AUA QI Summit 2017: Need for Physician-Led Stewardship of Imaging in Urology

Linthicum, Maryland ( Dr. Matthew Nielsen from the University of North Carolina and AUA Quality Improvement Summit Chair provided an excellent presentation to start this meeting at the AUA Headquarters in Linthicum, MD. As Dr. Nielsen notes, everyone loves advanced imaging, as highlighted by a 2001 poll of medical leaders who ranked MRI and CT scanning as the #1 most important medical intervention among 30 choices. However, advanced imaging is the fastest increasing sector of service utilization, considering there were 3 million CT scans performed across the country in 1985 compared to 85 million in 2010. According to the Institute of Medicine, 20-50% of advanced imaging may be avoidable (excess of $30 billion annually saved).
Dr. Nielsen highlights that the Merriam-Webster definition of “stewardship” is “the conducting, supervising, or managing of something, especially the careful and responsible management of something entrusted to one’s care.” Interestingly, stewardship is among the top 1% lookups, according to Merriam-Webster. In a 2015 Perspective piece in the New England Journal of Medicine, Durand and colleagues compared medical-imaging stewardship in the Accountable Care era to the CDC Antimicrobial Stewardship Framework [1]. For example, monitoring antibiotic prescribing and resistance patterns is akin to monitoring imaging utilization and appropriateness scores for providers and tracking per-capita costs and radiation doses [1].

The 2017 AUA QI Summit is focused on the challenges and opportunities for stewardship of urological imaging. Imaging is critical to the care of urology patients; however, we are under increasing scrutiny in the context of high cost, increasing utilization and growing appreciation for the harms of radiation exposure. Indeed, the AUA has been at the forefront of imaging stewardship by participating in the “Choosing Wisely” campaign among other efforts. For example, on the Choosing Wisely website AUA tab, the #1 initiative physicians should question is routine bone scan imaging for patients with low-risk prostate cancer. Dr. Nielsen also highlighted the R-SCAN initiative – a collaborative action plan that brings radiologists and referring physicians together to improve imaging appropriateness based on a growing list of Imaging Choosing Wisely topics.

Given the massive increase in CT-imaging volume, the harms of radiation have been thrust into the forefront of medical practice. The National Academy of Science notes that exposure in the range of a single CT-scan increases cancer risk, and that 2% of future US cancers will be attributed to CT-imaging. Furthermore, in addition to the increased volume of CT scans, there has been a 30-50% increase in dose/scan with profound dose variability in clinical practice.

According to Dr. Nielsen, particularly in the arena of imaging for urinary stone disease, this provides a unique opportunity for imaging stewardship across a collaborative effort with our colleagues in emergency medicine and radiology. The use of CT imaging for stone disease has soared in recent years, with limited evidence for improved patient-centered outcomes. Reduced-dose protocols have been developed, but the dissemination and adherence to these protocols in real-world practice is rare according to Dr. Nielsen (<2%). According to recent reports on a population-level, there is 5-fold variation in CT scan dose for renal colic with a mean dose of 11.2 mSv. Alternative imaging modalities, such as point-of-care ultrasound and radiology-driven ultrasound have found non-inferior outcomes to stone-protocol CT scanning for diagnosing urinary stone disease. However, ultrasound imaging during emergency department visits for renal colic is unfortunately not commonplace (~5-6%).

There are multiple ongoing efforts to reduce harms and costs associated with imaging for the large number of patients with stone disease, however there are important issues to resolve according to Dr. Nielsen. Although there is a strong push for ultrasound imaging, many cases may require CT imaging for ultimate management. Some of the concerns for radiation exposure from CT scanning are likely to be mitigated with more effective deployment of reduced-dose protocols. As part of an AUA initiative, development of a ‘Best Practice Statement’ is currently underway.

In summary, Dr. Nielsen highlights the numerous opportunities for urologists to collaborate and take a leadership role in the stewardship of imaging. This Summit is the first meeting to bring together representatives from urology, emergency medicine and radiology around the shared goals of imaging stewardship.

Speaker: Matthew E. Nielsen, University of North Carolina, Chapel Hill, NC, USA

Written by: Zachary Klaassen, MD, Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre, Twitter: @zklaassen_md, at the AUA Quality Improvement Summit - October 21, 2017- Linthicum, Maryland

Durand DJ, et al. Medical-Imaging Stewardship in the Accountable Care Era. N Engl J Med. 2015;373(18):1691-1693