1. Imaging for Uncomplicated Headache
When to Image Based on Choosing Wisely® and ACR Appropriateness Criteria®
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2. 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
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Intro to what the program is about and its benefits.
Website is
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.

3. 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
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Participants earn improvement activity credits.
More here:
Information about Protecting Access to Medicare Act here:

4. Problem: Overutilization of Imaging for Headache without Complications
Headache is one of the most common reasons for seeking medical care, both in the emergency department setting and in primary care offices [1, 2]. Although headache may indicate life-threatening pathology, the majority of patients with headache have relatively benign conditions [3].
Studies estimate that neuroimaging in patients with chronic headaches identifies significant abnormalities in only 1% to 3% of cases [4, 5, 6].
Despite this, data suggest that utilization of MRI and CT for headache visits may have almost tripled between 1995 and 2010 [7].
The problem statement
More information on the issue here:
References:
Becker WJ, Findlay T, Moga C, Scott NA, Harstall C, Taenzer P. Guideline for primary care management of headache in adults. Can Fam Physician. 2015;61(8):670–679.
Friedman, BW, Grosberg BM. Diagnosis and management of the primary headache disorders in the emergency department setting. (viii)Emerg Med Clin North Am. 2009;27(1):71–87.
You JJ, Gladstone J, Symons S, Rotstein D, Laupacis A, Bell CM. Patterns of care and outcomes after computed tomography scans for headache. Am J Med. 2011;124(1):58–63.e1.
Clarke CE, Edwards J, Nicholl DJ, Sivaguru A. Imaging results in a consecutive series of 530 new patients in the Birmingham Headache Service. J Neurol. 2010;257(8):
Sempere AP, Porta-Etessam J, Medrano V. Neuroimaging in the evaluation of patients with non-acute headache. Cephalalgia. 2005;25(1):30-35.
Wang SJ, Fuh JL, Juang KD. Quality of life differs among headache diagnoses: analysis of SF-36 survey in 901 headache patients. Pain. 2001;89(2):
Callaghan BC, Kerber KA, Pace RJ, Skolarus LE, Burke JF. Headaches and neuroimaging: high utilization and costs despite guidelines. JAMA Intern Med. 2014;174(5):819–821.

5. 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 imaging is not necessary for patients with uncomplicated headache, including:
American College of Radiology
American Headache Society
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Choosing Wisely includes 150 patient-friendly resources and more than 500 specialty society provided recommendations.
Learn more:

6. 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
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See next slide for more info on the Appropriateness Criteria (AC). 6

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

8. ACR Appropriateness Criteria for Headache
Variant 1: Chronic headache. No new features. Normal neurologic examination. Variant 2: Chronic headache with new feature or neurologic deficit. Variant 3: Sudden onset of severe headache (“Worst headache of my life,” “thunderclap headache”). Variant 4: Sudden onset of unilateral headache or suspected carotid or vertebral dissection oripsilateral Horner syndrome. Variant 5: Headache of trigeminal autonomic origin. Variant 6: Headache of skull base, orbital, or periorbital origin. Variant 7: Headache, suspected intracranial complication of sinusitis and/or mastoiditis. Variant 8: Headache of oromaxillofacial origin.
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

9. ACR Appropriateness Criteria for Headache
Variant 9: New headache in elderly patients. Sedimentation rate higher than 55, temporal tenderness. Suspected temporal arteritis. Variant 10: New headache in cancer patient or immunocompromised individual. Variant 11: New headache. Suspected meningitis/encephalitis. Variant 12: New headache in pregnant woman. Variant 13: New headache. Focal neurologic deficit or papilledema. Variant 14: Positional headache. Variant 15: Headache associated with cough, exertion or sexual activity. Variant 16: Post-traumatic headache.
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. 9

10. Appropriateness Criteria Rating by Value
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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. 10

11. Alignment of Appropriateness Criteria and Choosing Wisely
An AC example for the specific R-SCAN topic will be in all templates.
Variants 4-16 located here:
All imaging variants and clinical scenarios: 11

12. Alignment of Appropriateness Criteria and Choosing Wisely
An AC example for the specific R-SCAN topic will be in all templates.
Variants 4-16 located here:
All imaging variants and clinical scenarios: 12

13. Alignment of Appropriateness Criteria and Choosing Wisely
An AC example for the specific R-SCAN topic will be in all templates.
Variants 4-16 located here:
All imaging variants and clinical scenarios: 13

14. When to Use Imaging for Headache
For chronic headache with no new features, any imaging—CT or MR—is not appropriate.
For a headache that includes one or more of the following complications, a CT or MR may be appropriate:
Chronic headache with new feature or neurologic deficit
Sudden severe onset (“thunderclap headache”)
Headaches with sudden onset and maximum severity
Presence of neurological symptoms indicating a secondary cause
Signs suggesting a systemic disorder
Headaches that are worsened by exertion
Headaches that are new or different than a patient’s typical pattern of headaches, especially for individuals aged 50 and over
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15. When Not to Use Imaging for Headache
A medical history and neurologic exam should be performed before imaging is ordered. Often, due to patient demand and increased caseloads, patients are referred for imaging without completion of a comprehensive medical exam.
Radiologists noted that they often do not realize that a study is unnecessary until the patient is already in their office, presenting the challenge of explaining to a patient after a test has been ordered that imaging is not required.
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16. R-SCAN and Clinical Decision Support
CareSelect is a web-based version of the 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
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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. 16

17. Getting Started With R-SCAN rscan.org Standard template
To access ACR Select, visit the R-SCAN site and click on “Start your project.” 17

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Log in with an ACR username/password. If you don’t have an ACR username and password, the R-SCAN team can provide one. 18

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Click on “Practice with ACR Select.” 19

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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. 20

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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. 21

22. R-SCAN Uncomplicated Headache Educational Resources
Visit: rscan.org
Click: Resources
Click: Topic-specific Resources
Podcast
Imaging Order Simulation activity
Articles
Materials to share with patients
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A library of educational materials is available for each R-SCAN Choosing Wisely topic. 22

23. R-SCAN Resources With CME
Podcast
A radiologist and referring physician discuss strategies of image ordering for cases of uncomplicated headache; 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
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24. Key Points: Talking With Patients (1/2)
Here are talking points to explain to anxious patients why imaging is not necessary in cases where there are no accompanying complications:
Uncomplicated headaches are so infrequently associated with brain tumors and other serious conditions that imaging is extremely unlikely to find anything or to alter management.
Any benefits are vastly outweighed by the potential harms of radiation and potential for false positives from incidental findings, which may lead to additional unnecessary imaging and treatment (more costs and/or radiation exposure).
Detailed patient history and physical examination are more informative for a diagnosis than imaging in this case.
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When they’re needed, CT scans are very helpful. And the risk from a single scan is very small. But CT scans expose you to a strong dose of radiation. In some cases, it’s the same as having about 200 chest X-rays. Your body can often repair the damage CT scans cause to your tissue—but not always. And when it doesn’t, the damage could lead to cancer. The more times you’re exposed, the greater your risk of cancer.
Additionally, certain costs associated with imaging are not covered by insurance, such as payments to meet deductible thresholds and co-pays. 
Other important notes when speaking to patients:

25. Key Points: Talking With Patients (2/2)
Here are talking points to explain to anxious patients why imaging is not necessary in cases where there are no accompanying complications:
For many patients with chronic headache, pharmacologic and nonpharmacologic therapies are effective and relatively affordable.
Certain costs associated with imaging are not covered by insurance, such as payments to meet deductible thresholds and co-pays. 
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Other important notes when speaking to patients:

26. Self-Assessment Question 1
Which of the following are “red flag” symptoms of headache that may necessitate imaging?
Chronic headache in patient older than 50
Sudden onset of severe headache
Chronic headache
Headache lasting more than 4 hours
Answer: B

27. Self-Assessment Question 2
Which of the following are important history questions?
What is the pain level and location of pain?
Is the headache new or different from past headaches?
Was there trauma?
All of the above
Answer: D

28. Case 1
A 38-year-old man presents with acute onset of headache. A funduscopic examination reveals papilledema.
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: Contrast-enhanced MR imaging of the brain with and without contrast would be best to evaluate for masses and venous sinus thrombosis. A head CT scan with contrast would only be indicated if there is contraindication to MR.

29. Case 2
You are consulted regarding a 22-year-old woman who presents with headaches and a history of migraines. There have been no changes in the quality of the headache. In addition, there are no associated seizures or new focal neurologic signs.
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 is required. This patient has chronic headaches without new neurologic symptoms and has a normal neurologic examination.

30. Blank slide for radiologist to add custom info
Suggested topics for additions
Explain how to take a comprehensive medical history and perform adequate clinical follow-up for headaches. A medical history and neurologic exam should make it easy for a clinician to determine when imaging is necessary. Additional guidance would particularly support primary care clinicians, who sometimes receive limited training on neuroimaging during their medical education and may be less confident in judging when further evaluation is unnecessary.
Provide further guidance at the point of order, emphasizing how infrequently structural disorders present with headache.

31. Blank slide for radiologist to add custom info
Suggested topics for additions
Explain how to take a comprehensive medical history and perform adequate clinical follow-up for headaches. A medical history and neurologic exam should make it easy for a clinician to determine when imaging is necessary. Additional guidance would particularly support primary care clinicians, who sometimes receive limited training on neuroimaging during their medical education and may be less confident in judging when further evaluation is unnecessary.
Provide further guidance at the point of order, emphasizing how infrequently structural disorders present with headache.

32. Summary
Advanced imaging such as MR or CT is not indicated in the case of an uncomplicated headache and usually does not lead to improved change management.
Risks of imaging in this case:
Unnecessary testing and additional imaging due to incidental findings
Unnecessary exposure to radiation
Unnecessary cost to patient
Detailed patient history and physical examination are more informative in this case
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Headache is a common medical problem and a frequent cause of imaging overutilization. In patients with headache who present with complications, imaging is essential. In the majority of cases, however, imaging does not lead to improved patient outcomes, increases the risk of additional imaging and unnecessary care, exposes the patient to unnecessary radiation, and is costly to the patient.
Patients should be made aware that imaging rarely leads to improved management of their condition and of the dangers of radiation. Collecting a detailed patient history and completing a comprehensive neurological exam yields the best results for diagnosis and treatment in patients with uncomplicated headache.

33. Questions?