title: 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.
  
  
  METHODS
  A retrospective review was conducted of BC cases during the years 2012, 2014, and part of 2015. Patient, tumor and treatment characteristics were collected. Pre-operative MRI utilization was compared before and after care path implementation.
  
  
  RESULTS
  We identified 1,515 BC patients during the study period. Patients were more likely to undergo pre-operative MRI in 2012 than 2014 (OR: 2.77; P<0.001; 95% CI: 1.94-3.94) or 2015 (OR: 4.14; P<0.001; 95% CI: 2.51-6.83). There was a significant decrease in pre-operative MRI utilization between 2012 and 2014 (P<0.001) after adjustment for pre-operative MRIs ordered for care path indications.
  
  
  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.
authors.affiliation: Breast Services Department, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: Devina K S
authors.initials: DK
authors.lastname: McCray
authors.affiliation: Breast Services Department, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: Stephen R
authors.initials: SR
authors.lastname: Grobmyer
authors.affiliation: Breast Services Department, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: Holly J
authors.initials: HJ
authors.lastname: Pederson
keywords: Breast cancer (BC); care pathways; magnetic resonance imaging (MRI); pre-operative; value