The Appropriateness of Imaging: A Comprehensive Conceptual Framework

This review seeks to clarify and explicate an elusive concept: the appropriateness of diagnostic imaging. To ensure a common basis for discussion, several key components are articulated and defined. These include the diagnostic imaging procedure (DIP) itself, the subject (a patient), and the setting (a clinical scenario) in which the DIP is being considered. A review of the literature shows that appropriateness is a logical extension of empiric research, which has revealed substantial variation in the type and intensity of health services delivered to otherwise similar populations and communities in the United States. Against this background, the appropriate rate of a service in a population is transformed into appropriateness for an individual patient, which, when defined in terms of expected net health outcome, provides a conceptual link with the denominator of cost-effectiveness analysis. The complementary roles of clinical trials, technology assessment, decision-analytic modeling, and consensus methods in estimating appropriateness are compared and contrasted.

© RSNA, 2009

References

  • 1 Frush DP, Donnelly LF, Rosen NS. Computed tomography and radiation risks: what pediatric health care providers should know. Pediatrics 2003; 112: 951–957.
  • 2 Donnelly LF. Reducing radiation dose associated with pediatric CT by decreasing unnecessary examinations [editorial]. AJR Am J Roentgenol 2005; 184: 655–657.
  • 3 Don S. Radiosensitivity of children: potential for overexposure in CR and DR and magnitude of doses in ordinary radiographic examinations. Pediatr Radiol 2004; 34(suppl 3): S167–S172.
  • 4 Slovis TL. Introduction to seminar in radiation dose reduction. Pediatr Radiol 2002; 32: 707–708.
  • 5 Brindis RG, Douglas PS, Hendel RC, et al. ACCF/ASNC appropriateness criteria for single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI). J Am Coll Cardiol 2005; 46: 1587–1605.
  • 6 American College of Radiology, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, American Society of Nuclear Cardiology, North American Society for Cardiac Imaging, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology. ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR 2006 appropriateness criteria for cardiac computed tomography and cardiac magnetic resonance imaging: a report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group. J Am Coll Radiol 2006; 3(10): 751–771.
  • 7 Schaefer PW, Miller JC, Singhal AB, Thrall JH, Lee SI. Headache: when is neurologic imaging indicated? J Am Coll Radiol 2007; 4: 566–569.
  • 8 Stiell I, Wells G, Laupacis A, et al. Multicentre trial to introduce the Ottawa ankle rules for use of radiography in acute ankle injuries. Multicentre Ankle Rule Study Group. BMJ 1995; 311: 594–597.
  • 9 Brehaut JC, Stiell IG, Graham ID. Will a new clinical decision rule be widely used? the case of the Canadian C-spine rule. Acad Emerg Med 2006; 13: 413–420.
  • 10 Fisher ES, Wennberg JE, Stukel TA, et al. Associations among hospital capacity, utilization, and mortality of US Medicare beneficiaries, controlling for sociodemographic factors. Health Serv Res 2000; 34: 1351–1362.
  • 11 Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending. I. The content, quality, and accessibility of care. Ann Intern Med 2003; 138: 273–287.
  • 12 Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending. II. Health outcomes and satisfaction with care. Ann Intern Med 2003; 138: 288–298.
  • 13 Wennberg JE, Fisher ES, Skinner JS. Geography and the debate over Medicare reform. Health Aff (Millwood) 2002;Suppl Web Exclusives:W96–W114.
  • 14 Chassin MR, Brook RH, Park RE, et al. Variations in the use of medical and surgical services by the Medicare population. N Engl J Med 1986; 314: 285–290.
  • 15 Stano M, Folland S. Variations in the use of physician services by Medicare beneficiaries. Health Care Financ Rev 1988; 9: 51–58.
  • 16 Welch WP, Miller ME, Welch HG, Fisher ES, Wennberg JE. Geographic variation in expenditures for physicians' services in the United States. N Engl J Med 1993; 328: 621–627.
  • 17 Lurie JD, Birkmeyer NJ, Weinstein JN. Rates of advanced spinal imaging and spine surgery. Spine 2003; 28: 616–620.
  • 18 Chassin MR, Kosecoff J, Park RE, et al. Does inappropriate use explain geographic variations in the use of health care services? a study of three procedures. JAMA 1987; 258: 2533–2537.
  • 19 Leape LL, Park RE, Solomon DH, Chassin MR, Kosecoff J, Brook RH. Does inappropriate use explain small-area variations in the use of health care services? JAMA 1990; 263: 669–672.
  • 20 What do we mean by appropriate health care? Report of a working group prepared for the Director of Research and Development of the NHS Management Executive. Qual Health Care 1993; 2: 117–123.
  • 21 Guyatt GH, Feeny DH, Patrick DL. Measuring health-related quality of life. Ann Intern Med 1993; 118: 622–629.
  • 22 Siegel JE, Weinstein MC, Russell LB, Gold MR. Recommendations for reporting cost-effectiveness analyses. Panel on Cost-Effectiveness in Health and Medicine. JAMA 1996; 276: 1339–1341.
  • 23 Weinstein MC, Siegel JE, Gold MR, Kamlet MS, Russell LB. Recommendations of the Panel on Cost-effectiveness in Health and Medicine. JAMA 1996; 276: 1253–1258.
  • 24 Brennan A, Chick SE, Davies R. A taxonomy of model structures for economic evaluation of health technologies. Health Econ 2006; 15: 1295–1310.
  • 25 Pearl WS. A hierarchical outcomes approach to test assessment. Ann Emerg Med 1999; 33: 77–84.
  • 26 Fryback DG. A conceptual model for output measures in cost-effectiveness evaluation of diagnostic imaging. J Neuroradiol 1983; 10: 94–96.
  • 27 Dixon AK. Evidence-based diagnostic radiology. Lancet 1997; 350: 509–512.
  • 28 Brealey S. Measuring the effects of image interpretation: an evaluative framework. Clin Radiol 2001; 56: 341–347.
  • 29 Mackenzie R, Dixon AK. Measuring the effects of imaging: an evaluative framework. Clin Radiol 1995; 50: 513–518.
  • 30 Knutson D, Steiner E. Screening for breast cancer: current recommendations and future directions. Am Fam Physician 2007; 75: 1660–1666.
  • 31 Olsen O, Gotzsche PC. Cochrane review on screening for breast cancer with mammography. Lancet 2001; 358: 1340–1342.
  • 32 Wilkinson NW, Loewen GM, Klippenstein DL, Litwin AM, Anderson TM. The evolution of lung cancer screening. J Surg Oncol 2003; 84: 234–238.
  • 33 Henschke CI, Yankelevitz DF. CT screening for lung cancer: update 2007. Oncologist 2008; 13: 65–78.
  • 34 Blackmore CC, Magid DJ. Methodologic evaluation of the radiology cost-effectiveness literature. Radiology 1997; 203: 87–91.
  • 35 Hillman BJ. Outcomes research and cost-effectiveness analysis for diagnostic imaging. Radiology 1994; 193: 307–310.
  • 36 Hogstrom B, Sverre JM. Health economics in diagnostic imaging. J Magn Reson Imaging 1996; 6: 26–32.
  • 37 Mushlin AI, Ruchlin HS, Callahan MA. Costeffectiveness of diagnostic tests. Lancet 2001; 358: 1353–1355.
  • 38 Lessler DS, Sullivan SD, Stergachis A. Cost-effectiveness of unenhanced MR imaging vs contrast-enhanced CT of the abdomen or pelvis. AJR Am J Roentgenol 1994; 163: 5–9.
  • 39 Miller P, Kendrick D, Bentley E, Fielding K. Cost-effectiveness of lumbar spine radiography in primary care patients with low back pain. Spine 2002; 27: 2291–2297.
  • 40 Mushlin AI, Mooney C, Holloway RG, Detsky AS, Mattson DH, Phelps CE. The cost-effectiveness of magnetic resonance imaging for patients with equivocal neurological symptoms. Int J Technol Assess Health Care 1997; 13: 21–34.
  • 41 Simon DG, Lubin MF. Cost-effectiveness of computerized tomography and magnetic resonance imaging in dementia. Med Decis Making 1985; 5: 335–354.
  • 42 Black WC. The CE plane: a graphic representation of cost-effectiveness. Med Decis Making 1990; 10: 212–214.
  • 43 Brook RH. The RAND/UCLA appropriateness method. In: McCormick KA, Moore SR, Siegel RA, eds. Methodology perspectives. Agency for Health Care Policy and Research publication no. 95-0009. Rockville, Md: Public Health Service, Department of Health and Human Services, 1994; 59:–70.
  • 44 Hicks NR. Some observations on attempts to measure appropriateness of care. BMJ 1994; 309: 730–733.
  • 45 Brown BB. The Delphi method: a methodology used for the elicitation of opinion of experts. Santa Monica, Calif: RAND Corporation, 1968.
  • 46 Dalkey NC. The Delphi method: An experimental study of group opinion. Document no. RM-5888-PR. Santa Monica, Calif: RAND Corporation, 1969.
  • 47 Fitch K, Bernstein SJ, Burnand B, et al. The RAND/UCLA appropriateness method user's manual. Santa Monica, Calif: RAND Corporation, 2001.
  • 48 Jamal T, Gunderman RB. The American College of Radiology appropriateness criteria: the users' perspective. J Am Coll Radiol 2008; 5: 158–160.
  • 49 Kahan JP, Bernstein SJ, Leape LL, et al. Measuring the necessity of medical procedures. Med Care 1994; 32: 357–365.
  • 50 Kahan JP, Park RE, Leape LL, et al. Variations by specialty in physician ratings of the appropriateness and necessity of indications for procedures. Med Care 1996; 34: 512–523.
  • 51 Kravitz RL, Laouri M, Kahan JP, et al. Validity of criteria used for detecting underuse of coronary revascularization. JAMA 1995; 274: 632–638.
  • 52 Shekelle PG, Kahan JP, Bernstein SJ, Leape LL, Kamberg CJ, Park RE. The reproducibility of a method to identify the overuse and underuse of medical procedures. N Engl J Med 1998; 338: 1888–1895.
  • 53 Asch SM, Sloss EM, Hogan C, Brook RH, Kravitz RL. Measuring underuse of necessary care among elderly Medicare beneficiaries using inpatient and outpatient claims. JAMA 2000; 284: 2325–2333.
  • 54 Costanza ME. The extent of breast cancer screening in older women. Cancer 1994; 74: 2046–2050.
  • 55 Bassett LW, Manjikian V III, Gold RH. Mammography and breast cancer screening. Surg Clin North Am 1990; 70: 775–800.
  • 56 Coughlin SS, Wilson KM. Breast and cervical cancer screening among migrant and seasonal farmworkers: a review. Cancer Detect Prev 2002; 26: 203–209.
  • 57 Young RF, Severson RK. Breast cancer screening barriers and mammography completion in older minority women. Breast Cancer Res Treat 2005; 89: 111–118.
  • 58 Cascade PN. American College of Radiology appropriateness criteria project. Radiology 2000; 214(suppl): 3–46.
  • 59 Cascade PN. Setting appropriateness guidelines for radiology. Radiology 1994; 192(1): 50A–54A.
  • 60 Dorfman GS, Normand SL, Flamm CR. Utilization of diagnostic tests: assessing appropriateness. Acad Radiol 1999; 6(suppl 1): S40–S53.
  • 61 Bettmann MA. The ACR appropriateness criteria: view from the committee chair. J Am Coll Radiol 2006; 3: 510–512.
  • 62 Sistrom CL, Honeyman JC. Relational data model for the American College of Radiology appropriateness criteria. J Digit Imaging 2002; 15: 216–225.
  • 63 Sistrom CL. The ACR appropriateness criteria: translation to practice and research. J Am Coll Radiol 2005; 2: 61–67.
  • 64 Douglas PS, Khandheria B, Stainback RF, et al. ACCF/ASE/ACEP/ASNC/SCAI/SCCT/SCMR 2007 appropriateness criteria for transthoracic and transesophageal echocardiography: a report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group, American Society of Echocardiography, American College of Emergency Physicians, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and the Society for Cardiovascular Magnetic Resonance endorsed by the American College of Chest Physicians and the Society of Critical Care Medicine. J Am Coll Cardiol 2007; 50: 187–204.
  • 65 Hendel RC, Patel MR, Kramer CM, et al. ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR 2006 appropriateness criteria for cardiac computed tomography and cardiac magnetic resonance imaging: a report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group, American College of Radiology, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, American Society of Nuclear Cardiology, North American Society for Cardiac Imaging, Society for Cardiovascular Angiography and Interventions, and Society of Interventional Radiology. J Am Coll Cardiol 2006; 48: 1475–1497.
  • 66 Referral guidelines for imaging: radiation protection 118. Luxembourg City, Luxembourg: Office for Official Publications of the European Communities, 2001.
  • 67 Canadian Association of Radiologists. Diagnostic imaging referral guidelines: a guide for physicians. Saint-Laurent, Quebec, Canada: Canadian Radiological Foundation, 2005.
  • 68 Royal College of Radiologists. Making the best use of clinical radiology services: referral guidelines. London, England: Royal College of Radiologists, 2007.
  • 69 Kane RL, Lurie N. Appropriate effectiveness: a tale of carts and horses. QRB Qual Rev Bull 1992; 18: 322–326.
  • 70 Blackmore CC, Medina LS. Evidence-based radiology and the ACR appropriateness criteria. J Am Coll Radiol 2006; 3: 505–509.
  • 71 Sistrom CL. In support of the ACR appropriateness criteria. J Am Coll Radiol 2008; 5: 630–635.

Article History

Published in print: 2009