Guideline Compliance Regarding Chest Imaging of Suspicious cT1 Renal Masses in MUSIC-KIDNEY
Semerjian A, Ginsburg K, Qi J, Johnson A, Noyes S, Rogers C, and Lane BR. Guideline Compliance Regarding Chest Imaging of Suspicious cT1 Renal Masses in MUSIC-KIDNEY. Urol Pract 2023.
INTRODUCTION: Multiple urologic societies recommend chest imaging for suspicious renal masses using chest X-ray (CXR), or computed tomography (CT) as clinically indicated. The purpose of chest imaging is to assess for thoracic metastasis at the time of renal mass (RM) diagnosis. Ideally, imaging use and type is commensurate with risk related to tumor size and clinical stage. We examined current practice patterns with chest imaging compliance in the state of Michigan and implemented clinician education and VBR (value-based reimbursement) incentivization on guideline adherence.
MATERIALS AND METHODS: MUSIC-KIDNEY is a statewide initiative focusing on quality improvement for patients with cT1 RM. Data regarding chest imaging in MUSIC and panel discussion occurred at in-person MUSIC meeting in October 2019. Adherence to chest imaging guidelines was made a VBR metric at the tri-annual MUSIC meeting in January 2020. Adherence was defined as optional in RM(CT not indicated), recommended in RM 3-5 cm (CXR preferred), and required in RM >5 cm (CT preferred). The MUSIC registry was queried for percentage of patients receiving chest imaging by type. Factors associated with adherence were assessed.
RESULTS: There was significant practice level variation in chest imaging rates across the 14 contributing practices, ranging from 11 to 68%. Compliance with MUSIC guidelines for chest imaging during evaluation of T1RM was 81.8% overall, with only 61.8% of patients with masses >5 cm meeting the guideline requiring imaging with preference for CT. Factors associated with increased adherence included larger tumor size (T1b vs T1a) and solid (vs cystic or indeterminate) tumor (P < .05 for each). Prior to VBR introduction, 46.7% of patients underwent imaging of either type, compared to 49.0% post-intervention. Imaging rates only slightly increased in masses >5 cm (58.3% pre-VBR vs 61.2% after, P = .56) and 3-5 cm (50.0% pre-VBR vs 56.2% post-VBR, P = .0585).
CONCLUSIONS: Chest imaging guideline adherence during the initial evaluation of cT1 renal masses is acceptable, particularly given that most masses areHowever, despite consensus from major urologic societies regarding imaging for masses >4-5 cm, imaging rates were low across MUSIC. After educational and VBR incentive initiation, rates of imaging for 3-5 cm and >5 cm masses changed only slightly. There remains significant practice variability and room for improvement.
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