How to add value in radiology? 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 Thanks to Dr Maskell, Dr Remedios and Professor Sir Muir Gray for slides

Lord Darlington Lady Windermere's Fan Value A cynic was ‘a man who knows the price of everything and the value of nothing’. Lord Darlington Lady Windermere's Fan

Value Technical value, determined by how well resources are used for all the people in need in each sub group Allocative value, determined by how the assets are distributed to different sub groups in the population Personal value, determined by how well the decision relates to the values of each individual

Gap between technical value and clinical practice Primary care: Postcode access Secondary care: Patient flow trumps clinical need Deskilling of the medical workforce Pressure to increase productivity generates errors

The need for Referral Guidelines: safety Diagnostic 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

Health expenditure as % of GDP: inequality

Healthcare rankings: Value Commonwealth fund report 2014

Evidence for referral guidelines Following RCR guidelines, overall referrals fell 13% BMJ. 1993 Jan 9;306(6870):110-1 RCGP 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):319-21 Emerging evidence to show 2-20% improvement in conformance with clinical decision support tools.

Increasing value through Referral guidelines: Dissemination of Referral Guidelines Widely and freely available to end-users “If they haven’t heard it you haven’t said it” McLuhan Implementation of guidance decision support tools? “We shape our tools and thereafter our tools shape us” McLuhan Uptake need 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 9

CDS automatically as part of clinician workflow, Improving clinical practice using clinical decision support (CDS) systems: a systematic review Kensaku Kawamoto et al BMJ 2005;330:765 Analysis 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, Actionable recommendations provided, and Computer-based An effective system must minimise clinicians’ effort to receive and act on system recommendations http://www.bmj.com/content/330/7494/765

What next for iRefer? Abdocardia/ Ectopia Cordis Interna

Allocative Value Efficiency Costs are not only £££ but also Carbon costs, Time, particularly the Time of patients and carers and Lost opportunity v Efficiency Outcomes/costs Productivity Outputs/Costs

Value Efficiency Productivity Are the right patients being seen or is there either 1. harm from over diagnosis or 2. inequity from underuse v Efficiency Outcomes/costs Productivity Outputs/Costs

As the rate of intervention in the Population increases, the balance of benefit and harm also changes for the individual patient BENEFIT HARM The service provider needs to know that the options for a particular intervention are not static . As we treat more people we treat less severely affect people who have a different benefit to harm ratio Resources CLINICAL ECONOMIC VALUE Necessary appropriate inappropriate futile High Low Zero Negative

INCREASING VALUE FOR POPULATIONS AND INDIVIDUALS IS BY Ensuring 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

POPULATION AND PERSONALISED RADIOLOGY Deliver Care through Population- based Systems Develop clinical focus on populations HIGH VALUE IMAGING DIGITAL KNOWLEDGE Change the Culture to a collaborative culture Personalise care & decision making POPULATION AND PERSONALISED RADIOLOGY

Allocative Value Population 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

Triple Value Technical Value Efficiency Productivity Technical + Allocative + Personal Technical Value v Efficiency Outcomes/costs Productivity Outputs/Costs

Personal Value

5 current 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.

Technology New imaging modalities Portability/accessibility Reduced cost Personalised medicine Image analysis – machine learning Big data analytics

The President's predictions There will be more imaging Imaging will become part of the normal work of many more healthcare professionals Radiology services will be based around populations rather than hospitals Patients will become much more involved The role of computers in image analysis will increase but they will not replace human interpretation

Radiology patient clinician radiologist

Glazer Radiology 2011

Personal Value “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)

The future role of the radiologist A readily available resource for advice on diagnostic pathways At the interface between traditional primary and secondary care, taking control of patient pathways At the “front door” of the hospital promoting early discharge or appropriate acute management Central to the development of “personalised medicine” through molecular imaging Undertaking an increasing range of minimally invasive techniques, replacing traditional therapies eg in cancer care. Ready to engage directly with patients about their imaging

Three components of Value Allocative value, determined by how the assets are distributed to different sub groups in the population Technical value, determined by how well resources are used for all the people in need in each sub group Personal value, determined by how well the decision relates to the values of each individual

The Radiologist and Value Ensure optimum Technical value Control 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 budgets Become the Patient’s ‘Radiologist’ - Personal value, determined by how well the decision relates to the values of each individual

To achieve this we must become politicians One of the penalties for refusing to participate in politics is that you end of being governed by your inferiors. Plato