The formal radiology consultation service: an old idea whose time has come.

“If we physicians cannot alter expensive and sometimes irrational patterns of practice, changes will be imposed by a bureaucracy much less interested in the quality of patient care, the morale of physicians, on the future of diagnostic imaging” [1]. This concluding statement in a 1984 AJR editorial about radiology consultation seems eerily predictive of today’s initiatives to redesign our health care delivery system, motivated in large part by upwardly spiraling costs. Whereas in 1977, health care consumed 7% of the gross national product in the United States, today the figure approaches 14%. Diagnostic imaging represents only a tiny fraction of total national expenditures for health care, but we are now in an era when costs in every segment of the health care industryparticularly those that are seen as “high tech”-ane under intense scrutiny. The current campaign to contain costs naturally targets those areas thought to represent wasteful inefficiencies in the system, where health cane dollars can be saved without compromising the quality of care. The radiology consultation service described in this issue of the AJR by Khorasani et al. [2] offers the promise of such cost savings. Like “practice parameters” or “clinical pathways,” a radiology consultation service can provide the type of efficient clinical care for which health care regulators and providers are searching. The formal radiology consultation service is not a new idea. The concept was first developed and reported in 1979 by a group at the University of Vermont, who proposed that the radiologist assume a leadership role in designing imaging workups in complex cases [3]. As in the article by Khorasani et al., when the radiology department was asked by the clinical service for help in creating an imaging wonkup, a resident would review the patient’s problem list, the clinical findings, medical history, and results of previous imaging tests and then examine the patient, if necessary. The therapeutic expectations of the patient and the involved physicians were then reviewed and the case discussed with the appropriate staff radiologist. The proposed imaging workup was based on up-to-date publications and on local expertise; it was communicated to the requesting service on the same day both by phone and by a formal note of consultation in the chart. As the patient progressed through the workup, results were reviewed daily in order to modify the algorithm on the basis of new information. Although the Vermont group reported no data on the impact of this service, they encouraged others to offer formal consultation because of perceived efficiencies. In 1984, Baker et al. [4] reported the results of a similar radiology consultation service at Albert Einstein College of Medicine. This group described a 64% reduction in time to diagnosis and a 32% reduction in number of imaging studies for patients with pain in the right upper quadrant, gastrointestinab bleeding, or an abdominal mass. In a 1986 article by Baker and Stein [5], radiology consultation reduced the average length of hospital stay by 2.8 days. As is well known, the technology explosion in imaging has accelerated in the years since these reports were published. The current promise of still greaten dollar savings than reported in 1 984 and 1986 is almost certain. The initial enthusiasm for formal radiology consultation as a mechanism to make complex imaging workups more effi-