QA Tester – we’re hiring


Job Title: QA Tester

Reports to: Director of R&D

Location: Remote – Telecommute

Job Summary:

Early stage Healthcare IT Company specializing in delivery of Clinical Decision Support content to healthcare organizations and health plans. Seeking new team member who can fulfill the quality related responsibilities of a cross-functional, agile software development team.

The core function of this position is to own and manage testing responsibilities of our products to maintain and improve its quality, working with both engineering and product teams.

The successful candidate will demonstrate a willingness and ability to help create great software as part of a fluid, close-knit team of individuals who are smart, and love what they do.

This position will provide the successful candidate with personal development opportunities in a rapidly growing company with disruptive technology.

Principal Responsibilities:

  • Create test cases, test plans, and specifications as well as creating or acquiring test data sets.
  • Actively participate as a member of an agile development team and help the team deliver the highest quality products.
  • Work closely with engineers, product owners, and sales staff to create comprehensive feature requests, test plans, as well as contribute to internal and client documentation.
  • Develop standard testing and quality practices.
  • Drive the creation and maintenance of regression tests.
  • Increase functional test coverage by both expanding existing coverage, as well as creating new test suites.

Minimum Qualifications:

  • Two years of experience in testing web services and web applications.
  • Ability to think critically and understand complex systems.
  • Quick learner with high attention to detail.
  • Ability to perform root cause analysis and help triage issues.
  • Strong interpersonal, problem-solving, and documentation skills.
  • Passionate team member eager to collaborate to create great software.

Nice to have Qualifications:

  • Experience in the medical IT field.
  • Experience understanding relational data models, and writing SQL against relational databases
  • Knowledge of QA best practices and testing methodologies.

.NET Engineer – we’re hiring!

.NET Engineer

Job Title: Engineer

Reports to: Director of R&D

Location: Madison / Remote – Telecommute

Job Summary:

Early stage Healthcare IT Company specializing in delivery of Clinical Decision Support content to healthcare organizations and health plans. Seeking new team member who can do full stack development on a cross-functional, agile software development team.

As a .NET Engineer you will be a key member of the R&D team who will be actively developing across our entire stack with individuals who are smart, and love what they do. Serious candidates will be passionate about creating great software in a team-oriented, agile environment and able to demonstrate the ability to create innovative solutions.

This position will provide the successful candidate with personal development opportunities in a rapidly growing company with disruptive technology.

Principal Responsibilities:

  • Design and build software using .NET technologies in AWS
  • Play a significant role in designing and shaping the architecture of our code base.
  • Actively participate as a member of an agile development team helping deliver the highest quality products.
  • Work closely with fellow engineers and product owners to help create high quality software.
  • Create and execute problem solving strategies.


  • Experience preferred with .NET, ASP.MVC, C#, Entity Framework (EF), SQL, AWS, web based development, and service oriented architecture (SOA).
  • Comfortable with agile and Extreme Programming (XP) practices.
  • Quick learner with high attention to detail, adaptable to change.
  • Excellent time management and prioritization skills.
  • Collaborative personality with a solid work ethic and initiative, requiring minimal direction.
  • Passionate team member who is eager build great software.

Education and Experience:

  • Bachelor’s degree in Computer Science or related field, or equivalent combination of experience and education.
  • Experience in the medical field is a plus.
  • Senior candidates – 3 to 8 years of software development experience.
  • Junior candidates – 0-3 years of software development experience.

Does malpractice reform affect defensive medicine practices? | Medical Economics

Does malpractice reform affect defensive medicine practices?

Study looks at physician behavior in emergency departments before, after reform legislation

Physicians and health policy experts have long assumed that doctors are driven to practice defensive medicine because they fear being sued for malpractice. But a recent study of what happened in states that made it more difficult to sue some physicians casts doubt on that assumption.

The study examines the impact of changes in the behavior of emergency department (ED) physicians following the reform of malpractice laws in in three states: Texas, which in 2003 changed its malpractice standard for emergency care to “willful and wanton negligence;” and Georgia and South Carolina, which changed their standards to “gross negligence” in 2005.“From a legal standpoint, these two standards are considered synonymous and are widely considered to be a very high bar for plaintiffs,” the study’s authors write.

Malpractice insurance: Understanding the importance of coverage limits

The researchers looked at the numbers of computed tomography and magnetic resonance imaging procedures and inpatient admissions ED physicians ordered for a random sample of Medicare fee-for-service patients in the three states between 1997 and 2011. They focused on the imaging procedures because ED physicians frequently self-report them as examples of defensive medicine practices. Researchers also studied per-visit charges as a proxy for the intensity of the level of services provided to the patients.

The authors then compared patient-level outcomes before and after passage of malpractice reform both among the three reform states and in surrounding states, with the goal of isolating the specific impact of the reform legislation from other trends and from patient characteristics. The goal was to arrive at what the authors term “policy-attributable changes” in ED physician behavior.

After subjecting the data to regression analysis, the researchers found no decrease in rates of CT or MRI use or hospital admission in any of the three reform states, and no reduction in per-visit charges in Texas or South Carolina. Georgia experienced a 3.6% reduction in per-visit charges.

The authors note that ED physicians frequently cite the use of advanced imaging as example of a defensive medicine practice. “Our results challenge the validity of these assertions, or at least suggest that the use of emergency department imaging is unlikely to be affected by malpractice reform alone,” they write.

READ: Competition driving malpractice premiums down

Although the study focused on ED physicians, the results have wider implications for the debate over shielding doctors from malpractice suits would reduce defensive medicine practices, and thereby reduce the nation’s overall medical costs, says Daniel Waxman, MD, PhD, the lead author and an adjunct natural scientist at the RAND Corporation. “People have said over and over that malpractice reform is an important way to save money, and I think the interesting part of this study suggests that’s a blind alley,” Waxman says.

The study, “The Effect of Malpractice Reform on Emergency Department Care,” appears in the October 16 issue of the New England Journal of Medicine. – European Society of Radiology calls for safer and more appropriate use of imaging

ESR calls for safer and more appropriate use of imaging

by Lauren Dubinsky , Staff Writer
The European Society of Radiology announced earlier this week that it launched a “Call for Action” as part of its EuroSafe Imaging campaign that began in March. ESR started the campaign in an effort to reduce the increasing number of radiological exams that are conducted every year.

“This initiative is necessary, but also is very timely, because we are now facing, worldwide, a challenge to deal with the potential risks of radiation in health care without compromising the benefits, and this is the reason why I think it is very appropriate that this initiative is taken by the professionals; the radiologists,” Dr. Maria Del Rosario Perez of the World Health Organization, said in a statement.

The campaign backs the Bonn Call for Action that the WHO and the International Atomic Energy Agency launched in 2012, which is a proposal for the priorities that stakeholders should focus on regarding radiation protection in the medical industry for the next decade.

The “Call for Action” consists of 12 points that include advocating for the appropriate use of imaging, ensuring that radiation doses are within diagnostic reference levels, utilizing the “as low as reasonably achievable” principle, promoting the use of the latest equipment, empowering patients and teaming up with other stakeholders.

The ESR has already started making headway by working on introducing a new clinical decision support system for imaging referral guidelines. It will be a software tool that will help referring physicians recommend the most appropriate radiological exams for their patients.

The society is also working on developing templates for internal clinical audit. They already offer e-learning resources on radiation protection and special education sessions as well as the Patient Advisory Group for Medical Imaging to empower patients.

“We believe that this holistic approach is an important step towards joining forces for patient safety in Europe,” Guy Frija, founder of EuroSafe Imaging, chair of the EuroSafe Imaging Steering Committee and ESR past president, said in a statement. “And we believe too that the use of up-to-date equipment is of utmost importance for improving the safety of X-ray examinations. The ESR urges the European Commission to develop a European plan for the improvement of X-ray equipment, including CT across Europe.”

Standardization: An Answer to Three of Radiology’s Vexing Problems | Radiology Business

Standardization: An Answer to Three of Radiology’s Vexing Problems

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In healthcare, the bar for quality is being set ever higher. One key approach to attaining quality is standardization: Just as other industries have embraced Lean, Six Sigma, and the Toyota Production System, each of which leverages standardization as a tool to achieve quality improvement, imaging service providers are establishing standards for multiple aspects of imaging services delivery in the quest to enhance patient care as well as safety.

Consider the example of the University of Florida College of Medicine inGainesville, whose primary teaching hospital, Shands at the University of Florida (UF Shands), now utilizes standardized names for each imaging procedure, an initiative referred to as Standardized Nomenclature for Imaging Procedures (SNIPs), along with standardized reports. SNIPs serve to define consistent, predictable protocols, as well as to facilitate the assessment and comparison of clinical outcomes. They indicate modalities and anatomy; contain specific indications for imaging protocols; and are applied in ordering, requesting authorization for, scheduling, performing, interpreting, and billing studies. In ordering studies, clinicians choose a particular SNIP, which links to the appropriate exam and report template.

Anthony A. Mancuso, MD, professor and radiology department chair, says that the absence of such protocols generally leads to discrepancies between the clinical indicators for performing a given study and the caliber/relevance of the information it yields, in turn compromising quality as well as patient safety. “The construct of the protocol must be targeted to the specific clinical indications, or scenario,” Mancuso asserts. “Otherwise, there is no assurance that the exact answers being sought in an exam will show up in the report, and there is the risk of missing important findings (as well as of doing harm to the patient) because of the mismatch.”

Careful consideration

Mancuso emphasizes that properly formulating the SNIPS necessitated a meticulous approach by a team of colleagues. Notably, the team conducted a careful assessment of whether individual clinical indications should be classified under a single protocol, or under multiple protocols. “It’s not like there is a SNIP for every indication, and some indications do fit under one protocol,” Mancuso says. “However, the complexity was such that we did end up, for example, with more than 20 head and neck SNIPS, 30 SNIPS for the brain, and 10 to 15 SNIPS for the spine.”

Meanwhile, the standardization of reports—called structured reports at UF Shands—is an ongoing cooperative endeavor involving clinicians, radiologists, and, in some instances, specialists from several other departments, among them cardiology, surgery, neurosurgery, and otolarangology. To ensure that the purpose of standardization—specifically, quality attainment—is indeed fulfilled, clinicians have been and continue to be asked for specific feedback “about what they want to see in and know from individual reports,” Mancuso states. For instance, some clinicians were queried as to details to be incorporated in a structured report of a pancreatic cancer CT protocol.

Pushing the quality and safety envelope a few steps further, different series of questions, some developed based on input from radiologists alone and others, in tandem with additional suggestions from specialists outside the discipline, are also a component of each structured report. Dubbed “forced-choice observations,” these questions, which radiologists must answer, mesh tightly with individual protocols. Case in point: Some questions posed in a report of a children’s seizure protocol pertain to the normalcy of hippocampal formation and current hippocampal volume, as well to whether there is evidence of improper/abnormal brain development and/or long-term effects of seizures on the patient’s brain.

“Without this type of structured information, it is difficult for the clinician to determine if the radiologist who completed the report possesses knowledge in that domain and whether the data” are of real value, Mancuso states. “That all ties in to patient care.”

Yet another element of the standardized reports is a report acuity scale on which radiologists must rate the urgency with which referring physicians should review the findings. Ratings range from one to five, with a rating of one indicative of normal findings and a rating of two, indicative of the presence of a finding that merits review by the clinician, but may not necessarily warrant other action. A rating of three indicates the presence of actionable and non-actionable findings that should be reviewed within 24 hours if at all possible, while a rating of four or five means, respectively, that the findings must  be addressed within an eight-hour window from the time the report was received or immediately.

Mancuso concedes that there has been some resistance among UF Shands’ radiologists to the standardization of imaging protocols and reports alike; most or all of these physicians, he says, have pet imaging protocols and their own, personalized reporting style. On the imaging protocols side, the majority of complaints received concern the additional time and effort needed to ensure adherence.

But no exceptions to the rules are permitted. “Quite simply,” Mancuso notes, “we tell them this is a non-negotiable, because we owe it to our patients. They understand the logic in that argument.” To bolster efficiencies and soften radiologists’ resistant edge, the protocoling tool resides inside UF Health Shands’ RIS system. Toward the same end, each SNIP has an identifying number within the EHR, which in turn is linked to a CPT code; the latter is linked to a procedure code.

Meanwhile, radiologists’ objections to the reporting protocols center on a reluctance to deviate from preferred and, in many cases, long-ingrained approaches to preparation. Such objections are countered with the argument that reports generated in accordance with protocols are of higher and more consistent quality and hence, improve safety and caliber of patient care.

“However, it goes beyond this,” asserts Mancuso. “We continue to emphasize to our radiologists not only that standardization in reporting is what our clinicians want, but also that at some time, radiology will be held accountable for providing value —which comes partially from reporting consistency—and we need to be ready. Not to mention, again, that it’s just the right thing to do for our patients.”

To date, UF Shands has not attempted to quantify improvements resulting from having standardized either its imaging protocols or its reports. Nonetheless, Mancuso says, anecdotal evidence points to positive change. “Clinicians tell us they are getting what they want in terms of information,” he observes. “And where we previously received complaints” about reports pretty much daily, “we have not heard one in the past six months. Most importantly, we are doing what is right for our patients. ”

Not so incidental

Radiologists’ approach to the reporting and handling of incidental findings, known colloquially as incidentalomas, varies almost as much, if not as much, as their approach to the reporting of clinical findings in general. Again, quality implications come into play.

“Show a set of images with an indeterminate finding to several radiologists, and be prepared to hear multiple recommended courses of action,” states James A. Brink, MD, radiologist-in-chief at Massachusetts General Hospital (MGH) in Boston and the Juan M. Taveres Professor of Radiology at Harvard Medical School. “One might suggest follow-up scans at six-month intervals; another, more frequent follow-up scans. A third might advocate leaving things entirely alone, and another will say more invasive procedures need to be performed immediately. Under-recommend, and you may be denying the patient the care he or she really needs.”

On the other hand, over-recommend, and you risk subjecting the patient to stress and possible complications for a procedure that wasn’t needed in the first place, Brink says. “There also can be misunderstandings about the verbiage in reports.  And even if there are written guidelines, it isn’t always reasonable or feasible for radiologists to stop to find them or look them up. All of this can affect [the caliber of patient care].”

In 2009, Brink says, a study conducted at MGH revealed a 300% increase in the number of patients for whom follow-up imaging examinations had been recommended over the previous 15 years. A second internal study conducted last year showed that 50% of recommendations for patients in whom lung nodules had been detected via abdominal CT included errors in either under- or overutilization of follow-up CT procedures.

Algorithms for incidentalomas

To address such concerns and trends, a decision was made to devise standard algorithms for application by MGH’s radiologists in recommending a course of action for patients with pulmonary and adrenal nodules, and to incorporate these algorithms into a proprietary decision-support tool. Additional algorithms for handling and reporting on renal and craniovascular incidentalomas, among others, are currently being formulated. (So, too, are standardized diagnostic algorithms; for instance, a grading scale for lacerations of the spleen).

The decision-support tool runs on each of the radiology department’s workstations and is integrated with its speech-recognition software for ease of access and use. Radiologists locate the algorithms by clicking on the appropriate corresponding icon (pulmonary nodule or adrenal nodule). From there, they input into the system information about the nodule’s history, morphology, size, and growth pattern. Recommendations for follow-up are then generated; these, along with the historic, morphologic, and size data, are automatically entered into the radiology report.

Brink says an MGH team chose to introduce algorithms for addressing pulmonary and adrenal nodules, rather than for handling other types of incidentalomas, based on the belief that doing so would be the “most impactful, most do-able move.”  Both algorithms are drawn in part from content found within the American College of Radiology’s series of white papers on incidental findings; the pulmonary nodule algorithm also incorporates Fleischner Society recommendations for the management of small pulmonary nodules.

Future algorithms will take into account ACR principles, but will be derived from other sources where applicable. As an example of the latter, Brink cites an algorithm for determining follow-up protocols for liver lesions identified during MRI examinations of the breast; “the ACR’s principles apply to liver lesions found during dedicated imaging” of that particular organ, and a broader perspective is needed, he explains.

Several strategic steps have helped to foster stakeholder acceptance of the decision-support tool and algorithms. Notably, the latter were designed not only to be consensus-based and modifiable, but also  to reflect input from MGH’s radiology subspecialty chiefs, practicing radiologists, and referring physicians. “If you don’t build a standardized model that everyone trusts and feels comfortable with, you haven’t gained much in the way of value,” Brink says.

Although it is still in the “very early days,” he continues, the standardization initiative already appears to be a success. Adherence to radiology department guidelines for recommendations of follow-up imaging for pulmonary nodules now stands at 65%, up from 50% before the algorithms and decision-support tool made their appearance. In a recent internal study, concordance with the department’s guidelines increased by 96% in the 40% of cases in which the combination was used. Efforts to incent radiologists to use the two existing algorithms, and to leverage new ones as they emerge, are now underway.

Across a multi-site system

Imaging service providers like MGH and UF Shands clearly have much to gain from standardizing image acquisition and reporting protocols. The patient care benefits of radiation dose optimization also are significant and recognized beyond the walls of the radiology department, with additional advantages that bubble to the surface when dose metrics are standardized across health care providers’ systems rather than within individual hospitals alone.

Such is one of the major premises behind the University of California Dose Optimization and Standardization Endeavor (UC DOSE), undertaken by the University of California Health System with funding from the University of California’s Center for Healthcare Quality andInnovation.

Led by Rebecca Smith-Bindman, MD, professor of radiology and biomedical imaging, University of California, San Francisco (UC-SF), the project is aimed at standardizing and optimizing CT protocols across all five of the system’s academic medical centers: UC Davis Medical Center,UC Irvine Medical Center, UCLA Medical Center (Los Angeles), UC San Diego Medical Center, and UC San Francisco Medical Center.

Compliance with California State Bill 1237, which took effect on July 1, 2012 and requires the reporting of CT radiation doses in patients’ radiology reports, ranked among the health system’s rationales for moving UC DOSE forward. The law, however, was not the sole impetus for doing so, asserts J. Anthony Seibert, PhD, professor of radiology and assistant vice chair of radiology informatics, University of California, Davis (UC-Davis), who serves as that insitution’s co-principal investigator for the project at UC-Davis.

Says Seibert: “Sensationalized, high-profile incidents involving excessive radiation exposure—like the one at Cedars-Sinai Medical Center in Los Angeles in 2009—brought the issue of safety to the forefront. But it was also clear to us that standardization and optimization could break down barriers between our institutions. CT doses by protocol and indication are highly variable, both within and across institutions. When protocols are standardized, multiple hospitals within a system can be on the same page in imaging. Cross-system imaging services—for example, late-night reads for one institution by another—can be handled consistently, and care can be delivered at a lower cost.”

Under the project umbrella, a collaborative working group of radiologists, physicists, and CT technologists from all hospitals within the system authored a guidance document on dose reporting, and dose reporting procedures were automated via the implementation of a packaged software solution. Infrastructure (dose reporting software and database) and methods of capturing CT dose metric information—CTDIvol, dose-length product (DLP) and other dose-related indicators—for each type of CT examination across all UC medical centers were standardized and entered into a master database.

Additionally, CT acquisition protocols were optimized to achieve lower dose metric values while still providing acceptable image information and image quality. The latter was achieved by calling, for example, for CT tube current modulation, the application of iterative reconstruction algorithms, the elimination of unnecessary image acquisitions (like pre- and post contrast as opposed to one or the other) or the use of multi-phasic studies with one or more fewer phases.

“From the database, the exam-specific CT dose metric distributions provide average and percentile values, which are used to set local diagnostic reference levels and to identify outlier exams,” Seibert explains. He points out that such cross-hospital standardization paves the way for inter-institutional comparisons. These comparisons, in turn, bring to light opportunities for improvement that involve modifying and optimizing CT acquisition protocols to achieve low radiation dose without sacrificing the image quality deemed necessary for proper diagnosis. Deviations from the standards are reviewed, with areas of improvement sought in cases where they are deemed unjustifiable.

Getting buy-in

Concerted efforts were made to get radiologists on board with the project, as well as to ease implementation and encourage compliance. “Soliciting their input at every stage was and is crucial,” Seibert says. “Medical physicists understand what is being administered to patients, but radiologists’ involvement is critical because they are the ones who will be reading the exams. They need to see that their perspective is important.”

A system-wide meeting held last year offered educational sessions on dose reduction, along with opportunities for attendees to upload their protocols and benchmark them against those shared by others. Earlier this year, Smith-Bindman organized a two-day retreat to bring together radiology decision-makers from all UC medical centers. The goal of the meeting was to arrive at a consensus concerning the most common ways to image chest, abdomen/pelvis, and head, and to discuss low-dose protocols for lung and colon screening.

To spark discussions and encourage participation, radiologists from the various sites were asked to share CT images from their current clinical practice. Overall goals were discussed as a group, with additional breakout sessions focusing on neurologic, chest, and body imaging as needed to reach consensus. Both events helped to foster trust by allowing participants to see the data showing variation in radiation doses and then discuss low-dose protocols.

“Sharing is a powerful motivator (for compliance),” states John Boone, PhD, FAAPM, FSBI, FACR, professor of radiology and biomedical imaging, vice chair of radiology research, and co-principal UC-DOSE project investigator, UC-Davis. “It’s an entirely different scenario when you find out that your protocol has several times the dosage of someone else’s. You think that maybe your personal preference isn’t optimal, after all. What we’ve found is that you can discuss metrics and the whole dosing issue on the phone until the cows come home, but unless it is also done face-to-face, things don’t stick as well as they should.”

Moreover, a meeting of various radiology section chiefs from within the University of California Health System and principal investigators from each of its five sites to discuss dose metrics and the results of the project to date was held this past April. A follow-up meeting is scheduled for October of 2014. A virtual symposium, “The UCSF Symposium on Radiation Safety and Computed Tomography,” is available to radiologists, as well as to physicists, CT technicians, and the general public, at

Next up for UC DOSE participants is the standardization of CT scanning protocols, a task Siebert and Boone deem challenging because of the variety of scanners deployed across the system as well as because of variances in procedure nomenclature. “What is called a ‘head scan’ at UC-Davis may be called a ‘routine brain scan’ at one of our other hospitals,” Seibert notes. “There are different doses for different nomenclatures. Standardizing here—and matching nomenclatures with the intent of a protocol—will result in much better comparisons of procedures, too.”

Anecdotal evidence points squarely to system-wide radiation dose reduction, without “any untoward loss of image quality” and with a higher standard of safety for patients, Siebert and Boone say. Feedback from radiologists indicates that the caliber of CT images produced is more than appropriate for their needs. Identification of trends—for example, variations in DLP levels—has helped to reduce dosing discrepancies.

“We’ve sliced into the pie,” Seibert concludes. “Maybe it’s a small slice—but it is a very important one for the safety and quality of imaging going forward.”

Anesthesiology News – Intervention Reduces Inappropriate Pre-Op Chest X-Rays in Low-Risk Patients

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Policy & Management
Intervention Reduces Inappropriate Pre-Op Chest X-Rays in Low-Risk Patients

New Orleans—Chest x-rays often are included in routine preoperative testing for patients undergoing low-risk elective surgery but are infrequently indicated. An educational intervention successfully lowered the frequency with which this “inappropriate” test is ordered, and in so doing helped decrease the utilization rates of several other types of preoperative testing as well.

“Like most institutions, we were looking at costs and recognized we might not be operating as efficiently as possible,” said Jonathan P. Wanderer, MD, assistant professor of anesthesiology at Vanderbilt University, Nashville, Tenn. “As part of that, we’ve been implementing changes when medical practice suggests we should be doing things differently than we currently are. And one area where that’s clear is chest x-rays, which used to be part and parcel of the preoperative workup, but from a screening standpoint don’t have that much value.”


An electronic learning module was created that specified indications for preoperative chest x-rays; all surgical providers were required to complete the module during August 2012. The researchers then identified and analyzed preoperative testing orders between February 2009 and March 2014, including chest x-ray, electrocardiogram (EKG), basic metabolic panel (BMP), packed cell volume (PVC), platelets, comprehensive metabolic panel, complete blood count (CBC), partial thromboplastin time/prothrombin time (PTT/PT), type and screen, urinalysis and “other labs.” The procedures were then stratified according to American Society of Anesthesiologists (ASA) physical status and surgical risk classifications.

In all, 43,320 anesthetic records were identified before the intervention date, compared with 24,013 after. The rate of requested chest x-rays fell from 33% to 20% (P<0.001). More telling was the fact that during the last six months of data, chest x-rays were requested in only 16% of surgical cases. In the subpopulation of low-risk patients (ASA physical status 1) undergoing low-risk surgery, chest x-ray rates fell from 8% to 2% (P<0.001).

“Subsequent analysis revealed that there were a handful of clinicians who were responsible for almost all the remaining orders,” Dr. Wanderer told Anesthesiology News. “So we’ve been working with them directly, and have effectively dropped the rate even further. So I think we’re now down to the point where we’re ordering them when there’s an acute disease process or surgical procedure where imaging will be helpful.”

Perhaps not surprisingly, EKG, PCV, BMP, PTT/PT, comprehensive metabolic panel, CBC, urinalysis and platelets all showed statistically significant reductions in relative frequencies after the intervention date. Interestingly, type and screens and “other labs” showed statistically significant increases in relative frequencies after the intervention date.

Dr. Wanderer, who is reporting his findings here at the ASA’s 2014 annual meeting (abstract A1140), had only good things to report about the program’s success, which he said demonstrates that changing physician behavior may not be as difficult as some believe. “Some of our practices get backed into our routine procedures and aren’t really second-guessed,” he said. “We learned that some of the check boxes that were being selected during the preoperative workup weren’t an intentional decision by the surgeon, but were almost filled out by default.”

And because these practice patterns are certainly not limited to Vanderbilt, employing similar steps may help other institutions achieve the same benefits. “We’re now taking a closer look at our rationale for ordering EKGs, another area where we found that we could change our practice,” he added. “We’ve again ended up having conversations with our colleagues and convinced them that we needed a reason to order the test rather than just doing it routinely. And that has resulted in practice changes by merely asking the question: If we do this test, what value are we likely to get from it?”

Charles B. Watson, MD, emeritus chair of anesthesia and deputy surgeon-in-chief at Bridgeport Hospital in Bridgeport, Conn., explained that because of the low incidence of positive findings from age-related or routine chest x-rays, his institution does not perform routine chest x-rays unless the patient has known active disease or new findings suggestive of pulmonary pathology. “The ASA has published guidelines on preoperative testing since the early 2000s and not identified routine testing of healthy individuals as useful [Anesthesiology 2012;116:522-538],” he said.

As Dr. Watson explained, educating medical practitioners on the benefits of avoiding routine chest x-rays can sometimes take years, as it did at his institution. “Information was circulated by email, policy documents to offices and physicians, and in meetings/surgical conferences over the years,” he said. “Now, our staff rarely order chest films, and only with positive clinical findings. The surgical motivation for screening patients for active symptoms of pulmonary disease is the understanding that last-minute chest films will likely delay their procedures.”

—Michael Vlessides

Stress tests with imaging spike, with 30% of dubious value | Cardiovascular Business

Stress tests with imaging spike, with 30% of dubious value

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Use of cardiac stress tests with imaging in patients without a diagnosis of coronary heart disease surged in the U.S. over an 18-year span, according to a study published in the Oct. 7 issue of the Annals of Internal Medicine . Almost one in three of those tests was ruled as rarely appropriate.

Many studies that assessed trends over time in cardiac stress test use relied on Medicare data, and analyses designed to spot disparities focused on gender rather than race or ethnicity. To broaden the scope, Joseph A. Lapado, MD, of New York University Langone Medical Center in New York City, and colleagues used two national databases: the National Ambulatory Medical Survey and the National Medical Care Survey.

For their study, they looked at data from visits between 1993 and 2010 to office-based physicians and hospital-based outpatient clinics by patients who did not have a diagnosis of coronary heart disease. Within those visits, they identified if a cardiac stress test was performed or ordered.

They also assessed the appropriateness of the test, based on criteria established by various medical societies. They defined a test as rarely appropriate if the patient had no chest pain or angina as a reason for the visit or had ischemic equivalents.

Lapado et al found that the average annual rate of visits that led to a cardiac stress test being done or referred grew from 28 per 10,000 visits in 1993-1995 to 45 per 10,000 visits in 2008-2010. They saw no trend toward more frequent testing after adjusting for patient characteristics, risk factors and provider characteristics.

Cardiac stress tests with imaging commanded an increasing proportion of all stress tests over time. In 1993-1995, 59 percent of all tests used imaging. That grew to 87 percent in 2008-2010.

They determined that at least 30 percent of cardiac stress tests with imaging and 14 percent of stress tests without imaging were rarely appropriate, for a cost of $507.1 million ($494 attributed to tests with imaging, 2013 dollars). In addition, the imaging tests exposed patients to an estimated 10.2 million mSv of unnecessary radiation a year, and potentially 491 cases of future cancers.

The upward trend in cardiac stress test use carried through all races and ethnicities, although test rates were lower in Hispanics than other groups.

“[W]e provide novel evidence that national growth in cardiac stress test use can largely be explained by changes in population demographics, clinical risk factors, and provider characteristics rather than changes in physician ordering behavior,” they wrote. “In contrast to overall growth, the brisk increase in the use of imaging in cardiac stress tests was largely unexplained by these factors, and a substantial portion was for patients in whom imaging is rarely appropriate.”

Their findings suggest that at least in the case of cardiac stress tests, physician decision making is not contributing to health disparities. “However, reducing disparities in the burden of cardiovascular disease remains an important concern.”

More appropriate use of cardiac stress testing with imaging could reduce health costs


More appropriate use of cardiac stress testing with imaging could reduce health costs

October 8th, 2014 in Cardiology / 

In a new study recently published in the Annals of Internal Medicine, researchers at NYU Langone Medical Center concluded that overuse of cardiac stress testing with imaging has led to rising healthcare costs and unnecessary radiation exposure to patients.

In what is believed to be the first comprehensive examination of trends in cardiac stress testing utilizing imaging, researchers also showed that there are no significant racial or ethnic health disparities in its use. They also made national estimates of the cost of unnecessary cardiac stress testing with imaging and the health burden of this testing, in terms of cancer risk due to .

Cardiac stress testing, particularly with imaging, has been the focus of debate about rising , inappropriate use, and patient safety in the context of radiation exposure. Joseph Ladapo, MD, PhD, assistant professor in the Departments of Medicine and Population Health at NYU Langone, and the lead author of the study, and colleagues wanted to determine whether U.S. trends in cardiac stress testing with imaging may be attributable to population shifts in demographics, risk factors, and provider characteristics, and to evaluate whether racial/ethnic disparities exist in physician decision making.

They designed their study utilizing data from the National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) from 1993 to 2010. Patients chosen for the study were adults without  who were referred for cardiac stress tests.

Between 1993 to 1995 and 2008 to 2010, the annual number of ambulatory visits in the U.S. in which a cardiac stress test was ordered or performed increased by more than 50%. Cardiac stress tests with imaging comprised a growing portion of all of these tests—increasing from 59% in 1993 to 1995 to 87% in 2008 to 2010. At least 34.6%—or one million tests—were probably inappropriate, the researchers concluded, with associated annual costs and harms of $501 million and 491 future cases of cancer.

The authors also concluded that there was no evidence of a lower likelihood of black patients receiving a cardiac stress test with imaging (odds ratio, 0.91 [95% CI, 0.69 to 1.21]) than their white counterparts—although some modest evidence of disparity in Hispanic patients was found (odds ratio, 0.75 [CI, 0.55 to 1.02]).

The investigators concluded that the national growth in cardiac stress testing can be attributed largely to population and provider characteristics—but the use of imaging cannot. Physician decision making about cardiac stress testing also does not result in racial/ethnic disparities in cardiovascular disease.

“Cardiac stress testing is an important clinical tool,” says Dr. Ladapo, “but we are over using imaging for reasons unrelated to clinical need. This is causing preventable harm and increasing healthcare costs.

“Reducing unnecessary testing also will concomitantly reduce the incidence of radiation related cancer,” he adds. “We estimate that about 500 people get cancer each year in the US from radiation received during a cardiac stress test when, in fact, they most probably didn’t need any radiological imaging in the first place. While this number might seem relatively small, we must remember that ‘first, do no harm’ is one of the guiding principles in medicine.”

So what can be done to reduce unnecessary cardiac stress testing with imaging? “More efforts, such as clinical decision support, are needed to reduce unnecessary cardiac stress testing,” Dr. Ladapo concludes, suggesting greater use of stress testing without radiological imaging, such as regular exercise treadmill tests or stress testing with ultrasound imaging as opposed to CT imaging.

As to the reason why certain racial and ethnic minorities have poorer rates of treatment for cardiovascular disease and generally have poorer cardiovascular health outcomes compared to white patients, Dr. Ladapo concludes that no one has really explored whether there could be disparities in cardiac stress testing, which is a mainstay of diagnosing patients with heart disease in this country. “If we know that one minority group has a higher incidence of poorer outcomes from heart disease, perhaps we need to examine if they would benefit from more appropriate use of  testing,” he offers. “Perhaps one contributing reason they have poorer outcomes is because we are not testing them appropriately.”

Provided by New York University School of Medicine

“More appropriate use of cardiac stress testing with imaging could reduce health costs.” October 8th, 2014.

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