A scheme that rewards radiologists for promptly sending final reports to referring physicians could cut turnaround times by half, according to a new study.

The results lasted even after the program stopped, suggesting a change in office culture, and not just the dangling of a financial carrot, made the difference.

The study, published Friday in the September issue of the American Journal of Roentgenology, followed a program at Massachusetts General Hospital in Boston from 2006 to 2009. The program was launched after the hospital got complaints from referring physicians that preliminary reports were often left unsigned by staff radiologists, sometimes for days.

Preliminary reports are prepared by residents or fellows, under supervision of staff radiologists, after the completion of an exam. While referring doctors can use them, the reports often undergo editing during the radiologist's final review, according to Dr. Giles Boland, associate professor of radiology at Harvard Medical School, vice chairman of the department of radiology at Massachusetts General and lead author of the study.

"It's generally accepted while a preliminary report is OK, it's not the final say," he told DOTmed News.

To speed up turnaround times from generation of preliminary reports to the final signing, the program offered a reward of $2,500 every six months and $5,000 annually if radiologists had a turnaround time of less than 24 hours, investigated in a randomly chosen one-month period. After one year, the turnaround requirement was reduced to eight hours, and the annual reward cut in half.

Ultimately, the researchers examined 99,959 reports in a baseline period roughly three months before the program started, 104,673 in the months immediately following implementation of the program, and 91,379 reports after the two-year program had stopped.

The average time from getting the preliminary report to final signing-off fell dramatically, from 23 hours before the program started to 13 hours a few months after it was initiated, to four hours, two years after it ended.

Intriguingly, the entire process sped up, even though radiologists were only rewarded for the preliminary report-to-signature part. The time from completing the radiological exam to generating the preliminary report fell from 20 hours before the program to 12 hours two years later; and the total time - from completion of exam to final signing - fell by more than half, from 43 hours before the program to 32 hours shortly after the reward system started, and 16 hours after it ended.

There was wide variation among disciplines, though. For instance, emergency room radiologists had a baseline preliminary report-to-final signing time of nine hours, on average; after the pay-for-performance program started, it fell to an average of two hours. But for neurovascular radiologists, the baseline time was nearly three days. (It fell to about half a day after the study.)

Neuroradiologists, interventional and otherwise, were also the only discipline allowed to continue to have a 24-hour, and not an eight-hour window, a year after the program started. Their exams tend to be extremely complex, multi-hour affairs, Boland said.

But the differences among disciplines probably are not only owed to procedural complexity. It also has to do with the culture of the departments, Boland suggests. Chest radiologists and gastrointestinal radiologists have similar workloads, Boland and his co-authors argue. Yet chest radiologists had an after-program preliminary-to-final report time of around one hour, on average, whereas gastrointestinal rads took nearly five times as long.

Boland, who works in the GI department, credits the difference to culture. Cultural change can also help explain one of the study's most curious findings--that the greatest change was seen after the program ended when radiologists were no longer rewarded for bringing their turnaround times down.

What exactly brought this about, the researchers don't know, but perhaps "simply discussing the importance of an expedited [radiologist report turn-around times] to the radiologists in a more formalized and consistent manner (as was the case in this study) may have influenced some radiologists to be more attentive and diligent in signing their reports from a preliminary to a finalized status," the researchers wrote.

"The other piece is that now we've set up the expectation from referring physicians," Boland said, many of whom got used to reports being available the same day. "They start looking for the reports online, and if it doesn't come out, they start bugging us."

While the findings might not apply outside of an academic teaching hospital to private imaging centers - where competing radiologists often use their fast turnaround times as a sales point - it does hint that pay-for-performance schemes can be more about awareness-raising than anything else.

"There's a lot of psychology going on here," Boland said. "It's not completely understandable why and how it happened, and I think some of these things are tangible and some are intangible."