Insights Imaging (2017) 8:447–454

DOI 10.1007/s13244-017-0566-1

STATEMENT

ESR concept paper on value-based radiology

European Society of Radiology (ESR)

Received: 12 July 2017 / Accepted: 12 July 2017 / Published online: 30 August 2017
# The Author(s) 2017. This article is an open access publication

Abstract The European Society of Radiology (ESR) • VBH considers diagnosis only if wrong or a cause of
established a Working Group on Value-Based Imaging (VBI complications.
WG) in August 2016 in response to developments in • A correct diagnosis is the first outcome that matters to
European healthcare systems in general, and the trend within patients.
radiology to move from volume- to value-based practice in • Metrics to measure radiologists’ impacts on patient out-
particular. The value-based healthcare (VBH) concept defines comes are key.
“value” as health outcomes achieved for patients relative to • The value provided by radiology is multifaceted, going be-
the costs of achieving them. Within this framework, value yond exam volumes.
measurements start at the beginning of therapy; the whole
diagnostic process is disregarded, and is considered only if it
Keywords Value-based healthcare . Value-based radiology .
is the cause of errors or complications. Making the case for a
Health economics . Performance metrics . Patient outcomes
new, multidisciplinary organisation of healthcare delivery
centred on the patient, this paper establishes the diagnosis of
disease as a first outcome in the interrelated activities of the
healthcare chain. Metrics are proposed for measuring the qual- The concept
ity of radiologists’ diagnoses and the various ways in which
radiologists provide value to patients, other medical specialists European governments, like those in other parts of the world,
and healthcare systems at large. The ESR strongly believes are increasingly facing difficulties in managing their national
value-based radiology (VBR) is a necessary complement to health systems. This is due to a variety of causes: the most
existing VBH concepts. The Society is determined to establish important being an ageing population, a rise in the prevalence
a holistic VBR programme to help European radiologists deal of chronic conditions and the accelerating pace of medical
with changes in the evolution from volume- to value-based innovation—all of which have increased demand for state-
evaluation of radiological activities. of-the-art treatment. These factors, associated with a long-
Main Messages lasting economic crisis, constitute a severe threat towards
• Value-based healthcare defines value as patient’s outcome maintaining and safeguarding the current levels of healthcare
over costs. [1].
• The VBH framework disregards the diagnosis as an Short-term cost-cutting solutions and austerity measures
outcome. have been the first reactions to difficulties. These have, how-
ever, already reached their limit and are now negatively affect-
ing the quality of healthcare. At present, cost-saving and aus-
terity are fuelling a paradoxical effect, creating a vicious circle
* European Society of Radiology (ESR)
[email protected] of increased demands on healthcare and the need for greater
spending.
Thus, there is a need to re-imagine how health services are
1
Neutorgasse 9/2, 1010 Vienna, Austria financed.
448 Insights Imaging (2017) 8:447–454

The concept of value-based healthcare (VBH) has emerged working to identify metrics that allow measurement of the
as a framework for achieving better results, considering first “significant outcomes” within each of the steps of the value
those factors that matter most to patients, while optimising, at frame [5]. The International Consortium for Health Outcome
the same time, the cost of care delivery within the health Measurements (ICHOM) has already published a series of 20
system. Value is defined as health outcomes achieved for pa- outcome measurement sets for 20 different clinical situations
tients relative to the associated costs. Value (in this context) (such as breast, colon and lung cancer, stroke, dementia, cor-
depends on the results of care and is measured by reference to onary heart disease, and others). Other sets are under prepara-
the results obtained, and not to the volume of services deliv- tion. The organisation aims to publish standard sets to cover
ered [2]. PAS LA QUANTITE MAIS LA QUALITE QUOI more than 50% of the global disease burden by the end of
Within this concept, payments are assigned according to 2017 [6].
the outcomes of a given episode of care, and good outcomes Simultaneously, health economists are working on the
have to be obtained in the most efficient way to achieve a measurement of the costs of each step of the process, compris-
reduction in associated costs. ing materials, time, professional fees, etc. [7].
At present, care to a patient (or a patient population) with This may all seem sensible, but the value-based healthcare
any medical condition is usually delivered by a multitude of concept, as presently structured, is fundamentally flawed, not
specialists, working in different units and departments, each by what it seeks to achieve, but by what it does not even
taking care of the patient from the point of view of his/her consider. Significantly, no radiologist has been involved in
expertise. In a value-based healthcare environment, the whole any of this work, and radiology is not even considered in the
organisation has to change, and care for any medical condition value-based healthcare concept. The framework used to mea-
is given by specifically dedicated multidisciplinary practice sure health outcomes, in fact, starts only at the beginning of
units with deep knowledge, a broad skill range and excellent treatment (after most of the work of the radiologist has already
facilities, which provide the full continuum of care to the pa- been done). The entire diagnostic process, as a whole, is only
tient. Such a model allows, on one hand, the development of considered as affecting tier 2, in case of errors or complica-
the expertise necessary to achieve better short-term and long- tions, and then is only considered as having a negative effect
term outcomes and, on the other hand allows the measurement on outcomes; that is, when something goes wrong. Thus, a
and optimisation of the costs involved in the whole cycle of correct diagnosis seems to be taken for granted, as if it were a
care. For acute conditions, these practices will mainly affect commodity, and as if the work of a radiologist was analogous
physicians working in hospitals. Chronic diseases, however, to that of a machine for measuring blood biochemistry.
will see the involvement of a network of general practitioners Radiologists play a fundamental role in the diagnostic pro-
(GPs) and specialists working outside of the hospital to ensure cess of modern healthcare delivery. However, they are often
longitudinal follow-up of patients and evaluation of the final considered as factories producing imaging examinations, with
outcome of the care provided. Such changes are quite complex attention focused only on the number of procedures per-
and require a “revolution” of the whole healthcare system, from formed. Their work is considered as a chain of processes
an organisation centred on medical specialties to one centred on and their results, the diagnoses, are not regarded as an
the patient and his/her needs. Furthermore, a profound rethink- outcome.
ing of the role of hospitals in relation to their area of influence is In the clinical projects implementing value-driven
needed, with the development of an active role for care man- programmes that have been developed, radiology has been
agement and improvement not only within the hospital itself simply considered as a cost and measured as such. The diag-
but also for other providers in their network [3, 4]. nosis, and how it has been possible to reach it, has not been
Value measurements are based on a three-tiered framework regarded as the first important result of an entire episode of
(Table 1). Each tier contains two levels, each with one or more care [8].
dimensions related to the state of health reached by the patient A patient, however, is not a disease or a pathological con-
during and after treatment. The lowest tier (tier 1) measures dition, for which it is possible to classify and measure the
“sustainability of health” (with “care-induced illnesses” and results of treatment. He/she is an individual who seeks help
“recurrences” as internal dimensions); tier 2 relates to the “pro- for signs and symptoms with a view to understanding and
cess of recovery” (internal dimensions are “diagnostic or treat- curing the underlying reason for them. A correct, timely and
ment mistakes and their complications”, as well as “time to useful diagnosis is the first and crucially important step that
return to normal activities”); tier 3 is defined as “health status matters to each patient and to other healthcare professionals.
achieved or retained” (and its internal dimensions are “degree Therefore, the establishment of a correct diagnosis is the
of health recovery” and “overall survival”) [1]. first outcome that must be considered in the healthcare pro-
Measurements of both outcomes and costs are not easy. cess. It is an intermediate outcome, but definitely an outcome
Teams of experts, including physicians, health economy ex- nonetheless, and as such has to be considered in any value-
perts and representatives from patients’ organisations, are based healthcare paradigm. In addition, the contribution of
Insights Imaging (2017) 8:447–454 449

Table 1 Measuring value-based

care Tier 1 Sustainability of health Care-induced illnesses
Recurrences
Tier 2 Process of recovery Diagnostic or treatment mistakes and their complications
Time to return to normal activities
Tier 3 Health status achieved or retained Degree of health recovery
Overall survival

radiology to the exclusion of possible disease should be re- & To further develop the ESR’s programmes and projects in
membered; substantial benefit to patient outcomes can accrue accordance with the concept of value-based radiology
from radiology investigations that exclude significant disease.
In the present value-based healthcare model, none of these The group is led by the current ESR first Vice-President
outcomes are measured, or even taken into consideration. and initially comprised the Chair of the ESR Board of
The topic of value-based radiology (VBR) has been ad- Directors, the ESR Past-President, the Quality, Safety and
dressed by many recent papers, most of them reflecting the Standards Committee Chair, the Education Committee
ongoing debate within radiological societies and organisations Chair, the National Societies Committee Chair, the PIER
in the United States. The authors have emphasised the impor- Subcommittee Chair and the EuroSafe Imaging Chair and
tance of the active role that radiologists need to have in the industry liaison. Three group meetings were held in 2016
transition from volume-based to value-based healthcare and and in 2017, and the ESR Patients Advisory Group joined
have proposed new metrics that show the benefits provided by the working group in May 2017.
radiology to patients [9–14]. Our working group is facing a daunting task. It is difficult
The situation in Europe is different from that in the United to precisely define the concept of value-based radiology, and it
States. In many European countries, healthcare organisation is even more problematic to develop metrics which would
relies on a national health system that acts as facilitator, orga- allow a clear demonstration of the benefits contributed by
niser and payer, and provides care to citizens. In addition, the imaging to the care of patients.
situation is not homogeneous throughout Europe, since the There are many reasons for this. The most important is that
national systems differ in terms of organisation, governance radiologists’ work is not performed in isolation. Our results
and means of funding and payment. The concept of value- depend both on the appropriateness of referrals and on how
based healthcare, however, is being discussed also in our reports are understood and used by the physicians who
Europe, and a few experimental implementations of the sys- treat the patients. Even the outcomes of the therapeutic proce-
tem have already been initiated. Therefore, it is necessary to dures performed by interventional radiologists are linked to
understand the role of radiology in this new framework also those of the other doctors who precede and follow the inter-
from a European perspective, and to ensure that radiology is vention. In emergencies such as trauma and stroke it is even
properly represented in the development of concepts and more complicated, since the time from an accident or from the
healthcare planning. beginning of symptoms to diagnosis and treatment are critical
The European Society of Radiology (ESR) has established factors, which depend on the organisation of the whole emer-
a working group on VBR. Its goals are: gency system, not on that of the hospital and radiology depart-
ment alone. An altogether other issue is the problem of
& To develop a definition and conceptual framework for measuring the costs of radiation protection measures
VBR in Europe and to embed value-based radiology as a (which are enforced by the 2013/59/Euratom Directive
strategic paradigm for the Society’s activities in Europe) [15], the difficulty in fully assessing pa-
& To ensure the ESR’s ability to respond, shape and manage tients’ experiences throughout the diagnostic process,
healthcare trends towards value-based approaches rele- and the difficulties in understanding how continuous
vant for medical imaging professional education, teaching and research activities
& To increase and demonstrate the value radiology, radiolo- impact on the final diagnosis of each patient.
gy professionals and the ESR provide, and to improve
cooperation with all relevant stakeholders
& To establish a strategy for enhancing the visibility and The metrics
reputation of radiology, and for positioning the radiology
profession within the healthcare sector vis-à-vis other The activities chain within the radiology department, com-
medical professionals, patients, industry, political stake- monly called the “value chain”, has been explored in a number
holders and society at large of papers [14, 16, 17]. Each of the steps in the value chain is
450 Insights Imaging (2017) 8:447–454

composed of many different processes, and radiologists are Appropriateness can be measured through:
quite good at measuring and improving these. But improving
one or more processes does not necessarily lead to better 1. Analysis of compliance of requests by referring physi-
outcomes. cians with (institutionally approved) imaging referral
Although most potential improvements of certain steps aim guidelines
at workflow efficiency optimisation only, some are directed at 2. Identification of duplicate studies
aspects of the activities chain that are quite important for a 3. Rejection of unnecessary or redundant studies
high-quality diagnosis (our “outcome”). 4. Time and frequency of referring physician consultation
We believe that five of these process steps can be regarded 5. Ease of availability of radiologists for referrer consulta-
as key factors: tion [15]

1. Appropriateness of requests The radiological community, both in Europe and in other

2. Attention to radiation protection measures countries, has developed clinical decision support (CDS) sys-
3. Characteristics of the reports (correct, complete, well un- tems to ensure a consistent and appropriate utilisation of re-
derstandable, structured and properly used) sources by referring physicians. Their use would easily allow
4. Relationships between patients and radiology personnel measurement of these metrics [19]. In Europe, in order to har-
5. Continuous professional education, research and monise imaging appropriateness criteria throughout the differ-
innovation ent countries, the ESR has recently launched a computer-based
CDS tool called ESR iGuide. This provides a core standard
These steps address the most important ethical “values” in system, with guidelines adaptable to local (national and insti-
our discipline: attention to patients’ safety and wellbeing, at- tutional) situations [20], and its implementation and clinical use
tention to the quality of all aspects of the work, and develop- have already started in different countries.
ment of good relationships with patients and referring physi-
cians. All are considered as important not only by radiologists Radiation protection measures
but also by the patients who benefit from our services [18].
The development of metrics that allow evaluation of these The 2013/59/Euratom Directive enforces, among other things,
parameters would possibly facilitate some measuring of the the use of medical radiation protection measures in Europe.
quality of the diagnostic outcome. Together with an assess- Although it would be quite difficult to calculate the real ben-
ment of the costs involved, a measure of the final “value” of efit of the use of such measures on the quality of our principal
radiology could be obtained. outcome, the final diagnosis, radiologists must pay attention
We should not forget that metrics are a surrogate for to this topic by choosing a non-ionising examination tech-
“truth”, and not the actual care provided to and experienced nique whenever possible and the optimisation of procedures.
by patients and their families. Furthermore, they can be quite Furthermore, the Directive strengthens and expands the previ-
complex and difficult to measure accurately; some can address ous requirements regarding diagnostic reference levels and
the same point from different angles and some may deal with reinforces the need for education in this field of all involved
intangible assets whose direct relation to outcome can be hard personnel and of medical students [21]. A number of metrics
to demonstrate. concerning radiation protection can be put in place:

Appropriateness of requests 1. Presence of diagnostic protocols which entail choice of

non-ionising examinations whenever possible
This first step in the activity chain does not depend on radiolo- 2. Presence of “low-dose” protocols in all computed tomog-
gists alone. Although it would be desirable to have a discussion raphy (CT) equipment
between the referring physician and radiologist about the most- 3. Percentage of use of such protocols
appropriate imaging test to evaluate each patient, the workload is 4. Reporting to a radiation dose index registry of all
too great and this is not feasible in clinical practice. Personal exposures
contact before the examination is usually sought in a few, quite 5. Evidence of training programmes on radiation protection
difficult cases only. Appropriateness, however, together with aspects
awareness of radiation risk and audit, are at the foundation of
the justification process for every planned study. Provision of the
right exam to the right patient, at the right moment and for the Characteristics of the radiology report
right clinical indication, is of the greatest importance, and, in
terms of defining value, is one of the most important contribu- The report is an important aspect of our work, since it is the
tions of radiologists to the wellbeing of patients. gateway of communication with other healthcare providers
Insights Imaging (2017) 8:447–454 451

(and increasingly also with the patient). Ideally, the report 1. Presence within the department of detailed instructions for
should provide the final answer to the reason why the patient preparation for the different types of examinations and the
was referred. There is consensus in the literature about its final percentage of patients receiving them
characteristics: a good report should be timely, correct, com- 2. Distribution of customer satisfaction questionnaires (and
plete and “actionable” [12, 16]. Therefore, it has to be evalu- these are better if they have been developed together with
ated for completeness, accuracy, clarity, specificity, adherence patients’ representative organisations) and periodic audits
to guidelines and disease-based structure. There is a strong based on their results
trend to move away from “prose” reports towards “structured” 3. Existence of formal relationships between the department
reports, and to that effect templates are being developed. and patients’ organisations
There are possible metrics on the quality of the report that
can be established within radiology departments. They can Other metrics may relate more closely to the direct patient-
be obtained, for instance, through measurement of the time radiologist relationship.
from request to reporting, the number of discrepancies/errors Although it is not clear from the literature if patients prefer
meetings within a department (and, possibly, by the number of having the examination results directly communicated to them
discrepancies/errors found) and the establishment and regular by the radiologist or by the referring physician [25, 26], a
use of disease-specific structured reports that document infor- departmental policy that facilitates availability for queries
mation of unique importance for each condition. The latter and explanations, when requested, should be in place and
data are a measure of accuracy and completeness. measured. Agreement with patient organisations as to whether
However, how a radiology report is understood and used this should be a short in-person consultation upon request or
by referring physicians does not depend on radiologists alone specific time slots during the day would be preferable.
(and this is probably the most important aspect, directly relat- Furthermore, other methods of delivering examination re-
ed to the final outcome of the episode of care). It is known that sults to patients, such as online portals or patient gateways,
after direct consultation between radiologists and referrers, be through which patients can directly access their own results,
it direct person-to-person contact or during structured clinical- may also be considered.
radiological meetings [22, 23], significant new information
can be obtained and that (especially in cancer patients) both Continuous professional education, research
major and minor changes in diagnostic and therapeutic man- and innovation
agement occur quite frequently. Thus, metrics about the im-
pact of the report on patient management can be obtained This is probably the most difficult topic for which to identify
through measurements of the number of formal meetings be- metrics. It is clear that the ability to learn, improve and inno-
tween radiologists and other specialists, the number of cases vate is directly related to the quality of our final outcome, the
discussed in each of them and the percentage of cases in which diagnosis. In any company, it is only through the ability to
significant changes in therapy are decided after direct consul- launch new products, create more value for customers and
tation. In some countries, programmes have been developed to continually improve operating efficiencies that new markets
measure many of these quality and value parameters on a can be reached, increased revenues and margins obtained and
nationwide basis [24]. value for stakeholders created [27, 28]. However, improve-
ment through education and innovation takes time to impact
results, and often does so indirectly. It is, therefore, difficult to
Relationships between patients and radiology personnel understand how to measure its effects. This is even more com-
plicated in the medical sciences, where transition from theo-
This topic does not relate to customer satisfaction only. It retical knowledge into clinical practice may take a long time
deals with the entire patient-doctor relationship and, in and may not be straightforward.
radiology, is directly related to our “visibility” to patients. Continuous medical education (CME) throughout one’s
Availability to talk before, during and after the examina- whole career is a duty of all European doctors, radiologists
tion is probably the best way to improve the quality of the included. There are some differences in the rules established
“radiological experience” for each patient, and this can by the regulatory bodies of each country, but the same general
involve any of the personnel dealing with them, from principles apply throughout Europe [29, 30]. Compliance with
clerks at admission to nurses, radiographers and radiolo- national regulations regarding CME can be used as a metric,
gists. Any conversation, furthermore, should be polite and and the number of CME points collected per year by each
respectful. Availability is an “intangible asset” that may radiologist can be an additional one.
be difficult to measure properly, and assessing courtesy In recent decades, the growing complexity of our discipline
towards patients is even more difficult. Some metrics, and the need to provide high-quality services have led to the
however, can be established: evolution of a number of recognised radiological
452 Insights Imaging (2017) 8:447–454

subspecialties. A relatively large number of radiologists now- diagnostic examinations performed to decide on the feasibility
adays devote their practice to one or more subspecialty of the procedure and to guide it, and these are often performed
area(s), and this is true especially in large hospitals and aca- immediately before the intervention, in the same session, and
demic centres. Deeper knowledge of the clinical and radiolog- often by the same radiologist. It is not only a matter of correct
ical aspects of the chosen topics and capability to have a better diagnosis; the details of how to perform the therapeutic pro-
dialogue with the respective clinical specialists are well- cedure can often be chosen only from data obtained by spe-
known advantages of subspecialisation in radiology. cifically tailored diagnostic examinations. The quality of their
Furthermore, it has been shown that second opinions obtained results is therefore critical in determining the “value” of the
from consultations with subspecialised radiologists may result following therapeutic procedure. These too have to be consid-
in clinically important differences in detection and interpreta- ered and metrics about them must be developed.
tion, in comparison to the reports issued by a general radiolo-
gist. Thus, the number of examinations read by subspecialists
(either as a primary reading or as a secondary consultation) The perspective
can be used as a metric relating to the quality of the radiology
report [31–35]. Such services, however, are not available on a The concept of value-based healthcare has been developed as
24-h basis, and it is difficult to organise departmental activities a response to the financial pressures that are causing crises in
to ensure that the best possible competence can be offered to our health systems. Although driven, at least in part, by finan-
all patients at all times [36]. Both the presence of an cial imperatives, value-based healthcare can be seen from two
organisational structure that allows re-evaluation of out-of- different angles: it represents not only a necessary new ap-
hour studies from subspecialists the next working day, or in proach to guarantee financial sustainability but is also impor-
which it is possible to have on-call consultation from subspe- tant in and of itself as a focal point for evidence-based, mea-
cialists, as well as the usage rate of such services, can therefore surable and outcome-driven healthcare. This second aspect
be used as additional metrics. would be greatly significant, in fact, even in a system with
Things get even more complicated when it comes to re- unlimited resources. So there is both a financial need and a
search and innovation, since the translation of new discoveries compelling qualitative reason to re-imagine health services;
from bench to bedside is usually quite slow, and it is not therefore, the current situation is also an opportunity to im-
possible to measure the impact of research productivity of a prove healthcare in this sense [37].
radiologist, or of the whole radiological department, on the In the current thinking on value-based healthcare, we sadly
final diagnosis of each patient. However, there is no doubt note that the diagnostic process, as a whole, is not considered
that research is the future of any clinical discipline, including in the outcome evaluation process. Measurements start at the
radiology, and being active in research is key to keeping up to beginning of the therapeutic management of the patient, after
date with clinical and technical advances in our discipline. the diagnosis has already been established. In the currently
Therefore, at least in theory, research productivity within a prevailing model, the work of diagnosticians (radiologists,
department can be linked to the quality of the medical services pathologists, laboratory medicine specialists and even the
provided. Metrics about this topic can include the number and family doctor to whom the patient first goes when health
quality of papers published, the number of patents, and the problems arise) is not considered.
amount of research funding received per year. The ESR has decided to take a three-step approach to this
topic. The first is dedicated to determining a number of met-
Interventional radiology rics about topics that both radiologists and patients believe are
most important for the quality of our “outcome”. These are
Interventional radiology is somewhat different from diagnos- addressed in this article.
tic imaging, since the results of interventional procedures can The second step involves the creation of a general assess-
be considered directly as outcomes under existing models. ment programme of the activities performed by radiologists.
They fit perfectly within the value-based healthcare frame- This should consider these metrics and take into account all
work: patients’ preferences can be assessed, costs can be mea- the different perspectives from which the metrics can be eval-
sured and “value” calculated and compared to that of other uated (financial, radiological, patients’ and innovative).
therapeutic procedures. However, interventional radiology Hopefully, this approach will allow us to begin a discussion
procedures are not performed in isolation. As already noted, about the criteria by which radiology departments are
their outcome is linked to the work of the other doctors who assessed: not only on the number of examinations performed
precede and follow the intervention and are thus subject to the but also on the quality of their diagnostic outcome [37].
quality of both the referral and follow-up. Furthermore, in the The third step (similar to what has been done for the out-
existing VBH framework, no “value” can be calculated re- come measurements of different diseases by ICHOM) relates
garding the correct choice, the quality and the results of the to the identification of a number of different clinical situations
Insights Imaging (2017) 8:447–454 453

in which it is possible to analyse the diagnostic process, de- that a radiological diagnosis is a definite “outcome” accepted
lineate specific metrics along its course and measure the final by administrators, health economists, payers and political au-
quality of the outcome, taking into consideration both internal thorities, so that the contribution of radiology is considered as
and external factors affecting it. Examples could be: in pa- a valuable component in any future value-based healthcare
tients with stroke or trauma, the time from the accident or model.
onset of symptoms to imaging and image-guided therapeutic The discussion has just started…
procedures; or (this would be even more complicated) consid-
ering the integration of radiological findings with physical
Acknowledgements This is a publication of the ESR Working Group
examination, history-taking, laboratory tests and even patho- on Value-Based Imaging, prepared by its chairman, Prof. Lorenzo Derchi,
logical results in subjects with complex conditions, to “mea- ESR 1st Vice-President, supported by the 2017-18 and 2016-17 members
sure” the results of the whole diagnostic process. Another of the working group: Prof. Paul M. Parizel, Prof. Katrine Riklund, Dr.
example could be the influence of a radiological examination Adrian Brady, Prof. Laura Oleaga, Prof. Christoph Becker, Prof. Peter
Mildenberger, Prof. Guy Frija, Ms. Judy Birch (ESR-PAG), Prof. Marc
on subsequent patient pathways after referral to an emergency Dewey, Prof. Luis Donoso and Dr. E. Jane Adam; as well as Ms. Monika
department (e.g. findings of an abdominal CT help to decide Hierath and Mr. Florian Demuth (ESR EU and International Affairs
whether a patient will be transferred to gastroenterology or Department).
abdominal surgery). The paper has been provided for review to the ESR’s institutional
member societies, whose comments are gratefully acknowledged.
This article reflects the results of the first discussions within The paper was approved by the ESR Executive Council in July 2017.
the ESR Value-Based Imaging Working Group and attempts
to indicate possible metrics useful to calculate all the quality Open Access This article is distributed under the terms of the Creative
aspects of the outcome of the activities of a radiology depart- Commons Attribution 4.0 International License (http://
creativecommons.org/licenses/by/4.0/), which permits unrestricted use,
ment: the diagnosis. Its aim is, first and foremost, to launch a distribution, and reproduction in any medium, provided you give appro-
discussion within the ESR, and the radiological community as priate credit to the original author(s) and the source, provide a link to the
a whole, about this topic. Comments and suggestions about Creative Commons license, and indicate if changes were made.
the general concept of VBR and the metrics that have been
tentatively suggested are needed in order to understand if
these are considered as useful throughout the different References
European settings, to build consensus about them and to guide
the ESR’s strategy. 1. The Economist Intelligence Unit (2015) An introduction to value-
The discussions on the VBR concept will therefore based healthcare in Europe. https://www.eiuperspectives.
continue. economist.com/sites/default/files/ValuebasedhealthcareEurope.pdf
2. Porter ME (2010) What is value in health care? N Engl J Med 363:
First of all, the Working Group needs to involve other key
2477–2481
stakeholders. The ESR Patient Advisory Group has already 3. Ribera J, Antoja G, Rosenmöller M, Borrás P (2015) Hospital of the
discussed this topic and joined the Working Group at its Future. A new role for leading public hospitals in Europe. Center
May 2017 meeting. Representatives from associated indus- for Research in Healthcare Innovation Management (CRHIM),
tries also need to be involved. There are many challenges in IESE, Barcelona
4. Porter ME, Lee TH (2015) Why strategy matters now. N Engl J
the accounting and control systems in healthcare given the Med 372:1681–1684
complexity of the core operating processes, in addition to 5. Porter ME, Larsson S, Lee TH (2016) Standardising patient out-
the multiple and often conflicting sets of goals imposed on comes measurement. N Engl J Med 374:504–506
healthcare organisations by internal and external stakeholders 6. International Consortium for Health Outcome Measurements.http://
and the highly politicised environment. The development of a ichom.org. Accessed 3 June 2017
7. Kaplan RS, Porter ME (2011) The big idea: how to solve the cost
new full set of metrics adds to the already existing difficulties
crisis in health care. Harv Bus Rev 89:46–52 54, 56-61 passim
and can be perceived as an additional severe burden imposed 8. Lee VS, Kawamoto K, Hess R, Park C, Young J, Hunter C, Johnson
on radiology management. The technical feasibility and the S, Gulbransen S, Pelt CE, Horton DJ, Graves KK, Greene TH,
ease of monitoring these new metrics have to be considered. Anzai Y, Pendleton RC (2016) Implementation of a value-driven
Medical informatics solutions have to be found to facilitate outcomes program to identify high variability in clinical costs and
outcomes and association with reduced cost and improved quality.
measuring them easily, frequently and reliably. JAMA 316:1061–1072
However, to calculate the “value” of a diagnosis, all the 9. Patti JA, Berlin JW, Blumberg AL, Bryan RN, Gaschen F, Izzi BM,
metrics and the outcomes we have discussed will have to be Larson PA, Lewin JS, Liebscher LA (2008) ACR white paper: the
related to the costs of achieving them. Therefore, it will be value added that radiologists provide to the health care enterprise. J
Am Coll Radiol 5:1041–1053
necessary to work on this aspect too.
10. Hillman B (2009) Demonstrating the value of imaging to patients’
Finally, any activity on the VBR concept needs to be shared health. J Am Coll Radiol 6:543
and discussed with, as well as accepted by, external stake- 11. Gunderman RH, Boland GWL (2009) Value in radiology.
holders. It will be, first of all, necessary to have the concept Radiology 253:597–599
454 Insights Imaging (2017) 8:447–454

12. Boland GW, Duszak R Jr, McGinty G Jr, Allen B Jr (2014) Delivery examination results to patients: perceptions and preferences of pa-
of appropriateness, quality, safety, efficiency and patient satisfac- tients. AJR Am J Roentgenol 203:1034–1039
tion. J Am Coll Radiol 11:7–11 26. Koney N, Roudenko A, Ro M, Bahl S, Kagen A (2016) Patients
13. Patel S (2015) Value management program: performance, quantifi- want to meet with imaging experts. J Am Coll Radiol 13:465–470
cation, and presentation of imaging value-added actions. J Am Coll 27. Kaplan RS, Norton DP (1992) The balanced scorecard—measures
Radiol 12:239–248 that drive performance. Harv Bus Rev 72:71–79
14. Sarwar A, Boland G, Monks A, Kruskal JB (2015) Metrics for 28. Kaplan RS (2009) Conceptual foundations of the bilance score
radiologists in the era of value-based health care delivery. card. In: Chapman CS, Hopwood AG, Shields MD (eds)
Radiographics 35:866–878 Handbook of management accounting research. Elsevier, Oxford,
15. Boland GW, Glenn L, Goldberg-Stein S, Jha S, Mangano M, Patel pp 1253–1269
S, Schoppe KA et al (2017) Report of the ACR’s Economics 29. Maillet T, Maisonneuve H (2011) Long-life learning for medical
Committee on value-based payment models. J Am Coll Radiol specialists doctors in Europe: CME, DPC and qualification. Presse
14:6–14 Med 40:357–365
16. Enzmann DR (2012) Radiology’s value chain. Radiology 263:243– 30. Maisonneuve H, Matillon Y, Negri A, Pallarés L, Vigneri R, Young
252 HL (2009) Continuing medical education and professional revali-
17. Boland GW, Duszak R (2015) Challenges in delivering the value dation in Europe: five case examples. J Contin Educ Heal Prof 29:
chain. J Am Coll Radiol 12:409–411 58–62
18. European Society of Radiology (ESR) (2015) The ESR patient
31. Zan E, Yousem DM, Carone M, Lewin JS (2010) Second-opinion
advisory group (ESR-PAG). Insights Imaging 6:167–171
consultations in neuroradiology. Radiology 255:135–141
19. Brink JA, Arenson RL, Grist TM, Lewin JS, Enzmann D (2017)
Bits and bytes: the future of radiology lies in informatics and infor- 32. Lakhman Y, D’Anastasi M, Miccò M, Scelzo C, Vargas HA,
mation technology. Eur Radiol. https://doi.org.10.1007/s00330- Nougaret S, Sosa RE, Chi DS, Abu-Rustum NR, Hricak H, Sala
016-4688-5 E (2016) Second-opinion interpretations of gynecologic oncologic
20. European Society of Radiology (ESR) (2017) Summary of the pro- MRI examinations by sub-specialised radiologists influence patient
ceedings of the international forum 2016: “imaging referrals guide- care. Eur Radiol 26:2089–2098
lines and clinical decision support—how can radiologists imple- 33. Chalian M, Del Grande F, Thakkar RS, Jalali SF, Chhabra A,
ment imaging referral guidelines in clinical routine?”. Insights Carrino JA (2016) Second-opinion subspecialty consultations in
Imaging 8:1–9 musculoskeletal radiology. AJR Am J Roentgenol 206:1217–1221
21. European Society of Radiology (ESR) (2015) Summary of the 34. Eakins C, Ellis WD, Pruthi S, Johnson DP, Hernanz-Schulman M,
European directive 2013/59/Euratom: essentials for health profes- Yu C, Kan JH (2012) Second opinion interpretations by specialty
sionals in radiology. Insights Imaging 6:411–417 radiologists at a pediatric hospital: rate of disagreement and clinical
22. Dendl L-M, Teufel A, Schleder S, Rennert J, Stroszczynski C, implications. AJR Am J Roentgenol 199:916–920
Mueller-Schilling M, Schreyer AG (2017) Analysis of radiological 35. Wibmer A, Vargas HA, Donahue TF, Zheng J, Moskowitz C,
case presentations and their impact on therapy and treatment con- Eastham J, Sala E, Hricak H (2015) Diagnosis of Extracapsular
cepts in internal medicine. Rofo 189:239–246 extension of prostate cancer on prostate MRI: impact of second-
23. Brook OR, Hakmon T, Brook A, Dudnik E, Kuten A, Engel A opinion readings by subspecialized genitourinary oncologic radiol-
(2011) The effect of a radiology conference consultation on cancer ogists. AJR Am J Roentgenol 205:W73–W78
patients management. Ann Oncol 22:1204–1208 36. Norbash J, Bluth E, Lee CI et al (2014) Radiologist manpower
24. Faculty of Radiologists (2015) Guidelines for the implementation considerations and image 3.0: effort planning for value-based im-
of a National Radiology Quality Improvement Programme—ver- aging. Am Coll Radiol 11:953–958
sion 3.0. Faculty of Radiologists, Royal College of Surgeons in 37. European Society of Radiology (ESR); American College of
Ireland, Dublin http://www.radiology.ie/wp-content/uploads/2010/ Radiology (ACR) (2016) European Society of Radiology (ESR)
05/National-Radiology-QI-Guidelines-V31.pdf and American College of Radiology (ACR) report of the 2015
25. Mangano MD, Rahman A, Choy C, Sahani DV, Boland GW, Gunn global summit on radiological quality and safety. Insights
AJ (2014) Radiologists’ role in the communication of imaging Imaging 7:481–484