1. Admission and Preoperative Chest X-ray
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 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:

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 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
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Choosing Wisely includes 150 patient-friendly resources and more than 500 specialty societies 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 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

9. 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. 9

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:
All imaging variants and clinical scenarios: 10

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:
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.
All 3 variants are located here:
All imaging variants and clinical scenarios: 12

13. 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
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Source:

14. 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
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15. 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
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16. 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
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17. 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
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18. 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
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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. 18

19. 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

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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. 20

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Click on “Practice with ACR Select.” 21

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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. 22

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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. 23

24. 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
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A library of educational materials is available for each R-SCAN Choosing Wisely topic. 24

25. 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
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26. 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. 
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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:

27. 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

28. 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

29. 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

30. 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.

31. 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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34. 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.
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35. Questions?