Evidence-based clinical practice © P . . . . . . Professiomd Ltd 1997

Radiologists working with clinicians to improve the request process for radiological tests did not reduce the number of tests ordered

Bree RL, Kazerooni EA, Katz SJ. Effect of mandatory radiology consultation on inpatient imaging use. JAMA 1996; 276:1595-1598

Objective

To assess the effectiveness of a mandatory consultation service on resource use for an inpatient, internal medicine service.

Setting

A US university hospital with 888 beds.

Method

Randomized-controlled trial of internal medicine services (the UK equivalent is a consultant-based 'team').

Each internal medicine service received emergency admissions every fourth day. The services consisted of four junior doctors and

an attending physician. Two services were allocated to the intervention, two acted as controls. The method of randomization was not stated.

Literature review

No strategy given; 23 references.

Intervention

A consultant radiologist was allocated to each of the two services. The consultant radiologist approved all radiology requests from their service, including out-of-hours requests. Radiologists attended the ward for approximately 1 hour each day to discuss radiology requests.The radiology consultants

were urged to substitute equally effective but cheaper tests where possible but did not use specific practice guidelines. Nuclear medicine requests were not included in the intervention.

Outcome measures

• The cost of all radiology tests requested by the services (assess through a computerized system)

• Length of patient stay • Number of interventions per patient • The cost of tests ordered • The length of stay of patients • The number of interventions per patient.

Results

There was no difference between the services which received the intervention and those which did not.

Authors' conclusions

During the entire study period, only 62 of the approximately 3600 examinations" requested were denied by the radiologists, Given the high level of uncertainty about the indications of diagnostic tests for inpatients, radiologists may be unable to reverse most test requests. Attempts to reduce inpatient radiology resource use may not be a prudent investment for managed care organisations.

Commentary

Bree and colleagues report a novel intervention which attempts to contain the ever-increasing radiological workload. But mandatory radiology consultation appears to make no impact on the usage of radiology amongst inpatients. This may seem surprising for those who view high technology imaging as an expensive luxury, t but to those involved at the coal face the results merely underline the fact that internal medicine relies heavily on the diagnostic and therapeutic impact provided by modem radiology.

The randomized study itself is quite well-designed. In one group of patients, requests for radiological investigations were only honored if agreed by an assigned radiologist; in the control group, all requests were honored without discussion. One slight flaw is that patients in the control group were discussed at 'routine' weekly clinico- radiological conferences - an intervention which has already been shown to reduce unnecessary requests 2 and educate staff members about appropriate usage. Radiological consultation might have had greater effect had it been compared with a

health care delivery system in which there. was limited.dialogue with radiologists.

Another potential criticism is that the assigned radiologist responsible for vetting requests did not appear to have any firm guidelines concerning the appropriateness of radiological referrals, apart from their own experience. In the UK, there have long been guidelines 3 which have been commended by the NHS Executive and the authors comment that the American College of Radiology is now disseminating appropriateness criteria. 4

Although such guidelines set a yardstick and provide a good platform for purchasers of radiological contracts, there ts less evidence that their implementation reduces expenditure to any great extent.

It is not clear what incentive, if any, there was for the vetting radiologists. A change of only 2% seems low - even compared with a typical UK radiologist's daily practice. If a proportion of the savings made had been transferred to the radiology, budget, a higher rate of intervention might have occurred.

The hazards of the various imaging procedures could also have been studied in this paper. Patients deserve the imaging strategy which delivers the diagnosis with

the least risk and discomfort and the lowest radiation dose. It is the duty of the radiologist to reduce computed tomography of the pelvis in young women, even if it may mean referral for a more expensive test (magnetic resonance).

Despite the findings of this study, careful vetting of radiological requests is still strongly recommended. Only by such scrutiny will the fight patients get the right machines at the fight time, and only then are costly radiological resources used to greatest effect. 5

Professor Adrian Dixon Addenbrooke' s Hospital and University of

Cambridge, UK

R e f e r e n c e s

I. Kelsey Fry I. Who needs high technology2 Br J Radiol 1984; 57:765-772

2. Leung DPY, DAon AK. Clinico-radiological meetings: are they worth~ bile? Clin Radiol 1992; 46:279-280

3. Royal College of Radiologists. Making the best use of a Department of Clinical Radiology: Guidelines for Doctors. London, RCR 1995

4. Cascade PM. Setting appropriateness guidelines for radiology. Radiology 1994; 192: 50-54A

5. Mackenzie ILM, Dixon AK. Measuring the effects of imaging: an evaluative framework. Clin Radiol 1995, 50:513-518

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