Journal of the American College of Radiology : JACR
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This document outlines the usefulness of available diagnostic imaging for patients without known coronary artery disease and at low probability for having coronary artery disease who do not present with classic signs, symptoms, or electrocardiographic abnormalities indicating acute coronary syndrome but rather with nonspecific chest pain leading to a differential diagnosis, including pulmonary, gastrointestinal, or musculoskeletal pathologies. A number of imaging modalities are available to evaluate the broad spectrum of possible pathologies in these patients, such as chest radiography, multidetector CT, MRI, ventilation-perfusion scans, cardiac perfusion scintigraphy, transesophageal and transthoracic echocardiography, PET, spine and rib radiography, barium esophageal and upper gastrointestinal studies, and abdominal ultrasound. It is considered appropriate to start the assessment of these patients with a low-cost, low-risk diagnostic test such as a chest x-ray. ⋯ The ACR Appropriateness Criteria® are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.
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The Patient-Centered Outcomes Research Institute was created in response to a mandate to conduct comparative effectiveness research in clinical care to inform decision making. The institute will be funded by the Patient-Centered Outcomes Research Trust Fund, through congressional set-asides, and by Medicare and private health insurers, through a per beneficiary fee. The institute is governed by a board with a broad stakeholder constitution. ⋯ In imaging, patient-centered outcomes go beyond the traditional metrics of patient satisfaction. Instead, these outcomes need to encompass the benefits and harms, focus on outcomes relevant to patients, and provide information to inform decision making. Therefore, radiologists need to be involved as stakeholders in the design, conduct, and dissemination of this research.
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Value-based payment modifiers were legislated by Congress in the 2010 Patient Protection and Affordable Care Act. It is clear in the legislation, and the corresponding proposals published by the secretary of the US Department of Health and Human Services in late 2011, that the intent is to move from paying physicians for reporting to paying physicians for performance. The proposals, developed jointly with CMS, specify that the calculation of payments for performance will be a composite of quality and cost measures. ⋯ The role of medical specialty boards, such as the ABR, in the development and deployment of measures is highlighted in this context. CMS's recent conversations with board representatives have indicated their view that the boards' measure development activities are key to increasing physician (especially specialist) participation in the Physician Quality Reporting System to 50% by 2015, from 20% to 30% today. The ABR will continue its past activities in this arena, working with the American Board of Medical Specialties, CMS, and specialty societies, so that ABR diplomates will be able to simultaneously complete their Maintenance of Certification requirements, satisfy the requirements for CMS incentives, and avoid penalties.
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The health care reform legislation of 2010 was a response to chronic issues in the US health care system that had been unresolved for decades. Whether health care reform is implemented in its current form or in a variant, the issues to address remain the same. In addition, those issues that have not been specifically addressed in national legislation remain areas of potential future policy.
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Previous growth in the utilization of medical imaging has led to numerous efforts to reduce associated spending. Although these have historically been directed toward unit cost reductions, recent interest has emerged by various stakeholders in curbing inappropriate utilization. ⋯ These have demonstrated comparable effectiveness to radiology benefits managers in early projects but currently have only limited market penetration. In this first of a two-part series, the rationale for the development of utilization management programs will be discussed and their history and current status reviewed.