Excellence in Imaging: A Behavioral and Performance Needs Assessment of Imaging Competence Interprofessional Referrals and Collaboration

A Project Update

The American Society of Nuclear Cardiology is strategically working to transform the field of nuclear cardiology through the Excellencein Imaging campaign to support the profession in the dynamic and rapidly changing healthcare environment and to continue a pathway of growth that will serve to improve patient care and outcomes.

The American Society of Nuclear Cardiology is looking to build upon and expand current and existing efforts such as the ACC/AHA/ASNC Appropriate Use Criteria. The goal of the project is to understand the factors that impact referrals from referring primary care clinicians to nuclear cardiology imaging procedures.

The study will explore gaps in knowledge, skills, systems and behavioral issues that may play a role in appropriate and inappropriate referrals to nuclear imaging tets.

The purpose of the project is not to develop new appropriate use criteria but to understand the input factors in the decision-making process of referring physicians when referring patients to nuclear cardiology imaging tests. Partnerships and collaboration are critical to ensure the success of this study. ASNC is partnering with the American College of Physicians in an effort to build strong relationships with Internal Medicine and referring physicians.

To date, projects that have focused on the appropriate use criteria have focused on the appropriate and inappropriate utilization of various cardiac imaging tests and modalities. One of these studies, which United Healthcare funded through the ACCF, identified that referrals to cardiac MPI tests from outside of the cardiology practice had an inappropriate rate of 19%. We must reduce this rate.

While many organizations, such as the ACC, are now tracking appropriate or inappropriate imaging, there is limited information that helps to fully understand all of the factors related to the referral relationship patterns between primary care provider and specialist, as well as, the impact these patterns have on patient safety, clinical decision-making, outcomes, and cost.

To suggest that the best approach to address inappropriate referrals is that the rendering physician of the imaging test, simply refuses to perform the test and redirects the patient back the referring physicians is not ideal and does not uncover the root cause of the inappropriate referral. Currently, there is no joint accountability for the referral and test. This is what will be required to drive change and improve care and access.

As we move to increasing the value of health care that is delivered within health care systems, it will be necessary to understand and measure performance of these systems. To develop the performance measures and appropriate interventions, it will be necessary to clearly understand what factors are part of the referral process and what the gaps are in care/testing. Is it simply a knowledge or skill gap? is it a system issue? Is it behavioral?

The project is being led by AXDEV Group Inc., a leading international organization that specializes in assisting healthcare organizations and stakeholders improve professional competencies, interdisciplinary team practices, organizational functioning, and clinical practice efficiency. AXDEV is collaborating with recognized subject matter experts Vasken Dilsizian, MD, FASNC and Leslee Shaw, PhD, FASNC. The combined experience of these leaders will ensure a dynamic study and data that will support appropriate growth, quality improvement and value.

The goals of our project are to ensure timely and efficient access for patients to nuclear imaging:

1. Increase access and reduce cost in securing the right test for the right patient at the right time
2. Optimize inter-professional collaborations and communications
3. Reduce disparities in care
4. Increase patient safety

Project Milestones
The project is being divided into stepwise process covering three distinct phases of data gathering: literature review, qualitative interviews and quantitative surveys. The initial phase of the project has been completed and work is commencing on the second phase in January 2014. During the first phase of the project the context of the referral environment and the parameters for exploration were identified. These parameters include exploring the underuse of appropriate use criteria and radiation re-education strategies.

Additional elements that comprise the first phase included an in-depth literature search and consultation with subject matter experts to better understand the current practice environment and the referral process. Through an in-depth review of the current practice environment, it was determined that the interviews and surveys should be expanded to include other healthcare professionals such as nurse practitioners and physician assistants, as their role in writing referrals is increasing rapidly.

Finally, the domains of the investigation were determined. This will include a qualitative exploration of the issue of referrals. This will involve key informant interviews with imaging cardiologists, internists, and other healthcare professionals. This process will provide important information that will lead to a better understanding of the gaps that exist in the referral process.

The final phase of the data collection will serve as a quantitative validation. This will be accomplished through an online survey distributed to a larger audience of the same professions.

ASNC is strategically moving forward to further define quality and develop standards in the field of nuclear cardiac imaging. Through investigative projects and studies, such as this, ASNC will have the data necessary to develop focused educational resources, clinical practice guidelines and performance measures. This study will serve as an important foundation to help improve the value and appropriate use of nuclear cardiac imaging.

We thank our sponsors. This project is being funded through generous grants by GE Healthcare, United Healthcare Foundation and Mallinckrodt Pharmaceuticals.