Experience of an Academic Neuroradiology Division Participating in a Utilization Management Program

Background and Purpose

There has been a steady increase in the utilization of expensive outpatient imaging studies, with a resultant increase in health care costs. To reduce unnecessary and inappropriate studies, the authors' department has participated in a utilization management (UM) program; in this article, the authors report the experience of the division of neuroradiology.

Methods

Using evidence-based guidelines, a commercial UM program provides real-time decision support for physicians ordering expensive outpatient imaging studies. After consultation between UM personnel and a referring physician's staff, studies not meeting appropriateness criteria are referred to an academic radiologist for review. The radiologist can approve the study after reviewing the electronic chart or call the referring physician for further information. Studies are not denied by radiologists.

Results

For health plans of one large payer, 2,032 neuroradiologic studies were reviewed by 7 neuroradiologists during a 1-year period, of which 1,622 (80%) were approved. The remaining 410 studies (20%) were initially withdrawn by consensus or by no callback. Overall, 293 of the 410 (71%) studies (208 magnetic resonance, 85 computed tomography) initially not performed were not reordered (duration of follow-up, 3-15 months). Hence, 293 of 2,032 (14%) of all studies reviewed were not performed. The estimated cost of scans not performed was about $150,000. Approximately 6% of requests were changed to more appropriate studies.

Conclusion

The participation of academic neuroradiologists in a UM program affected the performance of many expensive outpatient imaging studies. There was a durable reduction in unnecessary and inappropriate studies. These results demonstrate the utility of evidence-based appropriateness criteria in radiology UM programs and the power of the sentinel effect.

Key Words: Utilization management, sentinel effect