The Effect of an Automated Mobile Patient Engagement Application on Emergency Department Revisits: Prospective Observational Study.

BACKGROUND: Revisits within 30 days to an emergency department (ED), observation care unit, or inpatient setting following patient discharge continue to be a challenge, especially in urban settings. In addition to the consequences for the patient, these revisits have a negative impact on a health system's finances in a value-based care or global budget environment. LifeBridge Health, a community health system in Maryland, United States, implemented an automated mobile patient engagement application as part of our enterprise-wide digital health strategy to improve patient engagement and reduce revisits to the ED. OBJECTIVE: The aim of this paper was to evaluate the effectiveness of a customized automated digital patient engagement application (GetWell Loop) to reduce 30-day revisits after home discharge from an ED. METHODS: The LifeBridge Health Innovation Department and ED staff from 2 participating health system hospitals collaborated with GetWellNetwork to customize their patient engagement application with automated check-in questions and other on-demand resources (eg, streaming content explaining aspects of self-care during COVID-19). An application link was emailed to adult patients discharged home from the ED. A study of ED visits for patients treated for general medicine and cardiology conditions between August 1, 2018, and July 31, 2019, was conducted using CRISP (Chesapeake Regional Information System for our Patients), Maryland's state-designated health information exchange. We also used data within GetWell Loop (GetWellNetwork) to track patient activation and engagement. The primary outcome was the number of ED patients who experienced a 30-day revisit and who did or did not activate their GetWell Loop account. Secondary outcomes included the overall activation rate and the rate of engagement as measured by the number of logins, alerts, and comments generated by patients through the application. Bivariate analysis comparing outcomes among patients who activated the GetWell Loop application to patients who did not was conducted using the Fisher exact test. Multivariate logistic regression modeling with elastic net regularization was also performed to account for potential confounders and potential collinearity of covariates. RESULTS: During this 1-year study, 1062 (27.4%) of 3866 of all emergency patients treated for general medicine or cardiology conditions, who received an invite to use the digital application, activated their account. The patients discharged from the ED, who were treated for general medicine conditions (n=2087) and who activated their GetWell Loop account, experienced a 30-day revisit rate of 17.3% (n=101) compared with 24.6% (n=369) for those who did not activate their account (P<.001). Of the patients treated for cardiology conditions (n=1779), 12.8% (n=61) of those who activated their GetWell account experienced a 30-day revisit compared with 17.7% (n=231) of those who did not activate their account (P=.01). The significance of these findings persisted after adjustment for confounding variables including age, race, sex, and payor in logistic regression modeling (adjusted odds ratio 0.75, 95% CI 0.62-0.92; P=.006). CONCLUSIONS: Our results suggest that a significant percentage of patients are willing to utilize a digital application following ED discharge to better engage in their own care, and that usage of such digital applications may significantly reduce 30-day revisit rates. LifeBridge Health's experience demonstrates that health care systems can leverage automated mobile apps to improve patient engagement and successfully impact clinical outcomes at scale.

Stratifying Deterioration Risk by Acuity at Admission Offers Triage Insights for Coronavirus Disease 2019 Patients.

OBJECTIVES: Triaging patients at admission to determine subsequent deterioration risk can be difficult. This is especially true of coronavirus disease 2019 patients, some of whom experience significant physiologic deterioration due to dysregulated immune response following admission. A well-established acuity measure, the Rothman Index, is evaluated for stratification of patients at admission into high or low risk of subsequent deterioration. DESIGN: Multicenter retrospective study. SETTING: One academic medical center in Connecticut, and three community hospitals in Connecticut and Maryland. PATIENTS: Three thousand four hundred ninety-nine coronavirus disease 2019 and 14,658 noncoronavirus disease 2019 adult patients admitted to a medical service between January 1, 2020, and September 15, 2020. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Performance of the Rothman Index at admission to predict in-hospital mortality or ICU utilization for both general medical and coronavirus disease 2019 populations was evaluated using the area under the curve. Precision and recall for mortality prediction were calculated, high- and low-risk thresholds were determined, and patients meeting threshold criteria were characterized. The Rothman Index at admission has good to excellent discriminatory performance for in-hospital mortality in the coronavirus disease 2019 (area under the curve, 0.81-0.84) and noncoronavirus disease 2019 (area under the curve, 0.90-0.92) populations. We show that for a given admission acuity, the risk of deterioration for coronavirus disease 2019 patients is significantly higher than for noncoronavirus disease 2019 patients. At admission, Rothman Index-based thresholds segregate the majority of patients into either high- or low-risk groups; high-risk groups have mortality rates of 34-45% (coronavirus disease 2019) and 17-25% (noncoronavirus disease 2019), whereas low-risk groups have mortality rates of 2-5% (coronavirus disease 2019) and 0.2-0.4% (noncoronavirus disease 2019). Similarly large differences in ICU utilization are also found. CONCLUSIONS: Acuity level at admission may support rapid and effective risk triage. Notably, in-hospital mortality risk associated with a given acuity at admission is significantly higher for coronavirus disease 2019 patients than for noncoronavirus disease 2019 patients. This insight may help physicians more effectively triage coronavirus disease 2019 patients, guiding level of care decisions and resource allocation.

Improving Awareness of LGBTQ Patient Preferences Among Radiology Staff Members.

BACKGROUND: Our health system set out to improve services to patients from the LGBTQ community as a step towards decreasing disparities in care. MATERIALS AND METHODS: A pilot education intervention targeting staff knowledge and skills regarding terminology with regards to gender fluidity and sexual orientation was designed and implemented. RESULTS: 81 staff members participated and we found improvements in knowledge but there remain uncertainties that can be addressed in future training sessions. CONCLUSIONS: LGBTQ staff education in radiology is feasible and effective. Additional education interventions may be necessary to address persistent knowledge gaps. Effects on patient acre are yet unknown.

Trends in Hospital Performance on the Medicare National Outpatient Imaging Metrics: A 5-Year Longitudinal Cohort Analysis.

PURPOSE: Medicare established its Hospital Outpatient Quality Reporting Program (HOQRP) to promote and incentivize quality care and appropriate utilization in the hospital outpatient setting. The program includes "imaging efficiency" metrics evaluating appropriate utilization of imaging examinations. Our purpose was to evaluate the longitudinal performance of the nation's hospitals on the HOQPR's imaging efficiency metrics. METHODS: Data were obtained from CMS Hospital Compare for hospitals participating in the Medicare HOQRP during both initial (January 1, 2011, to December 31, 2011) and follow-up (July 1, 2015, to June 30, 2016) periods. The six reported imaging efficiency metrics were: MRI lumbar spine for low back pain, mammography follow-up rates, abdomen and chest CT double scans (imaging with and without intravenous contrast), cardiac imaging for preoperative risk assessment for low-risk surgery, and simultaneous use of brain and sinus CT. Differences in imaging efficiency metrics were calculated using fixed effects linear regression models. RESULTS: Baseline and follow-up data were available for 3,960 hospitals. Median changes were MRI lumbar spine for low back pain: +3.6% (range: -27.9% to +31.4%; P < .001); mammography follow-up: -0.3% (range: -69.5% to +62.6%; P = .03); double scan abdomen CT: -1.9% (range: -73.5% to +32.3%; P < .001); double scan chest CT: -0.4% (range: -73.2% to +28.0%; P < .001); preoperative cardiac imaging: -0.7% (range: -10.0% to +9.9%; P < .001); simultaneous brain and sinus CT: -0.9% (range: -11.8% to +7.8%; P < .001). CONCLUSION: Medicare's nationwide hospital outpatient imaging efficiency reporting initiative was associating with worse performance in lumbar spine MRI utilization and small improvements in double CT scans. Because quality metrics are increasingly imposed on health care providers, health service researchers will need to rigorously evaluate their effectiveness before and during early implementation.

International Society for the Study of Vascular Anomalies Classification of Soft Tissue Vascular Anomalies: Survey-Based Assessment of Musculoskeletal Radiologists' Use in Clinical Practice.

AIM: There is controversy regarding the diagnosis and classification of vascular anomalies (VA). As torso and extremities are the second most common body part for presentation of VAs, musculoskeletal (MSK) radiologists play a central role in VA classification. The purpose of this study was to evaluate the awareness and clinical use of the International Society for the Study of Vascular Anomalies (ISSVA) classification by MSK radiologists. MATERIALS AND METHODS: A Web-based survey was designed and electronically sent to Society of Skeletal Radiology (SSR) members, with 3 questions on demographics and 7 questions on ISSVA classification use and knowledge. The Z-test for binomial proportions is used to assess for statistical significance between subgroups. RESULTS: The response rate was 12% (130 of 1091), comprised of 64% (83 of 130) academic and 36% (47 of 130) nonacademic MSK radiologists. VAs accounted for only a small (0%-5%) proportion of clinical practice in the majority 92% (119 of 130). Only 17% (22 of 130) of MSK radiologists used the ISSVA classification in practice. Of all respondents, 74% (94 of 127) considered hemangioma a type of vascular malformation (VM). There was no significant difference in the response characteristics between academic and nonacademic radiologists. A greater proportion of MSK radiologists with >5 years' experience provided responses that were discordant with the ISSVA classification compared with less experienced radiologists (0-5 years) in diagnosing hemangiomas in adult patients (P = 0.02), and using the presence of phleboliths to diagnose hemangiomas (P = 0.004). CONCLUSION: Our survey results indicate a lack of familiarity with the ISSVA classification by the MSK radiology community.

ACR Appropriateness Criteria® Sinusitis-Child.

Sinusitis is common in children that usually resolves spontaneously. Imaging is not part of the standard of care for initial diagnosis, however may be necessary in cases with persistent or chronic sinusitis to guide surgical intervention, or to rule out intracranial and vascular complications of sinusitis. Computed tomography (CT) and magnetic resonance imaging (MRI) are the leading imaging modalities. In this article, appropriateness in use of imaging modalities are discussed under common/clinically relevant scenarios. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Engaging Patients: Models for Patient- and Family-centered Care in Radiology.

This article examines how radiologists can meet the objectives of patient- and family-centered care set forth by the National Committee for Quality Assurance (NCQA) program for primary care providers. The breadth of initiatives in radiology that can be mapped to the NCQA objectives is impressive and invites the idea of creating a similar program in radiology. ©RSNA, 2018.

Understanding and Applying the Concept of Value Creation in Radiology.

The concept of value in radiology has been strongly advocated in recent years as a means of advancing patient care and decreasing waste. This article explores the concept of value creation in radiology and offers a framework for how radiology practices can create value according to the needs of their referring clinicians. Value only exists in the eyes of a customer. We propose that the primary purpose of diagnostic radiology is to answer clinical questions using medical imaging to help guide management of patient care. Because they are the direct recipient of this service, we propose that referring clinicians are the direct customers of a radiology practice and patients are indirect customers. Radiology practices create value as they understand and fulfill their referring clinicians' needs. To narrow those needs to actionable categories, we propose a framework consisting of four major dimensions: (1) how quickly the clinical question needs to be answered, (2) the degree of specialization required to answer the question, (3) how often the referring clinician uses imaging, and (4) the breadth of imaging that the referring clinician uses. We further identify three major settings in which referring clinicians utilize radiological services: (1) emergent or urgent care, (2) primary care, and (3) specialty care. Practices best meet these needs as they engage with their referring clinicians, create a shared vision, work together as a cohesive team, structure the organization to meet referring clinicians' needs, build the tools, and continually improve in ways that help referring clinicians care for patients.

Report of the ACR's Economics Committee on Value-Based Payment Models.

A major outcome of the current health care reform process is the move away from unrestricted fee-for-service payment models toward those that are based on the delivery of better patient value and outcomes. The authors' purpose, therefore, is to critically evaluate and define those components of the overall imaging enterprise that deliver meaningful value to both patients and referrers and to determine how these components might be measured and quantified. These metrics might then be used to lobby providers and payers for sustainable payment solutions for radiologists and radiology services. The authors evaluated radiology operations and services using the framework of the imaging value chain, which divides radiology service into a number of discrete value-added activities, which ultimately deliver the primary product, most often the actionable report for diagnostic imaging or an effective outcome for interventional radiology. These value activities include scheduling and imaging appropriateness and stewardship, patient preparation, protocol design, modality operations, reporting, report communication, and clinical follow-up (eg, mammography reminder letters). Two further categories are hospital or health care organization citizenship and examination outcome. Each is discussed in turn, with specific activities highlighted.

Impact of Medicare Shared Savings Program Accountable Care Organizations at Screening Mammography: A Retrospective Cohort Study.

Purpose To evaluate the impact of accountable care organizations (ACOs) on use of screening mammography in the Medicare Shared Savings Program (MSSP), the largest value-based reimbursement program in U.S. HISTORY: Materials and Methods Institutional review board approval was waived, as the study used publicly available unidentifiable data. Medicare data were retrospectively obtained for participating ACOs from 2012 to 2014. Baseline information and the ACO-20 measure (percentage of women aged 40-69 years who underwent screening mammography within 24 months) were obtained. Negative binomial regression models were used to evaluate baseline and longitudinal mammography use, with stratified analyses performed for year of entry into the ACO, number of beneficiaries, and geographic region. Results A total of 333 ACOs with 5 329 831 Medicare beneficiaries (mean size, 16 006 beneficiaries) participated in the MSSP. Screening use varied across ACOs (median, 63.0%; range, 8.8%-90.3%), with differences found across regions (use was highest in the Midwest [66.6%] and lowest in the South [58.2%], P = .038). A total of 208 ACOs reported longitudinal outcomes, with mean change in screening mammography use of +2.6% (range, -33.2% to +42.2%), with 128 (61.6%) ACOs reporting improvements (incidence rate ratio, 1.04; 95% confidence interval: 1.02, 1.07) (P = .002). No longitudinal differences in use were seen across regions (P = .078), year of entry (P = .902), number of beneficiaries (P = .814), or total composite quality score (P = .324), nor was there a difference between ACOs that saved money and those that did not (P = .391). Conclusion ACOs in the MSSP have produced small significant improvements in screening mammography use. © RSNA, 2016.

Partnering With Your Health System to Select and Implement Clinical Decision Support for Imaging.

Recent legislation mandates the documentation of appropriateness criteria consultation when ordering advanced imaging for Medicare patients to remain eligible for reimbursement. Implementation of imaging clinical decision support (CDS) is a solution adopted by many systems to automate compliance with the new requirements. This article is intended to help radiologists who are employed by, contracted with, or otherwise affiliated with systems planning to implement CDS in the near future and ensure that they are able to understand and contribute to the process wherever possible. It includes an in-depth discussion of the legislation, evidence for and against the efficacy of imaging CDS, considerations for selecting a CDS vendor, tips for configuring CDS in a fashion consistent with departmental goals, and pointers for implementation and change management.

Physicians' Perceptions of Radiation Dose Quantity Depend on the Language in Which It Is Expressed.

PURPOSE: Radiation dose information is increasingly requested by nonradiology providers, but there are no standard methods for communicating dose. The aim of this study was to compare physicians' perceptions of the amount of radiation associated with similar dose quantities expressed using different dose terms to evaluate the impact of word choice on physicians' understanding of radiation dose. METHODS: Internal medicine and pediatric residents were surveyed online for 42 days. After obtaining demographics and training levels, respondents were asked to rank five different radiation dose quantities, each corresponding to one of the five ACR relative radiation levels (RRLs) expressed using different dose terms. Respondents ranked the choices from least to greatest (ie, from 1 to 5) or indicated if all five were equal. For the final question, the same dose quantity was expressed five different ways. RESULTS: Fifty-one medicine and 45 pediatric residents responded (a 44% response rate). Mean differences in rankings were as follows: for chest x-rays, 0.109 (95% confidence interval [CI], -0.018 to 0.236); for cross-country flights, 0.462 (95% CI, 0.338 to 0.585); for natural background radiation, -0.672 (95% CI, -0.793 to -0.551); for cancer risk, -0.294 (95% CI, -0.409 to -0.178); and for ACR RRL, 0.239 (95% CI, 0.148 to 0.329). Statistically significant differences were found in the distributions of rankings (P < .001) and percentage of correct rankings across each radiation dose term (P < .001), with the ACR RRL having the highest percentage of correct rankings (61.2%). CONCLUSIONS: Adult and pediatric physicians consistently over- or underestimated radiation dose quantities using different terms to express radiation dose. These results suggest that radiation dose information should be communicated using standard terminology such as the ACR RRL scale to foster consistency and improve the accuracy of physicians' radiation risk perceptions.

Quality Measurements in Radiology: A Systematic Review of the Literature and Survey of Radiology Benefit Management Groups.

PURPOSE: As the US health care system transitions toward value-based reimbursement, there is an increasing need for metrics to quantify health care quality. Within radiology, many quality metrics are in use, and still more have been proposed, but there have been limited attempts to systematically inventory these measures and classify them using a standard framework. The purpose of this study was to develop an exhaustive inventory of public and private sector imaging quality metrics classified according to the classic Donabedian framework (structure, process, and outcome). METHODS: A systematic review was performed in which eligibility criteria included published articles (from 2000 onward) from multiple databases. Studies were double-read, with discrepancies resolved by consensus. For the radiology benefit management group (RBM) survey, the six known companies nationally were surveyed. Outcome measures were organized on the basis of standard categories (structure, process, and outcome) and reported using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS: The search strategy yielded 1,816 citations; review yielded 110 reports (29 included for final analysis). Three of six RBMs (50%) responded to the survey; the websites of the other RBMs were searched for additional metrics. Seventy-five unique metrics were reported: 35 structure (46%), 20 outcome (27%), and 20 process (27%) metrics. For RBMs, 35 metrics were reported: 27 structure (77%), 4 process (11%), and 4 outcome (11%) metrics. The most commonly cited structure, process, and outcome metrics included ACR accreditation (37%), ACR Appropriateness Criteria (85%), and peer review (95%), respectively. CONCLUSIONS: Imaging quality metrics are more likely to be structural (46%) than process (27%) or outcome (27%) based (P < .05). As national value-based reimbursement programs increasingly emphasize outcome-based metrics, radiologists must keep pace by developing the data infrastructure required to collect outcome-based quality metrics.

Mandatory Child Life Consultation and Its Impact on Pediatric MRI Workflow in an Academic Medical Center.

Pediatric patients undergoing MRI often require general anesthesia, which may improve image quality but is associated with significant medical risk and economic cost. It has previously been shown that certified child life specialists using high-tech interventions (eg, MRI-compatible video goggles) significantly reduce the number of pediatric MRI patients who require sedation. Most imaging centers lack such technology, however, and it remains unclear whether simpler and less costly child life interventions may be equally effective in avoiding general anesthesia. The aim of this study was to assess the impact of requiring mandatory child life evaluation for all patients aged 5 to 18 years undergoing MRI before referral for general anesthesia. Inserting this simple step into the scheduling workflow significantly reduced the use of general anesthesia in this population: general anesthesia was required in 564 of 2,433 MRI cases during the 1-year baseline period compared with 484 of 2,526 cases during the 1-year intervention period (P < .01 by z test for proportions; absolute reduction, 4.0%; relative reduction, 14.8%). The authors estimate that instituting mandatory child life evaluation avoided the use of general anesthesia in approximately 102 patients during the intervention period. Further subgroup analysis revealed that avoidance of general anesthesia was highly significant in the 5- to 10-year-old age group, whereas those aged 11 to 18 years experienced only a trend toward modestly decreased use of general anesthesia. These results suggest that mandatory evaluation for standard child life interventions is a worthwhile step that can save many children from unnecessary exposure to the risks, cost, and inconvenience of general anesthesia.

Entrepreneurship in the academic radiology environment.

RATIONALE AND OBJECTIVES: Innovation and entrepreneurship in health care can help solve the current health care crisis by creating products and services that improve quality and convenience while reducing costs. MATERIALS AND METHODS: To effectively drive innovation and entrepreneurship within the current health care delivery environment, academic institutions will need to provide education, promote networking across disciplines, align incentives, and adapt institutional cultures. This article provides a general review of entrepreneurship and commercialization from the perspective of academic radiology departments, drawing on information sources in several disciplines including radiology, medicine, law, and business. CONCLUSIONS: Our review will discuss the role of universities in supporting academic entrepreneurship, identify drivers of entrepreneurship, detail opportunities for academic radiologists, and outline key strategies that foster greater involvement of radiologists in entrepreneurial efforts and encourage leadership to embrace and support entrepreneurship.