Guest Editorial
Health Services Research in Radiology: Meeting the Needs of the Professions and the Patients Paul Cronin, MD, MS, James V. Rawson, MD, FACR Drs Cronin and Rawson would like to welcome you to the 2013 edition of the annual Radiology Alliance for Health Services Research (RAHSR) issue. Given the changing health care environment, health services research (HSR) will play a key role in policy making. It is important for radiologists to be at the table as well educated and active participants. The RAHSR encourages and promotes health services research and education, and in this edition, we will present reports reflecting important and timely issues in health services research. We believe that studying these reports will make you a more valuable contributor to the national discussion of how to improve health care. The first article in this edition, by Ms Relyea-Chew, JD, surveys the major regulations and current issues that pose challenges to the practice of diagnostic imaging in the United States, from the Deficit Reduction Act (DRA) of 2005 through the American Taxpayer Relief Act of January 2012. The article reviews how federal regulation has increased dramatically in recent years and how the primary statutes such as the American Recovery & Reinvestment Act, American Taxpayer Recovery Act, DRA, and Patient Protection and Affordable Care Act aimed at curbing escalating costs and reorienting the national priorities of health care have a direct effect on the specialty of diagnostic imaging in the United States (1). The theme of the Association of University Radiologists (AUR) 60th annual meeting was ‘‘Ethics and Professionalism in Radiology Education, Research, and Practice.’’ To this end, we present a review from Dr Grogan that addresses the medical and legal implications of disruptive physician behavior and the appropriate use of due process in peer review of disruptive physician behavior (2). This was also presented at the annual meeting. We also present a report from Dr Rawson and col-
Acad Radiol 2013; 20:1061–1062 From the Department of Radiology, Division of Cardiothoracic Radiology, University of Michigan Hospitals, B1 132G Taubman Center/5302, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5302 (P.C.); and Warren Professor and Chair, Department of Diagnostic, Therapeutic and Interventional Radiology, Medical College of Georgia, Georgia Regents University, Augusta, GA (J.V.R.). Received June 3, 2013; accepted June 4, 2013. Address correspondence to: P.C. e-mail:
[email protected] ªAUR, 2013 http://dx.doi.org/10.1016/j.acra.2013.06.001
leagues that reviews the cost of disruptive and unprofessional behavior and the potential savings if these behaviors are addressed (3). Rawson and colleagues also show how the systematic reduction of disruptive physician behaviors in academic medicine could yield significant financial savings, which could be reinvested in the academic mission (3). Health services research education is an important area, and therefore the fourth report in this edition introduces examples of HSR projects and the types of data resources that are available to facilitate such projects (4). Dr Heilbrun and colleagues demonstrate novel ways in which HSR can address the Accreditation Council for Graduate Medical Education (ACGME) requirements for scholarly activity of residents and faculty in academic radiology departments. In addition to meeting training requirements, Dr Heilbrun and colleagues show how HSR research offers future radiologists the opportunity to develop skills that will be essential as we transition from a volume-based health care delivery system to an outcome-based delivery system (4). For many years, RAHSR and the AUR GE Radiology Research Academic Fellowship (GERRAF) Award have had close ties. At the AUR annual meeting, the four GERRAF sessions are joint RAHSR/GERRAF sessions, as one of the aims of the AUR GERRAF fellowship is fostering scholarship in radiology (health care/health services) research. As mentioned, RAHSR encourages and promotes health services research and education. RAHSR membership is a requirement for the GERRAF fellows, and many RAHSR members are current/previous GERRAF fellows. The two previous RAHSR editors, Dr Blackmore (founding editor) and Dr Carlos, are GERRAF alumni, as is one of the current co-editors, Dr Cronin. Dr Carlos is currently chair of the GERRAF Board of Review. The reputation of the GERRAF program also reflects the professional eminence of the physicians who have served on its Board of Review over the years. Their personal commitments to preparing the next generation of academic radiology leaders have been of inestimable value to AUR GERRAF fellows past and present. Since their inauguration in 1992, AUR GERRAF fellowships have been one of the most sought-after awards in academic radiology. They have helped dozens of academic radiologists through (a) strengthening the research interest of radiologistinvestigators by broadening their opportunities for continuing 1061
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scholarship and (b) fostering original clinical and health services research in technology assessment, health and economic outcome methods, and decision analysis. The scope and diversity of the research projects selected by the GERRAF fellows reflect the enormous opportunity it provides to pursue meaningful research in many areas of technology assessment and patient outcomes. Many of today’s emerging leaders in academic radiology are GERRAF fellows. Therefore, it is with great pleasure that we present two studies first-authored by Dr Sadigh with Dr Kelly as the senior author (5,6). These two studies are part of the research performed during Dr Kelly’s AUR GERRAF fellowship, the title of which was ‘‘Cost-Effectiveness and Utility of Coronary Artery Computed Tomography Angiography (CTA) in Screening for Coronary Artery Disease.’’ In their two articles, Dr Sadigh and coauthors look at the impact of coronary computed tomography angiography (CCTA), a relatively new noninvasive technology in the daily practice of cardiac surgeons (diagnostic thinking efficacy and patient management planning) and its utility from a patient perspective (patient outcomes) (5,6). These studies at the higher levels of the technology hierarchy and their implications are important, since we face health care constraints with a greater emphasis on views of the consumers of diagnostic imaging (patients and requesting providers) and on decisions about provision and allocation. The systematic review and meta-analysis by Dr Foerster and colleagues of the diagnostic accuracy of diffusion tensor imaging in amyotrophic lateral sclerosis represent a multicenter collaboration (7). This research follows a report published by Dr Foerster in last year’s RAHSR edition (8). However, unlike its predecessor, a study-level data meta-analysis, this meta-analysis is an individual patient data meta-analysis (7). This has a number of advantages. First, it avoids ecologic/aggregate bias; second, it extends the accuracy of the meta-analysis. In addition, assessment at an individual patient data level allows more reliable meta-regression (through avoidance or ecologic bias) and easier assessment of heterogeneity. In meta-analyses of diagnostic test accuracy studies, data are dichotomized with the resultant loss of information and assessed as a binary outcome. Dr Foerster’s latest meta-analysis is progressive for a second reason—it is a meta-analysis of diagnostic test accuracy studies that assesses quantitative outcomes avoiding the loss of data with dichotomization (7). It is also with great pleasure that we present a study firstauthored by Dr Kanaan with Dr Kelly as the senior author (9). This is part of the research performed during Dr Kelly’s RSNA Education Scholar Grant: ‘‘The Influence of Evidence-Based Teaching Methodology on Appropriate
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Imaging Utilization in a Large Academic Radiology Department.’’ This study by Kanaan and colleagues, found that a single educational intervention had no effect on appropriate utilization rates for CTPA (9). Dr Hedner and colleagues present a retrospective study, the purpose of which was to assess whether the presence of information including clinical pretest probability (Wells score) or other known risk factors and symptoms given on referrals for CTPA had any correlation with the prevalence rates for pulmonary embolism (PE). A secondary aim was to evaluate for any differences between a tertiary (university) hospital and a secondary (regional) hospital setting regarding patient characteristics, the amount of relevant information given on the referrals, and prevalence rates (10). The authors found that the amount of relevant clinical information on the request did not correlate with prevalence rates, and pretest probability estimations were rarely performed, despite their inclusion in major society guidelines. This RAHSR issue of Academic Radiology illustrates how HSR contributes to radiology and medicine to improve the health care delivered by health care providers as well as patient outcomes. HSR allows us to study complex questions and offer strategies to improve patient outcomes. We hope you enjoy the edition!
REFERENCES 1. Relyea-Chew AM. Major regulatory changes and the impact on diagnostic imaging in the U.S., 2005-2012. Acad Radiol 2013; 20(9):1063–1068. 2. Grogan M, Knechtges P. The disruptive physician: a legal perspective. Acad Radiol 2013; 20(9):1069–1073. 3. Rawson JV, Thomson N, Sostre G, Deitte L. The cost of disruptive and unprofessional behaviors in health care. Acad Radiol 2013; 20(9): 1074–1076. 4. Heilbrun ME, Rawson JV, Shah M. Using health services research to meet ACGME resident research requirements. Acad Radiol 2013; 20(9): 1077–1082. 5. Sadigh G, Haft J, Pagani F, Prager R, Kazerooni EA, Carlos RC, Kelly AM. Impact of coronary CT angiography on surgical decision making for coronary artery bypass graft surgery. Acad Radiol 2013; 20(9):1083–1090. 6. Sadigh G, Carlos RC, Kazerooni EA, Kelly AM. Patient preferences for coronary computed tomography angiography versus conventional catheter angiography for the diagnosis of coronary artery disease. Acad Radiol 2013; 20(9):1091–1098. 7. Foerster B, Dwamena B, Petrou M, et al. Diagnostic accuracy of diffusion tensor imaging in amyotrophic lateral sclerosis: a systematic review and individual patient data meta-analysis. Acad Radiol 2013; 20(9):1099–1106. 8. Foerster BR, Dwamena BA, Petrou M, et al. Diagnostic accuracy using diffusion tensor imaging in the diagnosis of ALS: a meta-analysis. Acad Radiol 2012; 19(9):1075–1086. 9. Kanaan Y, Knoepp U, Kelly AM. The influence of education on appropriateness rates for CT pulmonary angiography in emergency department patients. Acad Radiol 2013; 20(9):1107–1114. 10. Hedner C, Sundgren PC, Kelly AM. Associations between presence of relevant information in referrals to radiology and prevalence rates in patients with suspected pulmonary embolism. Acad Radiol 2013; 20(9): 1115–1121.
