The AUA recognizes the importance of including residents and fellows in events, especially those related to quality improvement (QI) and patient safety. Therefore, a new program was established to promote resident and fellow involvement in the 2017 Quality Improvement Summit, Challenges and Opportunities for Stewardship of Urological Imaging. The inaugural program awarded travel scholarships to five individuals who attended the event and participated in a panel where they shared their reflections on the program and what lessons they learned.
As part of the follow up of their experience, the recipients elaborated on the answers provided at the Summit as well as addressed other QI topics. This article highlights select answers provided by the recipients.
Q: How did you become involved in quality improvement?
Halpern: I initially became interested in QI after the clinical experience of my early years in residency revealed the many pitfalls in patient care that I encountered on a daily basis. In order to study these issues in greater depth, I pursued a Master of Science in Health Policy and Economics during a dedicated research year (which helped me to understand the academic discourse surrounding quality) and facilitated research projects pertaining to quality improvement in urology. Furthermore, I joined and ultimately came to lead the Housestaff Quality Council, which complemented my academic coursework by introducing me to the practical aspects of designing and implementing QI initiatives. Ultimately, I sought to expand my involvement beyond the local institutional level to the field of urology at large, which led to my attendance of the Quality Improvement Summit.
Ahn: My involvement in QI stems from my interest in applying aviation safety practices to medicine. As a certificated commercial pilot, I studied aviation safety theory and practices such as checklists, near-miss reporting, and accident investigations. My research year in residency allowed me time to visit and collaborate with heads of safety at Boeing and Alaska Airlines in Seattle, learning how we could translate and apply practices at our hospital systems. My involvement in imaging stewardship specifically stems from my study on national imaging patterns after kidney stone procedures, where we found both a great paucity and variability in patients receiving post-operative imaging. At a time when cost, resource allocation, and patient morbidity and mortality are under great scrutiny, I see many avenues to improve and further patient care in the field of urology and beyond.
Slopnick: During our research year in residency, we were required to participate in a month-long “rotation” with the quality office at our hospital. I found it interesting and continued working with the department.
Raskolnikov: Before residency, I focused my time on basic science and clinical research rather than QI. I liked that research tried to answer the question, “how can we do this better?” When we’d see a patient with prostate cancer in clinic, for example, and be puzzled by his prostate biopsy results, it was easy to become frustrated with the limitations of TRUS-guided biopsy. Working on MRI/US fusion-guided prostate biopsy research was a natural extension of that experience. As a resident, I began to see things from a slightly different perspective. In many cases, we’ve gone through the painstaking work of establishing basic science principles and translating them to clinical research, but then fall short in setting up systems to actually deliver this care. That doesn’t make sense. In my own institution, I noticed unexplained variability in the care that patients with kidney stones were receiving during acute stone episodes. We’re now working with a multi-disciplinary group on a QI project that seeks to establish best practices for such patients and standardize them throughout our multi-hospital system.
Robles: Near the end of my second year of my residency at Washington University in Saint Louis, we had a patient death on the consult service related to preventable factors. I was involved in the subsequent root cause analysis and efforts to resolve the patient safety issues that led to this unfortunate event. I really enjoyed the process and felt like we made important improvements in the end. I then sought out additional surgical QI opportunities in my division and department, ultimately becoming involved with hospital-wide QI committees.
Q: Is the stewardship of urologic imaging an important part of QI?
Halpern: Stewardship of urologic imaging is paramount. Imaging is essential to the delivery of urologic care, and as such, it is incumbent upon urologists to ensure that the use of imaging is optimized in caring for our patients by maximizing diagnostic yield and minimizing both unnecessary evaluations and radiation exposure.
Ahn: Absolutely. Imaging utilization in urology has rapidly expanded with prostatic MRI and abdominal/pelvic CT imaging. Many kidney stone patients are receiving multiple CT scans for single stone episodes of care, receiving inappropriately high doses of cumulative radiation over a lifetime. The secondary malignancy risks of cumulative radiation are well documented. The advent of low dose CT scans has helped this issue; however, as I learned from the Summit, there are barriers to widely instituting low dose CT protocols and great variability in what is classified as low dose with regards to radiation exposure. There is great potential for imaging overutilization and we as providers must balance cost, radiation, and resource rationing with medical utility and benefit to the patient.
Slopnick: Yes, I believe so. It’s definitely an area that urologists can have more intention with patient care. Meaning, each imaging test shouldn’t be a knee-jerk response to a certain complaint, but rather the necessity of each imaging test should be deliberate.
Raskolnikov: It is. As urologists, we benefit from cutting-edge imaging technology that can help to improve the care that we provide. At a minimum, though, intensive imaging increases costs. It also has the potential to cause direct harm to patients through ionizing radiation, for example. If we don’t come up with strategies to mitigate these risks, it seems likely that payors or others without our clinical experience or patients’ best interests may eventually do so on our behalf.
Robles: Yes, I think we are really ignorant of the cost and health risks of cross-sectional imaging that we use routinely.
Q: The AUA collaborated with the American College of Radiology and the American College of Emergency Physicians for the Quality Improvement Summit. Are there other specialties the AUA should work with regarding imaging? Why? How did you view the collaboration? How can the AUA build upon it?
Halpern: The collaboration with other specialties truly strengthened the Quality Improvement Summit. The diversity of knowledge, experiences and perspectives offered by attendees from the other specialties greatly informed the overall discourse. I think the AUA can build upon this collaboration by continuing cross-disciplinary initiatives through construction of educational materials for the constituents of all disciplines and, ultimately, joint policy or guideline statements.
Ahn: I would consider having representatives from family practice and internal medicine since physicians in those fields are frequently on the front line of diagnosing and initially triaging kidney stones (similar to emergency medicine physicians). My prior experience for instituting changes in system practices has taught me the importance of having all stakeholders at the discussion table. I was impressed with the collaboration at the meeting, not just because of the expertise from different specialties, but also because of the gaps in knowledge that became apparent. I recall talking to an emergency physician representative, who had never heard of silent hydronephrosis. I as a urology representative didn’t appreciate, until now, the emphasis on patient ED visit times that emergency physicians are assessed by. In my opinion, the Summit succeeded in bringing specialty experts together to help define the current problems facing imaging utilization and stewardship. The Summit, however, seemed primarily beneficial only to those that attended. The AUA could build upon this Summit by drafting a white paper to summarize and disseminate the lessons learned. Updated guidelines or best-practice statements on appropriate imaging should also be the ultimate goals of these collaborations. It is our job as specialty representatives to not only define the problems facing the field, but to propose the solutions as well.
Slopnick: The collaboration was fantastic – the best part of the Summit, in my opinion. It was enlightening to hear various perspectives on the issue and have an open discussion with other specialties. Involvement of primary care physicians would also be relevant, since urologists receive many referrals for nephrolithiasis, elevated PSA, etc. from PCPs in addition to emergency physicians.
Raskolnikov: The ACR and ACEP are key stakeholders in this discussion, which made the collaboration very productive. In the future, it may also be helpful to engage primary care physicians, since they perform the vast majority of kidney stone follow-up for those patients who don’t ultimately establish care with a urologist.
Robles: Only other major group I’d consider would be primary care and good imaging stewardship for conditions that are commonly referred to us (stones, hematuria, renal mass etc). These patients often have the wrong imaging ordered initially by their PCP and then have to have repeat CT scans once they see us.
Q: What takeaways from the Quality Improvement Summit will/have you tried to introduce to your practice?
Halpern: The Quality Improvement Summit alerted me to the tremendous variability in radiation exposure and protocols across institutions. Furthermore, I have a much greater appreciation for the radiation doses associated with various routine imaging studies, and I have already begun to incorporate this appreciation into daily practice – scrutinizing each imaging study that is ordered on the urology service, particularly those with high radiation doses (ex: CT urogram), to ensure that it is truly the optimal and necessary test for the individual patient.
Ahn: I hope to institute and standardize low-dose CT imaging at our main and associated hospitals. This will require significant outreach and collaboration with the local radiologists and emergency physicians, whom I hope will share our concerns and goals. I would also like to establish imaging criteria and guidelines for different imaging utilization through EMR-based care pathways, particularly for stone disease.
Slopnick: I am more aware of the negative implications of CT scan radiation and will be more likely to order a low-dose CT for stone evaluation when appropriate. I have educated my peers on the issue and plan to ask our radiologists about our protocols.
Raskolnikov: For me, the most important takeaway is access to a network of like-minded individuals who are working on exciting QI projects. The Quality Improvement Summit ensures that we don’t all have to reinvent the wheel; if an idea works at one institution, it’s likely to have applicability elsewhere. On a more day-to-day level, I’ve found myself pausing to think for just a bit longer whenever I order advanced imaging. These pauses have already led me to counsel patients and consulting teams differently on several occasions.
Robles: I thought the data presented on the harms of CT radiation was really eye-opening and I’m much more cognizant of this when I order imaging now.
Q: Were there topics you were hoping would be addressed at the Quality Improvement Summit that were not? How can the AUA improve the Summits?
Halpern: The topics at the Quality Improvement Summit were fairly comprehensive with regard to imaging. However, one area that I was hoping might be discussed is the role of upper tract imaging in the evaluation of microscopic hematuria.
Ahn: In addressing imaging stewardship for stone disease, I believe another topic worth addressing is follow-up imaging for patients with a history of or known active stone disease. My perception of the Summit was that the majority of time was spent on initial imaging for diagnosis or before urologic referral; however, the use of imaging after urologic evaluation or procedures both in the short and long term, I would argue, are just as important given our knowledge of the life-long disease risk of kidney stones.
Slopnick: More discussion and less “lectures.” Really enjoyed the small group discussion. Alternatively, have the small group discussion session earlier in the day, because I think it prompted a lot of ideas for more discussion later in the day.
Raskolnikov: I felt that the agenda and content were excellent. The only minor improvement would be to make presenters’ slides available electronically. This would cut down on the somewhat distracting practice of audience members taking photos of presentations.
Robles: I’m personally very interested in opiates and post-operative pain management, but I thought the QI Summit this year was great.