A statewide quality improvement and financial incentive program in Michigan helped reduce the use of chest x-rays in children with asthma, bronchiolitis, and croup by nearly 40% in a statewide emergency network, new research showed.

Despite guidelines that discourage routine use of chest x-rays, each year about 40% of children who enter a US emergency room with those airway conditions undergo the imaging tests. Superfluous chest x-rays raise the cost of healthcare, expose children to unnecessary radiation, and can trigger inappropriate prescribing of antibiotics for findings that often are due to viruses.

Many national campaigns, including Choosing Wisely, have aimed to reduce routine chest x-rays but have not resulted in consistent decreases.

The Michigan Emergency Department Improvement Collaborative (MEDIC) launched the program in March 2019 to decrease routine use of chest x-rays in children with common respiratory conditions. Some sites chose to adopt the MEDIC program within a financial incentive program. MEDIC is led by emergency physicians and is funded by Blue Cross Blue Shield of Michigan (BCBSM) and Blue Care Network, which includes pediatric centers and general academic and community emergency departments (EDs).

Wide Range of EDs Included

Researchers led by John A. Greco, MD, PhD, with the Departments of Emergency Medicine and Pediatrics at the University of Michigan in Ann Arbor, Michigan, analyzed data from visits between May 2017 and April 2023 at 39 EDs. These included three children’s hospitals, 12 general hospitals with dedicated pediatric beds, and 24 general hospitals without pediatric beds. Sites included urban, suburban, and rural locations and were staffed by pediatric emergency medicine or general emergency medicine physicians. Greco and his colleagues published their findings on April 7 in Pediatrics.

The primary outcome was use of chest x-rays as a proportion of emergency visits for asthma, bronchiolitis, and croup. The researchers aggregated performance monthly at the test sites and then assessed improvement trends overall. They also assessed changes in emergency revisits for respiratory conditions within 72 hours and admission rates before and after the intervention.

Assessments included 114,238 respiratory visits. Networkwide use of chest x-rays dropped from 34.3% of all emergency respiratory visits at baseline to 21.1%. In sites that chose use of chest x-rays as an incentive measure, such imaging decreased from 32.5% to 19.2%.

Networkwide use of chest x-rays fell from 19.8% to 11.4% for patients without a potential indication for the scan and from 41% to 31.8% for patients who had a potential indication for an x-ray. The authors noted that the target for percentage use was originally 30% but that was adjusted down to below 20% as the achievable rate statewide became clearer with time across MEDIC sites.

Rates of emergency revisits for respiratory conditions did not change significantly from preintervention to postintervention (3.4% vs 3.6%; P = .22); admission rates increased modestly (21.5% vs 22.5%; P < .0001).

Intervention Components

The quality initiative had four main components: performance measurement, audit and feedback, a financial incentive program, and distribution of a quality improvement toolkit with clinical guidance on which patients with respiratory conditions typically do not require a chest x-ray.

The financial incentive program included two potential carrots. A pay-for-performance bonus was tied to aggregate hospital-level performance on a set of annual quality measures. Each MEDIC ED could choose pediatric chest x-rays as a measure of focus for the incentive. A second incentive, value-based reimbursement, rewarded individual clinicians with a higher reimbursement rate for meeting specific targets for a given initiative.

Benefit of Financial Incentives

“The incentive amounts depend on performance across a suite of quality measures. Exact dollar amounts or percentage adjustments were not available to the investigators,” Greco told Medscape Medical News. “Our results demonstrated that hospitals participating in the financial incentive program had better performance than hospitals that selected other incentive measures.” 

Shabnam Jain, MD, MPH, professor in the Department of Pediatrics at Emory University School of Medicine and Children’s Healthcare of Atlanta, said teasing out which component of the intervention was most important in decreasing chest x-rays was difficult. However, MEDIC, which has been in operation since 2015 and has the support of a large insurance company, may have played a large role, she said.

“It is in Blue Cross’ interest to reduce waste of any kind. In many projects focused on healthcare resource stewardship, the insurer is not usually involved this directly,” Jain, who was not involved in the new research, said.

MEDIC is managed by a coordinating center, which works with clinical champions and clinicians trained in data capture. “Having state-wide infrastructure like that does improve feasibility and scaling than doing one-off institutional projects,” she said.

Health Benefits of Fewer X-Rays

All providers should be concerned about reducing the numbers of chest x-rays, not just to cut healthcare costs, but more importantly, to reduce potential adverse effects such as radiation exposure, Jain said. Curbing the number of unnecessary chest x-rays also can influence downstream consequences such as overprescribing of antibiotics for findings that are often due to viruses, she noted.

While insurers often have a reputation for cutting costs and limiting options, Jain said, “when you collaborate with clinicians to create stewardship interventions using evidence-based principles, I think it’s the way to go.”

Support for MEDIC was provided by Blue Cross Blue Shield of Michigan and Blue Care Network as a part of the BCBSM Value Partnerships program.

Greco and Jain reported having no relevant financial conflicts of interest.

Marcia Frellick is a Chicago-based, independent healthcare journalist and a regular contributor to Medscape.