Exploring the impact of QualityPath‘s quality standards for CT and MRI

QualityPath® will expand to include most outpatient computed tomography (CT) and magnetic resonance imaging (MRI) tests on Jan. 1, 2017.

We asked Amy Moyer, manager of value measurement, to explain how quality standards will create a measureable difference for employees and family members who need these tests, as well as employers who pay for CTs and MRIs as part of their self-funded health benefit plan.

Why are we adding CT and MRI tests to QualityPath?

Amy Moyer

Amy Moyer, manager of value measurement

Our members purchase a lot of these and they spend a lot on them. One in 11 people who get care through The Alliance network has an outpatient CT or MRI each year. And there’s wild variation in the cost of those scans so there’s certainly opportunity for cost improvement. For example, the cost of an MRI of a lower leg joint varies from $440 to $3,130 in The Alliance network.

As we started digging into the quality of CTs and MRIs, we discovered there’s opportunity to improve care itself, which made it a good fit for this program.

You’ve had to overcome some misconceptions about CT and MRI, including the assumption that quality doesn’t vary and doesn’t make a significant difference to patients. Are you surprised by that reaction?

I’m not surprised, because that’s the traditional view of CTs and MRIs. The traditional approach is that these tests are a commodity and there is no difference between the hospitals and clinics that offer them, so you should just go to the lowest unit cost provider, if you know how to find out who they are. That’s how we tend to look at and purchase our health care. But the reality is very different: CT and MRI quality does make a significant difference, both to patients’ outcomes and to the cost of care.

You worked with a blue-ribbon panel and an expert physician consultant to develop the QualityPath standards. What do they aim to achieve?

When you use clinics and hospitals that have QualityPath designation for CT and MRI scans you will know four things:

  • Your scan is truly needed.
  • Your scan will be done in the safest way possible.
  • Your scan will answer questions about your health issue that are materially important to your care.
  • The doctors and other health care professionals who order the scan, perform the scan and “read” the scan are following national quality standards for diagnosis and follow-up care.

Beyond the technical quality of the scan, what are some of the quality issues you identified for CTs and MRIs?

There are two main quality issues. First, there’s overuse, which means the scan didn’t need to be done. It did not help answer a question about what care you needed. That can lead to many different issues. At its simplest, it’s a waste of time and money for everyone involved. At its most complex, it can result in the diagnosis of “problems” that aren’t causing issues for the patient, and will not in the future, but start the patient down the road to additional treatment anyway.

Second, there’s misuse, which means the scan won’t deliver the information that the clinician is seeking. For instance, ordering the scan with or without the use of contrast dyes can impact whether the scan is effective, so it’s important to get that right.

Do QualityPath standards prevent unnecessary CT and MRI tests?

Yes. An unnecessary scan is never a bargain, to the patient or the payer. That’s why every designated hospital or clinic must have a process in place to verify that scans are appropriate based on national, evidence-based criteria. We also use national measures of scan appropriateness to check whether these standards are followed. So QualityPath helps prevent unnecessary scans.

What are the quality-related risks for the patient?

quality compass

The one that comes to mind first is the radiation risk associated with CT scans. The radiation from one abdominal scan equals that from 400 chest X-rays. If the CT scan is not needed that is a lot of unnecessary radiation. Some patients will have a reaction to the contrast dye used for CT and MRI scans. If the test was not needed that is a preventable allergic reaction.

These tests can also be stressful. We tend to think of MRIs as a simple procedure where you just lay inside a tube-like space. But patients sometimes have to hold a specific position for an MRI. Bolsters or straps are used to help support patients in this position, but it can still be painful for someone with a joint injury. Patients are in a relatively small space during an MRI, which means that an MRI can be a very trying situation for people with claustrophobia or noise sensitivity.

Let’s talk more about CT scans and radiation. Is unnecessary radiation a genuine problem?

That’s an important question. We know CT scans can also be highly beneficial when they identify a serious problem or point health care toward a solution. So it’s a careful balance. When all the signals point to a situation where more scans likely means more cancer, then we need to be extra sure that we’re getting maximum benefit from the scan.
The more we learn about radiation, the more we find that it’s an issue. For one thing, we absolutely know that radiation exposure increases your cancer risk. Consumer Reports did an excellent article on this issue where they noted that the radiation from CT scans is linked to a higher rate of cancer. A low-dose CT scan can expose you to as much radiation as 200 chest X-rays, according to Consumer Reports. And again, the more radiation you are exposed to over time, the more your lifetime risk of cancer increases. There is no safe lower limit.

An MRI does not use radiation. Are there other issues associated with MRI tests?

doctor and MRI

MRI tests, and CT tests, sometimes offer more information than is useful, which can create its own issues. Part of the reasoning behind the overuse guidelines included in QualityPath is that there tends to be variations in people’s bodies. The scan may uncover some of those variations, which could be normal and not the source of any issues. But once they’re uncovered, everyone feels the need to do something about it, whether it will help the patient in the end or not. A congenital malformation of the spine might be mistaken for an injury that requires surgery, for example. Or an MRI may reveal normal wear-and-tear that doesn’t impair function and so doesn’t require surgery, but in some cases, the patient might be offered the option of the surgery anyway.

Are there other issues that QualityPath addresses?

The use of highly sensitive imaging has led to overdiagnosis of some problems. “Overdiagnosis” occurs when we spot a potential issue that isn’t causing a problem for the patient, but we work it up and treat it aggressively anyway just in case it could develop into something more serious.

An example is overdiagnosis of thyroid cancer, which was the subject of a study published in August 2016 by the New England Journal of Medicine. The study linked the huge increase in thyroid cancer diagnosis to the use of highly sensitive CTs, MRIs and ultrasounds. These tests can reveal small, non-life-threatening tumors that often exist in a thyroid gland without causing symptoms. Once the tests find the tumor, it starts a “cascade” of treatment. Treatment often includes surgery to remove all or part of the thyroid, which is followed by hormone medications that the patient takes for a lifetime. The study indicated that overdiagnosis was a factor in an estimated 70 to 80 percent of thyroid cancer cases identified in women from 2003 to 2007.

Even one of these occurrences can represent big dollars and big patient harm. This is why it’s so important to ensure a scan is truly necessary, for the right scan to be used in the first place and to make sure recommendations for follow-up care are evidence-based. These requirements are built into QualityPath. It won’t completely prevent all unneeded or incorrect scans from occurring, but it will help keep many “cascades” from starting.

How do quality standards for CT and MRI reflect QualityPath’s overall approach to health care quality?

In QualityPath, we can take a holistic view of the health care system and what happens to patients. If you take a very narrow snapshot, then taking the traditional route to a test or a surgery may appear to be the most cost-effective choice. But when you look at what happens to a patient along the entire path, you may find that the total costs are higher or that it’s a bad choice for the patient.

It’s really about looking for the maximal value. We want to find the sweet spot for optimizing cost and quality at the same time. That’s what matters most to patients and purchasers.

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Darla Dernovsek
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Darla Dernovsek

Marketing Communications Manager at The Alliance
Darla Dernovsek joined The Alliance in 2013 as marketing communications manager. Dernovsek is responsible for managing and developing communication strategies as well as marketing plans to help fulfill The Alliance mission by raising market awareness.

Dernovsek has more than 25 years' experience in communications, public relations and marketing. From 1992 until joining The Alliance, Dernovsek owned her own freelance marketing and writing business to provide marketing consulting and writing for health-care related entities and credit union organizations. Earlier, she was the director of public relations for Rockford Memorial Hospital and city editor for the Beloit Daily News.

Dernovsek graduated from the University of Wisconsin-Eau Claire with a bachelor of arts degree in journalism.

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