Original articleDefining Quality in Radiology
Introduction
Since the publication of the Institute of Medicine’s 1999 report To Err Is Human: Building a Safer Health System [1], there has been increased interest in quality in medicine. The report’s authors estimated that there may be as many as 100,000 preventable deaths each year at medical centers in the United States. Preventable deaths are caused by errors of omission, commission, communication, and other sources. This report highlighted the potential benefit to health care in the United States from improvements in the quality of care [1, 2].
Coincident with increased awareness of a quality deficit is the continued rise in health care costs. As of 2003, the United States was spending 15.2% of its gross domestic product on health care [3]. This is by far the highest of all developed nations in the world, at least 50% higher than the number two country, Switzerland, and nearly double the average among developed countries of 8.3% [3]. Despite these expenditures, however, the World Health Organization in 2006 reported that the United States lags behind most other developed nations in the important health outcomes of life expectancy and infant mortality and, as of 2000, had only the 37th best health care in the world [3]. It is not unexpected that payers repeatedly question the value and the quality of the health care being provided in this country. Coincident with these rising health care costs is an escalation in growth in imaging procedures. Imaging procedure volume is expected to nearly double in the decade from 1998 to 2008.
One response to the inadequate quality and the high expense of US medical care has been the establishment of pay-for-performance programs. These programs feature lower payments to lower quality providers and presumably increased payments to providers that can demonstrate higher quality. The goal of such programs is to lower cost but also, importantly, to force improvement in provider quality.
Pay-for-performance programs require quality metrics to function. In response to a proposed 4.9% cut in professional fee components from the Centers for Medicare and Medicaid Services, the American Medical Association negotiated an agreement whereby the planned cut would be canceled, and in response, the American Medical Association would produce 140 quality metrics during calendar year 2006, which could be implemented as part of pay-for-performance schemes [4].
In radiology, the above-mentioned factors have led to increased interest in the development of radiology quality metrics. The ACR now has a metrics committee charged with developing radiology quality metrics [4]. An additional independent group, the Radiology Quality Summit, convened for the first time in September of 2005 in Sun Valley, Idaho, with a manifesto emphasizing developing methods of measuring and improving radiology quality [5].
The implications of the development of radiology quality metrics, however, go beyond pay-for-performance and current reimbursement schemes. As organized radiology moves toward defining radiology quality, in effect, radiology is defining for itself the role and responsibilities of radiologists. By defining quality radiology, the ACR and others are defining, on some level, the standards that must be met to function as a radiologist. In the past, quality has primarily been defined through credentialing. Certification from the American Board of Radiology, possibly supplemented by a certificate of added qualification, was the basic quality standard in radiology. The development of these new quality metrics will supplement and in some ways supplant credentialing as the measure of radiologists’ qualifications.
On an even broader level, proposed quality metrics will define roles that radiologists should function in and therefore will define the profession of radiology for future generations. As turf battles continue in radiology, the quality metrics defined by radiology can be used to argue either for or against different providers’ providing imaging services. Nonradiologists could evaluate themselves under ACR or other radiology metrics and argue that they practice quality radiology. Thus, if radiologists are to argue that they provide superior quality radiology, they must ensure that quality metrics encompass the breadth of activities that differentiate true quality as it relates to patient care.
In current discussions of radiology quality metrics, two broad frameworks have evolved. These can be labeled the radiologist “production” approach and the radiologist “professional” approach. The objectives of this essay are to describe and contrast these differing perspectives on radiology quality and to define quality metrics under the different models. I also seek to explain why radiology as a profession needs to be proactive in defining quality.
Section snippets
Radiologist Production Model
In the radiologist production model, radiologists are an integral part of a production process whereby images are produced and interpreted, and results are communicated. Patients arrive for imaging, and radiologists carry the responsibility for supervising the technical aspects of the imaging, the accurate interpretation of the imaging studies, the generation of reports of the examinations and findings, and the communication of the results to referring clinicians. Radiologists are responsible
Radiologist Professional Model
By contrast, the radiologist professional model uses a broader definition of the role of radiologists and therefore how quality in radiology should be measured. Under the radiologist professional model, radiologists are physicians who are experts on the use of imaging for diagnosis, specialists in imaging acquisition and interpretation, and consultants on the application of imaging information to clinical care. Accordingly, radiologists have an explicit role in using imaging to improve the
Discussion
Current reimbursement in radiology is based purely on the production functions of image interpretation and report generation. However, quality in radiology includes an additional range of professional functions, including the selection of subjects for imaging, the determination of optimal imaging approaches, tailoring imaging interpretations to specific clinical scenarios, and ensuring appropriate management on the basis of imaging results. Most radiologists incorporate at least some of the
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