In 2016, Sudip Saha, MD and his colleagues at the Kaiser Permanente Mid-Atlantic Group noticed a large difference in the amount of ordering for nuclear stress tests among its five medical centers in Virginia, Maryland and Washington, D.C. The number of referrals for advanced non-invasive imaging ranged from 2.3 per thousand patients to 8.6 per thousand, a swing of more than 370 percent.
“Part of the reason for the wide variation was that we had a different culture at every site and region,” said Saha, who along with Joseph Lodato, MD and Nancy Ortiz, MPH, CPHQ, PMP received the first place award in the American Society of Nuclear Cardiology (ASNC) 2019 Choosing Wisely Challenge.
The Kaiser Permanente Mid-Atlantic region serves 770,000 patients and has 1,600 physicians, including about 30 cardiologists and about 20 nuclear cardiology technicians in nine cardiology centers. With different processes for test referrals at the various sites, and in some cases ordering done by emergency room physicians with little to no input from a cardiologist, it stood to reason that imaging order patterns could substantially diverge.
Through a multi-pronged approach that involved more standardization of ordering processes, clinical education and revised protocols for imaging that would reduce radiation exposure for patients, the Mid-Atlantic Permanente Medical Group has been able to reduce pre-op imaging referrals for low-risk non-cardiac surgeries as well as annual stress tests for asymptomatic patients with known coronary artery disease.
Saha said his team did not approach the imaging imbalance with a predetermined idea of what the ordering numbers should be, but looked at the relative illness of patients for guidance; they found that the level of referrals for stenting and coronary bypass surgery were fairly consistent throughout the region.
“We tried to figure out what is the right number for us, the appropriate number, that shows we are taking care of our patients optimally,” said Saha, adding that a second and equally important consideration was how to introduce consistency among ordering practices.
In efforts to improve workflow, Saha’s project encouraged greater use of the Heart Phone, an existing tool that gives a physician 24/7 access to a cardiologist for consultation about a referral. The group relies heavily on telemedicine for chart reviews by cardiologists to assess appropriateness of tests, and has instituted measures to reduce inter-reader variability, which involved differences in how specialists were reading and interpreting studies.
They also began a CME journal club open to all urgent care and primary care physicians, nuclear cardiology technicians and nurse practitioners regarding stress tests. “It was really focused on going back to basics on chest pain management, knowing when and when not to order certain tests,” said Saha, adding that initiatives such as the CME series and seeking feedback from physicians provided the opportunity for simple fixes.
For instance, the Mid-Atlantic Permanente Medical Group uses two modalities for stress testing – exercise and pharmacologic. Some urgent care and primary care physicians did not realize that the exercise test qualified as a nuclear stress test, as well as the pharmacologic test.
In addition to creating a sustainable framework for reducing unnecessary imaging through tracking referrals and numbers of imaging tests, and aligning interpretation of results, the group is also tracking the doses of radiation delivered in each imaging test with the goal of reducing overall radiation exposure for patients.
Saha said he was particularly proud of the Stress First initiative, a stress test protocol that eliminates the step of imaging the heart when at rest for certain cardiac patients. Generally in a stress test, imaging of the heart is done twice – before and after exertion. The project started in northern Virginia and now is followed through the region, resulting in up to 70 percent less radiation exposure for patients and saving 30-50 percent of patients the extra imaging step.
In addition, he said that clinicians have remarked that image quality has improved as variation in usage has fallen to 2.2, 3.7 and 4.6 per thousand depending on the medical center. Saha believes that bringing technicians and allied health professionals together with clinicians to discuss imaging practice and protocols increased the “shared wisdom” of the group and resulted in higher quality performance as well.