Project Title: Improving Musculoskeletal (MSK) X-ray Ordering Processes at UHNBC.
Background: A working group was recently established at UHNBC in an effort to standardize the process of plain x-ray ordering for all acute and chronic MSK conditions. The working group consists of physician representation from primary care, emergency medicine, radiology, and orthopaedic surgery, as well as non-physician representatives from radiology management, radiation technologists, a quality improvement coach, and a patient partner. The project is led by Dr. Anthony Costa (Orthopaedic Surgeon,UHNBC), and is supported through the Specialist Services Committee (SSC) Physician Quality Improvement Initiative (PQI).
Through establishment of the above working group, a set of local, consensus-generated, recommended first-line, plain x-ray ordering guidelines for all acute and chronic MSK conditions was created. Evaluation of current x-ray ordering practices at UHNBC for acute and chronic MSK conditions revealed that 34% of studies completed at UHNBC would not conform to the local consensus-generated guidelines. Further, approximately 77% of x-ray studies originating outside of the ER or specialty clinics (such as the orthopaedic cast clinic or hip/knee arthroplasty clinic) would not conform to the recommended guidelines.
As there are approximately 22,000 plain x-ray series completed each year at UHNBC for patients with acute and chronic MSK-related problems, approximately 7480 of these would not conform to local consensus generated guidelines. The billing fees that would need to be submitted to MSP from UHNBC (including professional and technical fees only) in order to add additional views to these studies, or to repeat the studies entirely, ranges from $132,097-$262,099/year.
To address the above problem, a quality improvement (QI) project is now underway to standardize the x-ray ordering process at UHNBC, starting first with all x-rays for knee and shoulder-related pathology. Beginning in mid-May, all knee and shoulder x-ray series ordered at UHNBC will default to include the views recommended in the consensus-generated guidelines. Non-recommended views will only be completed if a clear reason is given for ordering alternate views (eg rare clinical entity; required for surgical planning). In most instances, the only change to imaging completed will be the addition of 1-2 extra views and/or weight-bearing views added. This change will occur at the radiology department level, and will NOT require any changes to referring practitioners’ current image ordering practices*.
The trial period will start early June 2021 for 3 weeks. During the trial period, evaluation will be done on a weekly basis, and will consist of standard quality improvements measures including primary outcomes, process measures, and balancing measures to ensure the new ordering process is not only effective, but also not having unintended negative consequences.
If the trial period is successful, the hope is to expand the standardized ordering process to include all other MSK-related joints/body areas by September 2021. Once fully implemented, the aim of this quality improvement project would be to improve the proportion of x-ray imaging series completed at UHNBC that conform to local consensus-generated guidelines for acute and chronic MSK problems to greater than 90% within 6 months. This in turn should lead to improved patient and provider experiences of care, better patient outcomes, and decreased per-capita healthcare costs.
For further information about this QI project, please contact Marna DeSousa (PQI Coach, NHA) at marna.desousa@northernhealth.ca. For more information, see the complete set of consensus guidelines for acute and chronic MSK x-ray ordering at UHNBC.
*NOTE- If ordering an x-ray view or x-ray series that is different from what is listed in the guidelines below; please write the specific indication on the imaging requisition (eg. specialist consult clinic, rare clinical entity, needed for pre-op planning, etc).