1. 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

2. 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

3. 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

4. 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

5. 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
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:
Low level of knowledge of dose; only 1:3 doctors received formal training in radiation protection
Soye & Paterson. BJR 81 (2008),

6. Health expenditure as % of GDP: inequality

7. Healthcare rankings: Value Commonwealth fund report 2014

8. Evidence for referral guidelines
Following RCR guidelines, overall referrals fell 13%
BMJ Jan 9;306(6870):110-1
RCGP Randomised controlled trial showed fewer referrals and better conformance
Oakeshott, Kerry, Williams. Br J Gen Pract 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 Apr;58(4):319-21
Emerging evidence to show 2-20% improvement in conformance with clinical decision support tools.

9. 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

10. 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

11. What next for iRefer?
Abdocardia/ Ectopia Cordis Interna

12. 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

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

15. 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

16. 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

17. 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

18. 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

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

20. Personal Value

21. 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.

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

23. 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

24. Radiology
patient
clinician
radiologist

25. Glazer Radiology 2011

26. 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)

27. 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

28. 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

29. 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

30. 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