Reinitiation of Withdrawn or Modified Neuroimaging Requests After Collaborative Consultation

November 17, 2015

Despite efforts in recent years to control excessive diagnostic imaging, overuse of medical imaging continues and, in the process, exposes patients to unnecessary radiation and may inconvenience them with multiple trips to a hospital or clinic for further testing. Both public and private health insurers have tried several measures to reduce the overuse of imaging, such as establishing decision support systems for ordering physicians at care sites; reducing reimbursements for imaging studies through the Deficit Reduction Act of 2005; and requiring that requests for imaging be authorized before the study is conducted.

The goal of pre-authorization is to make sure that provider requests for imaging align with evidence-based guidelines. If they don’t align, the requested test may be denied. Rather than issuing a flat denial, consultative pre-authorization programs engage in peer-to-peer conversations with providers to either get the information needed to justify the initial request or to guide providers to an alternative test. One concern about pre-authorization is that it burdens physicians with extra steps that ultimately may not help the patient. If the physician’s order is changed to a different test whose results are diagnostically inadequate, the patient will be forced to go back to the doctor for additional testing.

One way to determine whether pre-authorization modifications meet physicians’ and patients’ needs is to see how often providers re-order the same initial test that had been changed in the pre-authorization review process. A recent study, “Reinitiation of Withdrawn or Modified Neuroimaging Requests after Collaborative Consultation,” found that HealthHelp’s unique non-denial model of physician-led, collaborative reviews is remarkably effective, surprising even the study’s primary author. The results show that doctors rarely need to order their original test again. This suggests that the recommended, altered test met the needs of the ordering physician.

The study analyzed four years of clinical data, looking at cases where physicians’ pre-authorization consultation with a consulting radiologist led to a modified test request. The authors wanted to see how often physicians re-ordered the initial test within 30 days of the modified test. They chose a 30-day test period because it seemed a reasonable time frame for a doctor to order follow-up testing for a somewhat urgent problem if the first test was inadequate. If the follow-up period was too long, the study might include tests ordered for something other than the original ailment, which would make the data inaccurate. If the follow-up period was too short, the study might miss some re-ordered tests. The research examined data from four common neuroimaging sequences: 1) request for head Computed Tomography (CT) modified to head Magnetic Resonance Imaging (MRI); 2) request for both head CT and intracranial Computed Tomography Angiography (CTA) or both head MRI and intracranial Magnetic Resonance Angiography (MRA) modified to a request for a single study; 3) request for both a CT of the head and sinuses modified to a request for a single study; and 4) request for an MRI of the head and orbits modified to a request for a single study.

The results: In three of the sequences, no provider reinitiated a study within 30 days. In the fourth sequence, only four out of 64 (6%) withdrawn requests for head CT/MRI or head CTA/MRA were re-initiated within 30 days. Overall, for 99.2% of the requests that were modified through peer-to-peer consultation, the originally requested test was not performed in the subsequent 30 days. Adam C. Powell, Ph.D., lead author of the study, said he was surprised by the extraordinarily low rate of recidivism. He had expected the study to yield a modest recidivism based upon his intuition and findings from prior research. One academic neuroradiology department interacting with the same pre-authorization program reported that 71% of all studies not performed following peer-to-peer consult were not subsequently reordered in a follow-up period that ranged from three to fifteen months. “It can be difficult to compare prior research on the re-initiation of imaging study requests, as the sequences of interaction examined by different researchers varies,” the report states. “However, the extremely low rate of reinitiation found by this research is consistent with the literature.”

Since the HealthHelp pre-authorization process guarantees non-denial, physicians know that their requested tests will be approved even if they don’t agree with the pre-authorization recommendation of a consulting radiologist. The study states, “The findings of this research show that when providers agree to modify their requests through peer-to-peer consultation, they rarely need to perform the study in the initial request, indicating peer-to-peer consultation may be an effective way to improve the quality of care.” Giving patients the right test the first time increases safety for patients by reducing their exposure to excessive radiation and additional risks. It also decreases medical costs by reducing the need for additional testing and improving patient outcomes.

This initial study raises questions for further research. Follow-up studies could look at imaging use for other parts of the body besides the head, so that results may be generalized to imaging across specialties. If the research is consistent with the findings of this study, it could compel more providers and payers to adopt HealthHelp’s non-denial model of collaborative consultative pre-authorization.

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