The United States Congressional Budget Office estimates that 5 percent of the country's gross domestic product (GDP) is spent on medical tests and procedures that do not improve patient outcomes. In an effort to reduce unnecessary testing, procedures and related spending, the federal Centers for Medicare & Medicaid Services (CMS) has named Penn Medicine and two other organizations among a select few health care organizations in the country designated as a "qualified provider-led entity" (QPLE).
The designation will allow Penn to develop its own evidence-based criteria to assist physicians and providers of advanced imaging services in making the most appropriate imaging decisions for clinical conditions. This process will also help reduce the number of unnecessary procedures.
"Our goal is to assure that Penn Medicine patients receive the highest quality and most appropriate imaging exams for their conditions," said Charles E. Kahn, Jr., MD, MS, professor and vice chair of radiology. "Penn Medicine already uses a set of national appropriateness guidelines, but the QPLE designation allows us to extend those guidelines to meet the needs of our patients who receive highly specialized care."
These guidelines will help improve quality of care for patients while making the most efficient use of radiology services. Beginning in January 2020, physicians ordering advanced diagnostic imaging exams-;such asCT scans, MRIs, nuclear medicine exams, and PET scans-;will be required to consult qualified, evidence-based "appropriate-use criteria" housed in a clinical decision support mechanism. Clinical decision support mechanisms are electronic tools that indicate which tests are appropriate for patients with certain medical conditions or diagnoses.
For example, the American College of Radiology has developed a CMS-approved tool that Penn Medicine currently uses, which includes over 250 medical conditions and possible diagnoses, ranging from cardiac and gastrointestinal problems to headaches, chronic back pain, and vaginal bleeding. Clicking on "Crohn's disease" produces a chart showing that a CT scan of the abdomen with IV contrast is "usually appropriate" while a certain form of PET scan is "usually not appropriate" in assessing these patients.
Each organization approved as a qualified provider-led entity must follow strict CMS guidelines and rules for developing appropriate-imaging criteria, including: a multidisciplinary team; management of conflicts of interest; formal topic development and evidentiary review processes; publication of the appropriate use criteria; and a public comment form.
Penn Medicine's Imaging Appropriate Use Criteria program is overseen by a multidisciplinary steering committee headed by Kahn. The committee will use a formal, peer-reviewed, and widely-accepted methodology to assess the quality of evidence and strength of recommendations for proposed new or revised diagnostic tests or strategies. This new designation also means that Penn's can provide additions, deletions, and refinements to any CMS-approved clinical decision support mechanisms that are currently in use.
"In just the past week, CMS reconfirmed that January 1, 2020 will be the start date for the congressionally-mandated program," said co-author of Penn's QPLE application Ari Borthakur, PhD, MBA, an associate director of Radiology. "With an early approval, Penn Medicine gets a head start in developing its own imaging recommendations to best serve its mission."
The authors of proposed new items must adhere to a rigorous process, including supplying a detailed narrative discussing relevant medical literature and providing evidence for adopting the proposed new guidelines. Authors might, for example, recommend adding or removing procedures or treatments as a result of new technology or evidence-based findings. An extensive, multi-round review of the proposal then will take place. Approved changes will be posted on the committee's website and disseminated internally to Penn Medicine physicians and imaging providers.