Impact of value based breast cancer care pathway implementation on pre-operative breast magnetic resonance imaging utilization

Abstract

Background: Bilateral breast magnetic resonance imaging (MRI) is commonly used in the diagnostic workup of breast cancer (BC) to assess extent of disease and identify occult foci of disease. However, evidence for routine use of pre-operative MRI is lacking. Breast MRI is costly and can lead to unnecessary tests and treatment delays. Clinical care pathways (care paths) are value-based guidelines, which define management recommendations derived by expert consensus and available evidence based data. At Cleveland Clinic, care paths created for newly diagnosed BC patients recommend selective use of pre-operative MRI. We evaluated the number of pre-operative MRIs ordered before and after implementing an institution wide BC care paths in April 2014. Conclusions: Implementation of online BC care paths at our institution was associated with a decreased use of pre-operative MRI overall and in patients without a BC care path indication, driving value based care through the reduction of pre-operative breast MRIs.

Bilateral breast cancers in an Asian population, and a comparison between synchronous and metachronous tumours

“…Although not routine in our institution, some centres provide routine magnetic resonance imaging of breasts for patients with newly diagnosed breast cancer, especially for those who opt for breast‐conserving surgery. The clinical benefit of routine magnetic resonance imaging of breasts as a preoperative workup has yet to be appreciated, although it has its uses for multifocal, multicentric tumours, selected tumour pathologies (e.g. lobular carcinomas), and may be useful in the Asian setting where the average Asian woman with breast cancer tends to be younger and possesses denser breasts.…”

“…The clinical benefit of routine magnetic resonance imaging of breasts as a preoperative workup has yet to be appreciated, 27 although it has its uses for multifocal, multicentric tumours, selected tumour pathologies (e.g. lobular carcinomas), and may be useful in the Asian setting where the average Asian woman with breast cancer tends to be younger and possesses denser breasts.…”

The implementation of value-based healthcare: a scoping review

“…In 15 articles, the concept of VBHC was defined by reference to its value or its goals only, without defining the VBHC concept. Six conceptualized value in VBHC [26][27][28][29][30][31], six conceptualized goals of VBHC [7,[32][33][34][35][36] and three conceptualized both value and goals in VBHC [37][38][39]. The remaining articles (N = 11) did not include a conceptualization of VBHC [40][41][42][43][44][45][46][47][48][49][50].…”

“…The studies that measured the effects of implementing both 'measure outcomes and costs for every patient' and 'organize into IPUs' (N = 6) reported: increased patient satisfaction [40], decreased length of stay [40,44], increased quality of life [18], reduced costs [14,26] and decreased healthcare utilization [35]. The studies (N = 2) that measured the effects of 'organize into IPUs' , showed an increase in quality adjusted life years and financial benefit for the provider [19]; and a decrease in pre-operative MRIs [33]. The implementation of bundled payments (N = 2) led to a decrease in patients admitted to skilled nursing facilities [50], total medical expenditure [34] and length of stay [50].…”

Mastectomy Flap Thickness and Complications in Nipple-Sparing Mastectomy: Objective Evaluation using Magnetic Resonance Imaging

“…Preoperative breast MRI may be utilized in breast cancer screening or in the diagnostic work-up of known breast cancer. 49 , 50 Postoperative MRI after surgical management of breast cancer is less commonly utilized in infrequent cases of potential residual breast tissue or in the work-up of palpable masses. 51 , 52 …”