Teaching hospital documents the pros and cons of going to overnight attending rad coverage

In 2013 Boston Medical Center, a 496-bed teaching hospital affiliated with Boston University, bit the bullet and rolled out 24/7 in-house attending radiology with an eye on improving patient care. The bitten bullet ended up carrying an annual price tag of $850,000. Have the returns been worth the investment?

Yes and no, report Stephanie Coleman, MD, and BU radiology colleagues in the July-August edition of Current Problems in Diagnostic Radiology.

The researchers describe their work evaluating the effects of the change on, most specifically, turnaround times (TATs) and work relative value units (wRVUs) before and after the transition.

The team also looked at radiology residents’ perceptions of the new arrangement—which affected their familiar processes for providing preliminary reads—and considered the logistics needed to launch and sustain 24/7 attending coverage.

The authors point out that their research comes at a time when many radiology practices, including academic centers, are moving to in-house 24/7 attending coverage.

In survey phases of the research project, 65 radiologists responded to a preimplementation survey (22 attendings, 30 residents, 13 unspecified), while 55 responded to a postimplementation survey (20 attendings, 1 fellow, 24 residents, 10 unspecified).

Examined imaging modalities included radiography, CT, MRI and ultrasound.

Among the team’s key findings:

• Turnaround times: Before 24/7 implementation, the TAT for CT was 11:57, for radiography 4:22, for MRI 10:00, and for ultrasound 8:04. Postimplementation, the TAT for CT was 3:46 (69 percent reduction), for radiography 2:29 (43 percent reduction), for MRI 9:22 (7 percent reduction), and for ultrasound 4:34 (43 percent reduction).
• Work RVUs: The daytime neuroradiology section experienced a decrease in wRVUs of 11 percent (from 24,841.28 to 22,127.66). The emergency radiology section experienced a 6 percent decrease in wRVUs (from 18,709.92 to 17,625.72).

In their section summarizing their findings in qualitative analysis, Coleman et al. note that they recorded consensus among radiologists around the sense that in-house overnight attending availability did indeed add value to patient care while also occasioning a sense of increased patient safety.

Further, overnight attendings noticed high appreciation among clinicians for speedy final reports. The most grateful specialty department here may have been surgery, whose members “need to decide whether their patients should undergo surgery at night or not,” the authors write.

Previous research has shown that working long overnight hours can bring on fatigue and diminished diagnostic agility, but the attendings in the current study did not bear that out.

In their discussion, Coleman and colleagues state that their study shows how it is that a 24/7 in-house attending coverage system can have both positive and negative effects.

There were measurable improvements of report TAT and wRVU metric performance, they stress, along with perceived increased clinician satisfaction.

“The work climate for residents at night was improved, but there was some loss of trainee independence,” the authors add. “There were concerns regarding the quality of overnight attending interpretations in areas that they were not specifically fellowship trained in, such as neuroimaging.”

Somewhat surprisingly, the residents—who early on expressed concerns over loss of independence and call autonomy by having attendings on the premises at all hours—did not reiterate this perceived concern in the postimplementation survey.

Among the limitations the authors acknowledge: They were unable to ascertain the effect of 24/7 coverage on metrics that have a direct bearing on patient care.

Coleman and team conclude that the initiative “came at a significant financial cost, in our example of $850,000”—which was mostly additional salary—“although it is too early to derive cost-effectiveness calculations from the expense or to derive quantifiable added financial benefits.”

The decrease in delays between preliminary and final reports under a 24/7 in-house attending system “may improve emergency and inpatient department workflows and liability exposure, but there is currently a paucity of measurable metrics to support this assumption,” they add. “In the future, measurable effects on resident education and patient care would be of significant interest in both understanding and supporting 24/7 attending radiologist in-house implementation.”