Dr Mark Alexander RCR Treasurer Consultant in Clinical Radiology and Radionuclide Radiology Head of School East of England Patient Previously Director of Medical Education and Medical Director Clinical Director of Imaging ID: 932313
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How to add value in radiology? Dr Mark AlexanderRCR TreasurerConsultant in Clinical Radiology and Radionuclide RadiologyHead of School East of EnglandPatientPreviously Director of Medical Education and Medical Director, Clinical Director of ImagingThanks to Dr Maskell, Dr Remedios and Professor Sir Muir Gray for slides
Slide2A cynic was ‘a man who knows the price of everything and the value of nothing’. ValueLord DarlingtonLady Windermere's Fan
Slide3Technical value, determined by how well resources are used for all the people in need in each sub groupAllocative value, determined by how the assets are distributed to different sub groups in the populationPersonal value, determined by how well the decision relates to the values of each individualValue
Slide4Gap between technical value and clinical practicePrimary care: Postcode accessSecondary care: Patient flow trumps clinical needDeskilling of the medical workforcePressure to increase productivity generates errorsTechnical Value
Slide5The need for Referral Guidelines: safetyDiagnostic radiology in USA accounts for as much radiation than natural causes (15% in 1980 to 48% in 2006)
NCRP 160
http://www.ncrponline.org/
CT exams have increased at 10% pa in USA from 3-80 million since 1980
44% of CT exams not justified in USA
Hadley JL, Agola J, Wong P.
AJR
2006; 186: 937-942
http://www.ncbi.nlm.nih.gov/pubmed/16554560
Low level of knowledge of dose; only 1:3 doctors received formal training in radiation protection
Soye & Paterson. BJR 81 (2008),725-729
http://bjr.birjournals.org/cgi/content/abstract/81/969/725
Slide6Health expenditure as % of GDP: inequality
Slide7Healthcare rankings: ValueCommonwealth fund report 2014
Slide8Evidence for referral guidelinesFollowing RCR guidelines, overall referrals fell 13% BMJ. 1993 Jan 9;306(6870):110-1RCGP Randomised controlled trial showed fewer referrals and better conformance
Oakeshott, Kerry, Williams.
Br J Gen Pract. 1994 Sep;44:427-8.
Randomised trial
with an educational reminder messages in reports is effective in
reduction by up to 20%
& does not affect quality of referrals.
Eccles , Steen , Grimshaw , Thomas , McNamee , Soutter, Wilsdon , Matowe , Needham , Gilbert. The Lancet, 2001; 357: 1406 – 1409. Over 12 consecutive months
no evidence of the effect of the intervention wearing off Ramsay, Eccles, Grimshaw, Steen. Clin Radiol
. 2003 Apr;58(4):319-21Emerging evidence to show 2-20% improvement in conformance with clinical decision support tools.
Slide9Increasing value through Referral guidelines:Dissemination of Referral GuidelinesWidely and freely available to end-users “If they haven’t heard it you haven’t said it” McLuhanImplementation of guidance decision support tools? “We shape our tools and thereafter our tools shape us” McLuhanUptakeneed buy-in by users and preferably ownership
“Computers can do better than ever what needn’t be done at all. Making sense is still a human monopoly”
McLuhan
Monitoring
clinical audit, feedback and education
“We drive into the future using only our rearview mirror ”
McLuhan
Slide10Analysis of 70 randomised controlled trials identified 4 features to improve clinical practice—CDS automatically as part of clinician workflow
,
CDS at the
time & location
of decision making,
A
ctionable
recommendations
provided, and
Computer-based
An effective system must minimise clinicians
’
effort to receive and act on system recommendations
Improving clinical practice using clinical decision support (CDS) systems:
a systematic review Kensaku Kawamoto et al BMJ 2005;330:765
http://www.bmj.com/content/330/7494/765
Slide11What next for iRefer?Abdocardia/ Ectopia Cordis Interna
Slide12Allocative ValuevProductivity
Outputs/Costs
Efficiency
Outcomes/costs
Costs are not only £££ but also
Carbon costs,
Time, particularly the Time of patients and carers and
Lost opportunity
Slide13vProductivityOutputs/Costs
Efficiency
Outcomes/costs
Value
Are the right patients being
seen or is there either 1. harm from
over diagnosis or
2. inequity from
underuse
Slide14Slide15As the rate of intervention in the Population increases, the balance of benefit and harm also changes for the individual patient
Necessary appropriate inappropriate futile
High Low Zero Negative
BENEFIT
HARM
Resources
CLINICAL
ECONOMIC
VALUE
Slide16Ensuring that every individual receives high personal value by providing people with full information about the risks and benefits of the intervention being offered and relating that to the problem that bothers them most and their values and preferences Shifting resource from budgets where there is evidence from unwarranted variation of overuse or lower value to budgets for populations in which there is evidence of underuse and inequity Ensuring that those people in the population who will derive most value from a service reach that service Implementation of high value innovation funded by reduced spending on lower value interventions for the population
Increased rates of higher value intervention eg helping a higher proportion of people die well at home funded by reduced spending on lower value care in hospital in that population
INCREASING VALUE FOR POPULATIONS AND INDIVIDUALS IS BY
Slide17HIGH VALUE IMAGING
Deliver Care through Population- based Systems
Develop clinical focus on populations
Personalise
care &
decision
making
Change the Culture to a collaborative culture
POPULATION AND PERSONALISED RADIOLOGY
DIGITAL KNOWLEDGE
Slide18Population based Radiology Focuses primarily on populations defined by a common need for example bb a symptom such as breathlessness, a condition such as arthritis or a common characteristic such as frailty in old age, not on institutions , or specialties or technologies. Its aim is to maximise value and equity for those populations and the individuals within them It will be delivered not by commissioners but by radiologists practising population medicine
Allocative Value
Slide19vProductivityOutputs/Costs
Efficiency
Outcomes/costs
Technical Value
Triple Value
Technical + Allocative + Personal
Slide20Personal Value
Slide215 outstanding problems:Unwarranted variation in access, quality, cost and outcome, and this reveals the other four Patient harm, even when the quality of care is high Waste, that is anything that does not add value to the outcome for patients or uses resources that could give greater value if used for another group of patients Inequity, and Failure to prevent the diseases that healthcare can prevent, stroke in atrial fibrillation for example. 5 current outstanding problems:
Slide22New imaging modalitiesPortability/accessibilityReduced costPersonalised medicineImage analysis – machine learningBig data analyticsTechnology
Slide23There will be more imagingImaging will become part of the normal work of many more healthcare professionalsRadiology services will be based around populations rather than hospitalsPatients will become much more involvedThe role of computers in image analysis will increase but they will not replace human interpretationThe President's predictions
Slide24Radiologypatientclinician
radiologist
Slide25Glazer Radiology 2011
Slide26“Direct communication of results to patients should be the overall, long term goal of our profession.”ACR white paper: the value added that radiologists provide to the healthcare enterprise (JACR 2008)Personal Value
Slide27A readily available resource for advice on diagnostic pathwaysAt the interface between traditional primary and secondary care, taking control of patient pathwaysAt the “front door” of the hospital promoting early discharge or appropriate acute managementCentral to the development of “personalised medicine” through molecular imagingUndertaking an increasing range of minimally invasive techniques, replacing traditional therapies eg in cancer care.Ready to engage directly with patients about their imagingThe future role of the radiologist
Slide28Allocative value, determined by how the assets are distributed to different sub groups in the populationTechnical value, determined by how well resources are used for all the people in need in each sub groupPersonal value, determined by how well the decision relates to the values of each individualThree components of Value
Slide29Ensure optimum Technical valueControl allocative value, determined by how the assets are distributed to different sub groups in the population, on a population basis – create regional population based radiology organisations to manage whole budgetsBecome the Patient’s ‘Radiologist’ - Personal value, determined by how well the decision relates to the values of each individualThe Radiologist and Value
Slide30One of the penalties for refusing to participate in politics is that you end of being governed by your inferiors.PlatoTo achieve this we must become politicians