Admission and Preoperative Chest X-ray When to Image Based on Choosing Wisely® and ACR Appropriateness Criteria® Standard template

What Is R-SCAN? Collaborative activity for referring clinicians and radiologists to improve patient care through clinical improvement R-SCAN Collaboration Goals: Ensure patients receive the most appropriate imaging exam at the most appropriate time based on evidence-based appropriate use criteria Reduce unnecessary imaging tests focused on imaging Choosing Wisely® topics Lower the cost of care Standard template Intro to what the program is about and its benefits. Website is www.rscan.org Time commitment: staff time dedicated to an R-SCAN project ranges from 15 to 30 hours over a three- to six-month period. You can also gain experience using a clinical decision support (CDS) tool; gaining experience with CDS now will help referring clinicians be prepared for the implementation of federal reimbursement requirements for CDS consultation prior to ordering advanced imaging. This alternative to pre-authorization reduces time and expense for practices and patients when imaging is the next step in the diagnostic process.

Why Participate? R-SCAN Offers: Data-driven system for moving toward value-based imaging and patient care Opportunity to focus on highly relevant imaging exams to improve utilization Collaborators can fulfill their Improvement Activity requirements under the MIPS Easy way to practice with clinical decision support (CDS) technology In preparation for PAMA Free and immediate access to Web-based tools and CME activities Standard template Participants earn improvement activity credits. More here: https://rscan.org/images/PDFs/RSCAN_Improvement-Flyer_v4.Web_09-11-17pdf.pdf Information about Protecting Access to Medicare Act here: https://www.acr.org/Advocacy-and-Economics/Advocacy-News/Advocacy-News-Issues/In-the-April-21-2017-Issue/ACR-Answers-Frequent-Questions-About-CDS-Mandate

Problem: Overutilization of Admission and Preop X-rays Long history of “routine” chest radiographs Admission Preoperative Daily bedside portables in ICU Inadequate indication for reimbursement Studies have long shown few patient benefits from routine chest x-ray The problem statement More information on the issue here: http://www.choosingwisely.org/clinician-lists/american-college-radiology-admission-preop-chest-x-rays/ http://www.jacr.org/article/S1546-1440(16)31336-9/abstract

Using Evidence to Guide Imaging Ordering Choosing Wisely campaign Collaborative effort between ABIM Foundation and over 70 medical specialty societies Helps patients and medical professionals avoid wasteful or unnecessary medical tests, treatments and procedures Many medical associations agree that admission or preoperative chest x-rays for ambulatory patients with an unremarkable history and physical exam are inappropriate or unnecessary, including: American College of Surgeons American College of Physicians American College of Radiology Standard template Choosing Wisely includes 150 patient-friendly resources and more than 500 specialty societies provided recommendations. Learn more: www.choosingwisely.org

Using Evidence to Guide Imaging Ordering ACR Appropriateness Criteria® Assist referring physicians and other providers in making the most appropriate imaging or treatment decisions for specific clinical conditions Employs input of physicians from other medical specialties and societies to provide important clinical perspectives Standard template See next slide for more info on the Appropriateness Criteria (AC). 6

ACR Appropriateness Criteria: The Facts 178 clinical imaging topics and over 875 clinical variants  Basic access is free Learn more at acr.org/ac Standard template New AC topics are added annually. 7

ACR Appropriateness Criteria for Routine Chest Radiography Variant 1: No clinical concern on basis of history or physical examination. Variant 2: Suspicion of acute or potentially unstable chronic cardiopulmonary disease by history or physical examination. Variant 3: Increased risk, patient- or procedure-related (ie, advanced age [particularly >70 years], unreliable history and physical examination, high-risk surgery). The AC variants for the specific R-SCAN topic will be in all templates. The major clinical indications – or “variants” – are considered for each AC topic. Explain how AC works and what the variants are. 8

Appropriateness Criteria Rating by Value Standard template Exams associated with imaging for the individual clinical indications are rated according to their value as determined by the members of the AC panels. The panels use the following approach for determining the exam’s rating, or value: The guideline authors conduct a systematic search of scientific literature, identify most relevant articles, and develop initial ratings. A larger panel reviews and carries out rating rounds. Topics updated every 3 years or more frequently where needed. 9

Alignment of Appropriateness Criteria and Choosing Wisely An AC example for the specific R-SCAN topic will be in all templates. All 3 variants are located here: https://acsearch.acr.org/docs/69451/Narrative/ All imaging variants and clinical scenarios: https://acsearch.acr.org/docs/69451/Narrative/ 10

Alignment of Appropriateness Criteria and Choosing Wisely An AC example for the specific R-SCAN topic will be in all templates. All 3 variants are located here: https://acsearch.acr.org/docs/69451/Narrative/ All imaging variants and clinical scenarios: https://acsearch.acr.org/docs/69451/Narrative/ 11

Alignment of Appropriateness Criteria and Choosing Wisely An AC example for the specific R-SCAN topic will be in all templates. All 3 variants are located here: https://acsearch.acr.org/docs/69451/Narrative/ All imaging variants and clinical scenarios: https://acsearch.acr.org/docs/69451/Narrative/ 12

Cost Concerns of Admission and Preoperative Chest X-Ray 1993 meta-analysis of 14,390 surgical patients Only 0.1% of CXR cases with change in management based on CXR 1993 cost of $40.60*/patient Cost to health care system per finding that influenced patient management was $40,600* Brigham and Women’s Hospital monthly preop CXR orders decreased from 453 to 255 following EPIC go-live. *Adjusted for inflation Customized topic slide Source: https://www.jacr.org/article/S1546-1440(16)31336-9/fulltext

Radiation Concerns of Admission and Preoperative Chest X-Ray Keeping radiation exposure as low as reasonably achievable is also critical concern as imaging has increased. X-ray Radiation Dose Estimates 2-view CXR –0.1 mSv Chest CT –7 mSv Low Dose Chest CT –1.5 to 3 mSv Mammography –0.7 mSv Sievert (Sv) is SI derived unit of dose equivalent Does 1 Gy damage (absorbed dose) 1 Sv = 100 rem = 8.38 Roentgens Background 1 mSv every 10 days Customized topic slide

When to Order Admission or Preop X-Ray Use Don’t use Advanced patient age (especially >70 years) Suspicion of acute or potentially unstable chronic cardiopulmonary disease Unreliable history and physical examination High-risk surgery No history of cardiopulmonary disease No clinical suspicion for acute or unstable chronic cardiopulmonary disease Customized topic slide

Admission and Preoperative CXR Evaluation Look for the following clinical indications: Disease that would preclude surgery Acute process requiring delay of surgery Disease warning for anesthesia Public Health protection in OR and PACU Customized topic slide

CXR Prior to Hospital Admission or Surgery General health of patient Confirm suspected cardiopulmonary disease that could alter patient management Oncology patients Identify metastases that change treatment Primary disease in chest as cause of disease Customized topic slide

R-SCAN and Clinical Decision Support CareSelect is a web-based version ACR Appropriateness Criteria, comprising over 3,000 clinical scenarios and 15,000 imaging indications CareSelect provides evidence-based decision support for the appropriate utilization of medical imaging procedures R-SCAN participants gain free access to a customized, web-based version of CareSelect, a helpful first step for aligning ordering patterns with appropriate use criteria Standard template One of R-SCAN’s many free tools is the CareSelect CDS product, a digital version of the ACR AC. Specifically, the team uses CDS to rate the value of exams ordered for one of R-SCAN’s Choosing Wisely topics before and after an educational program is carried out. All R-SCAN participants have free access to the web-based tool to explore the AC guidelines for other imaging topics. Consulting CDS will be a requirement for the ordering of advanced imaging for Medicare patients starting in 2019, so R-SCAN provides a good way to check out this technology. 18

Getting Started With R-SCAN rscan.org Standard template To access ACR Select, visit the R-SCAN site and click on “Start your project.” 19

Standard template Log in with an ACR username/password. If you don’t have an ACR username and password, the R-SCAN team can provide one. 20

Standard template Click on “Practice with ACR Select.” 21

Standard template Check out the instructions for how to enter data and then click on the “Enter case data” button to explore the AC guidelines and exam ratings. 22

Standard template Here’s an example: Enter a patient’s age and gender. Select the body area of interest. Search on a clinical indication. Select the indication that’s the best match. Review the appropriateness score and note the associated cost and radiation exposure. Select the exam. 23

R-SCAN Admit and Preop CXR Educational Resources Visit: rscan.org Click: Resources Click: Topic-specific Resources Podcasts Imaging Order Simulation activity Articles Materials to share with patients Standard template A library of educational materials is available for each R-SCAN Choosing Wisely topic. 24

R-SCAN Resources With CME Podcast A radiologist and referring physician discuss strategies of image ordering related to preoperative/admission chest x-ray; approved for .5 CME Learn more Imaging Order Simulation Activity Test your knowledge in selecting the best imaging exam for various indications Free with CME Standard template

Key Points: Talking With Patients If you do not have a heart or lung disease and have no symptoms, a chest x-ray is highly unlikely to improve patient outcomes. X-rays expose you to radiation, which, if repeatedly exposed over time, can increase your risk for cancer. Certain costs associated with imaging are not covered by insurance, such as payments to meet deductible thresholds and co-pays.  Customized topic slide Many people have a chest X-ray before they have surgery. This is called a “pre-op” chest X-ray. “Pre-op” stands for preoperative, which means that it is before an operation, or surgery. If you have a heart or lung disease, you may want to get a pre-op chest X-ray. It can show medical problems, like an enlarged heart, congestive heart failure, or fluid around the lungs. These could mean that your surgery should be delayed or cancelled. However, if you don’t have signs or symptoms of a heart or lung disease, you should think twice about having a chest X-ray before surgery.  Other important notes when speaking to patients: http://www.choosingwisely.org/patient-resources/chest-x-rays-before-surgery/ https://www.jacr.org/article/S1546-1440(17)31655-1/fulltext?code=jacr-site

Self-Assessment Question 1 Which patient with +ppd should have preop CXR? 50 year-old asymptomatic man with history of childhood BCG and travel to Asia and Africa for work 50 year-old asymptomatic woman treated with INH for 6 months 50 year-old woman living in a household with active TB who complains of occasional coughing spells 50 year-old asymptomatic man with +ppd conversion and normal CXR 3 months ago Answer: C

Self-Assessment Question 2 Which patient would benefit from baseline CXR before surgery? 70 year-old asymptomatic woman with severe kyphosis 70 year-old asymptomatic man who has frequent episodes of flash pulmonary edema 70 year-old asymptomatic woman with history of asthma 70 year-old asymptomatic patient who had cardiac surgery 6 months ago Answer: B

Self-Assessment Question 3 The decision to order CXR should be made: Based on patient age Based on surgery being performed Before the patient arrives for preop evaluation As part of the preop patient assessment Answer: D

Case 1 An 81-year-old woman with a history of diabetes mellitus and hypertension (both well-controlled with medication) is scheduled for an elective laparoscopic-guided cholecystectomy. Questions: What imaging would be most appropriate for this patient? What other questions would you ask? What is the focus of your physical exam? Each template will include a few case examples. Answer: Routine preoperative chest radiograph. A routine preoperative chest radiograph is the recommended preoperative imaging study for a patient over the age of 70, regardless of past medical history.

Case 2 A 32-year-old man presents for anterior cruciate ligament reconstruction. He is otherwise asymptomatic and has no history of cardiopulmonary disease. Questions: What imaging would be most appropriate for this patient? What other questions would you ask? What is the focus of your physical exam? Each template will include a few case examples. Answer: No imaging. Appropriateness criteria states that no preoperative imaging is warranted for a young patient without a significant past medical history or chronic diseases.

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Summary Absent clinical concern as a result of patient history and/or physical examination, routine admission and preoperative chest x-rays typically do not identify abnormalities that lead to improved patient outcomes or change in management. Evidence against this routine practice has been established for decades. Unnecessary CXR results in avoidable radiation exposure to patients, extra costs, and potential unnecessary downstream testing. Patients with or a history of chronic cardiopulmonary disease, >70 years, unreliable history and physical examination, or undergoing high risk surgery may warrant CXR. Standard template, but content will be customized

Questions?