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• W2126080306 abstract "“QUALITY” HAS BEEN A heightened focus of interest in radiology, particularly over the last decade or so. Administrative bodies, referrers, payers, and also patients are zeroing in on the quality of both the imaging test and its interpretations, and certainly we can only anticipate further increasing attention in this area 1-3. As believers and strong proponents of quality care, advocacy of the highest standards of image quality should be an unequivocal agenda of choice from among other progressive agendas in radiology today. Thus, should not image quality be of paramount importance, not only from the perspective of the patient care for but also for the general well-being of radiology community? However, in this editorial I have the daunting task of convincing the discerning reader otherwise, that outcomes are more relevant than image quality. “Image quality” is simpler to define, measure, and improve compared to “outcomes,” as there are relatively a finite number of confounding factors to address. With magnetic resonance imaging (MRI), image quality may be inferred reasonably by subjective measures such as the absence of artifacts and “crispness” of images, or perhaps objectively using signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), or other measures 4-6. Outcomes, on the other hand, are a heterogeneous group of entities with numerous definitions and multiple confounding factors. It can be difficult if not impossible to account for the precise impact of individual variables on outcomes. The delivery of healthcare has been quantified with the model, “structure + process = outcome” 7. This definition has also been extended to the use of the clinical value compass, which cites the four points of 1) medical outcomes, 2) patient satisfaction, 3) functional status, and 4) cost 8-10. Outcomes generally imply measures on a clinical scale; many are classified as “doctor-reported outcomes” (DROs), with examples including disease-related morbidity, disease-free survival, and mortality. However, importantly, there are other outcome measures which are not strictly based on clinical outcomes, described as patient-reported outcomes (PROs). These are based on how patients feel or function in relation to a health condition and its therapy without interpretation by healthcare professionals, and include physical, social, and psychological functional status, health perception, and quality of life 11-13. In this discussion, the term “outcomes” hereafter refers to the “traditional” definition of outcomes as most relevant applicable to us as clinicians. The field of MRI has grown exponentially since its introduction in the 1970s. The growth in this field is significantly attributable to dramatic advances in technology in several areas, including magnet technology, gradient strength advances, radiofrequency (RF) coil technology, and computer sciences. The available magnetic field strengths have multiplied several-fold since introduction, while the gradient strengths have dramatically increased, now accomplishing imaging with speed and resolution unthinkable a few decades ago. Over the recent few years, ultrahigh field magnetic field strengths (7 T) are moving quickly from the research realm into clinical reality, particularly in neuroimaging. Astonishing advances in coil design from single receiver to multichannel design and the plethora of new pulse sequences have pushed the limits of MRI beyond what was perhaps imagined early on. Paralleling the rapid technologic advances, there has been phenomenal growth in the clinical applications of MRI. MR imaging today not only provides anatomical information, but also quantitative/functional information. Neuropathophysiology and fiber tracts, blood flow, cardiac function, metabolites/biochemical processes, tumor biophysiology, and blood oxygen levels are just a few examples of what MRI can accomplish today. But in all this frenzy, should we not ask ourselves: Is the additional information making a difference? Despite all this phenomenal technical progress, can one assume that improved image quality simply leads to better outcomes? It is not unreasonable to postulate that there are limits to which further improvement in image quality have no tangible impact on diagnosis and outcomes. For MRI, the relationship between image quality metrics and diagnostic test performance (without even going as far as outcomes) is really an unknown in many scenarios. The study of the relationship between image quality and reader performance within the field of radiology has classically been referred to as “psychophysics” 14. Durand et al 15 developed an MRI psychophysics methodology based on introducing synthetic MRI noise in clinical quality images to produce simulated image sets with standardized levels of noise. They have demonstrated a plateau effect on gains in diagnostic performance after realizing initial gains with regard to image quality (noise). Thus, optimization/minimization could be applied to MRI to achieve a cost-effective MRI process that brings the benefits at a reasonable cost while preserving the quality of care. One can obviously agree to MRI having made a tremendous impact on diagnosis, treatment, and surveillance. However, it is rather difficult to generalize and blanket all current utilization of MRI under this umbrella. A winning scenario is application of MRI to quantitate liver and cardiac iron concentration, which has made a profound impact on management of iron overload, essentially replacing liver biopsy for liver iron quantification 16. MRI quantification of extrahepatic iron has also had a great impact on patient care and overall understanding of iron overload pathophysiology. The observations of Anderson et al 17 that many patients with MRI-detected cardiac iron overload have normal left ventricular ejection fraction showed the ability of MRI to predict cardiac dysfunction before toxicity manifested. Iron cardiomyopathy, once a leading cause of death in thalassemia major, is now relatively uncommon in centers with regular MRI screening of cardiac iron resulting from early recognition of cardiac iron loading. The role of MRI in staging pelvic malignancies, particularly rectal cancer, is noteworthy with regard to impact on management and outcomes. Preoperative MRI has been shown to have a beneficial effect on surgical performance and treatment outcome in patients with rectal cancer 18-20. However, the results for MRI restaging for evaluating treatment response after preoperative chemotherapy for locally advanced rectal cancer are more heterogeneous 21. I am certain that image quality has an impact on these results in both the above-discussed scenarios, but to what extent, and will additional technical developments further improve clinical outcomes? Similarly, MRI has had significant impact on the diagnosis and management of prostate carcinoma, even though the impact on long-term disease outcomes is difficult to measure. Given the significant size of the general population that will be diagnosed with prostate cancer, there is a need to reassess MRI utilization with cost effectiveness in mind. There is a need to strategize and determine the essential risk groups for which MR service must be provided and optimized. Liver MRI and liver-specific contrast agents is yet another area of need that requires some rationalization. While the incremental diagnostic value of hepatobiliary phase imaging with Gd-EOB-DTPA-enhanced liver MRI is well supported in many clinical scenarios, there remains a need for further outcome studies for its applications such as in detection and staging of hepatocellular carcinoma (HCC) in cirrhosis. Diffusion-weighted imaging (DWI) is routinely used in the abdomen, particularly in liver MRI, with promising results for liver lesion detection and characterization 22, 23. While it is useful for lesion detection compared to T2-weighted imaging, there is no strong evidence to suggest further imaging with contrast is unnecessary 24, 25. The results for lesion characterization are also modest at best, and certainly not compelling enough to negate the usage of intravenous contrast material. Thus, the utility of adding liver DWI to liver MRI must be debated with regard to impact on diagnostic outcomes, cost effectiveness/efficiency, and overall outcomes. Preoperative breast MRI is increasingly used in the workup of breast cancer patients and can lead to changes in surgical management. However, it has not been established whether these alterations in the surgical decision process influence clinical outcomes. One recent systematic review in the surgical domain 26 has concluded that the routine use of supplementary breast MRI should be discouraged until compelling evidence of its effectiveness is available, based on their results that “breast MRI is a highly sensitive but nonspecific method that leads to changes in surgical management with increased numbers of extended surgical interventions without conclusively proven effects on clinical outcomes as decreased reoperation rates or improved patient survival.” In this environment, it may be best for us to focus our efforts toward addressing these conclusions of impact on outcomes rather than image quality. The positive impact of MRI in musculoskeletal radiology is highlighted by the significant reduction in utilization of diagnostic arthroscopy for evaluation of internal derangements of the knee. MRI has accomplished this by providing a safer, less expensive, and noninvasive option demonstrating high sensitivity and accuracy comparable to diagnostic arthroscopy 27-29. Today, MRI is available to prevent unnecessary arthroscopy, and along with clinical considerations help triage internal derangements that can then be treated by arthroscopic surgery 30. Although image quality can be considered integral to these positive outcomes for MRI, it alone without validating impact on outcomes would not have made it possible for general acceptance of MRI as a replacement for diagnostic arthroscopy. MRI is generally the preferred modality for the evaluation of soft-tissue masses after radiography. However, while the radiologic appearance of certain soft-tissue tumors or tumor-like processes, such as myositis ossificans, fatty tumors, hemangiomas, peripheral nerve sheath tumors, and pigmented villonodular synovitis may be unique, MRI remains relatively limited in its ability to precisely characterize these tumors, with a correct histologic diagnosis reached on the basis of imaging studies in only approximately one-quarter to one-third of cases 31-34. Despite these limitations, the use of MRI in the evaluation of soft-tissue lesions is widely prevalent. It has been suggested 35 that an optimal MRI protocol—comparison with radiography, interpretation using all important parameters, planning biopsy site, and staging—will assist the orthopedic oncologic team in achieving optimal results. This perhaps justifies MRI utilization by showcasing the impact on management and outcomes. A very important scenario where the debate of image quality versus outcomes has been settled by outcomes is exemplified by the status of MRI in low back pain (LBP). In 2007, the American College of Physicians and the American Pain Society published LBP management guidelines 36. Despite substantial advancements in MRI technology during the past two decades, the main conclusions of many guidelines 37-40 are almost the same. All of the guidelines emphasize the importance of a focused history and thorough physical examination before any imaging is ordered. In addition, all agreed that for patients with acute LBP and without any risk factor for serious spine abnormalities, imaging (including MRI) within the initial 4–8 weeks should not be performed, since this did not ultimately improve outcomes. At the healthcare system level, there is a constant pressure to balance quality, impact on outcomes, and costs. Increased costs to achieve superlative image quality without improving outcomes, while reducing access due to high cost, can be only counterproductive to the field. Documenting the impact of improving image quality is not only necessary for validation and improvement of the professional care we provide, but also is becoming an important parameter whereby insurers and providers are assigning dollar figures for the work we do. In some scenarios, failure to show impact on outcomes has or will result in reduction or annulation of reimbursement. Even If the reader is still not convinced with regard to the importance of outcomes over image quality, what I can conclude without hesitation is that failure to demonstrate positive impact on clinical outcomes will not keep the window of opportunity to achieve higher standards of image quality open for long. Kartik Jhaveri, MD University Health Network Mt. Sinai and Womens' College Hospital Toronto, ON, Canada" @default.
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• W2126080306 title "Image quality versus outcomes" @default.
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