology would be a natural fit. A surfeit of new, highly expensive medications could support a steward focused on appropriate use. Primary care could have stewards look at antimicrobials (for which there is little outpatient stewardship) as well as use of tests and other medications.
In addition to appropriateness criteria, stewardship can incorporate informed patient involvement in decision-making (such as salvage chemotherapy or many forms of knee surgery). A structure for stewardship could be justified as part of patient safety and quality improvement. By improving appropriateness of care, patients would face less risk of medical harm and a lower burden of care (fewer tests and medications to remember).
Policies To Support Medical Stewardship
Whether a system can support multiple experts reviewing appropriateness with primary clinicians is an important question. The potential savings from removing unnecessary care would be greater than the costs of scattered professionals targeting the highest volume, lowest-value care.
However, low-value care is often provided because it is encouraged by our reimbursement systems. Foregoing unnecessary surgery or imaging would have the perverse impact of decreasing revenue under fee-for-service reimbursement. So, beyond the expertise to trim the harmful effects of unnecessary care, we need payment systems that reward providers and hospitals that take the necessary steps to limit overuse. Durand and coauthors point out that alternative models of Medicare payments may change this financial incentive.
The proposal to expand stewardship beyond antimicrobials is astute and should improve the appropriate use of imaging. Clinician-led stewardship efforts in many areas could intelligently limit unnecessary care while assuring provision of effective care. Stewards will need knowledge of evidence-based medicine and support from leadership to be successful. Expansion of stewardship would allow clinicians to lead in high-value care while protecting patients during the inevitable move towards more accountable care.
Author’s Note
The author received funding from the US Department of Veterans Affairs, CDC, and AHRQ.
from Health Affairs Blog http://ift.tt/1NiCpzQ
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