National Trends in the Utilization of Skeletal Radiography From 2003 to 2015

PurposeExamine recent trends in the use of skeletal radiography and assess the roles of various nonradiologic specialties in the interpretations.MethodsMedicare Part B fee-for-service claims data files from 2003 to 2015 were analyzed for all Current Procedural Terminology, version 4 (CPT-4) procedure codes related to skeletal radiography. The files provide examination volume, and we calculated utilization rates per 1,000 Medicare beneficiaries. Medicare’s physician specialty codes were used to determine the specialties of the providers. Total utilization rate trends were analyzed, as well as those for radiologists and nonradiologists. We determined which nonradiologist specialties were the highest users of skeletal radiography. Medicare place-of-service codes were used to identify the locations where the services were provided.ResultsThe total utilization rate per 1,000 of skeletal radiography within the Medicare population increased 9.5% from 2003 to 2015. The utilization rate for radiologists increased 5.5% from 2003 to 2015 versus 11.1% for nonradiologists as a group. Among nonradiologist specialties in all health care settings over the study period, orthopedic surgeons increased 10.6%, chiropractors and podiatrists together increased 14.4%, nonphysician providers (primarily nurse practitioners and physician assistants) increased 441%, and primary care physicians’ rate decreased 33.5%. Although radiologists do almost all skeletal radiography interpretation in hospital settings, nonradiologists do the majority in private offices. There has been strong growth in skeletal radiography in emergency departments, but a substantial drop in inpatient settings.ConclusionsThe utilization of skeletal radiography has increased more rapidly among nonradiologists than among radiologists. This raises concerns about self-referral and quality.     

The effect of self-referral on utilization of advanced diagnostic imaging

OBJECTIVE: This article reviews the evidence on the relationship between recent increases in utilization of diagnostic imaging and self-referral. The evidence shows that self-referral invariably leads to higher utilization and the attendant higher costs. CONCLUSION: Because most physicians do not own advanced imaging equipment, their own best interests are being thwarted by the practice of self-referral. Congress and the Centers for Medicare and Medicaid Services should restrict the in-office ancillary services exception to the Stark laws as it applies to advanced imaging.     

Is terminology used effectively to convey diagnostic certainty in radiology reports?

RATIONALE AND OBJECTIVES: This study was performed to assess the extent of agreement among radiologists and nonradiologists in perception of diagnostic certainty conveyed by words and phrases commonly used in radiology reports. MATERIALS AND METHODS: The study was performed in a large academic radiology department. To determine the commonly used terminology for conveying diagnostic certainty in radiology reports, 12 randomly selected radiologists from six different subspecialties were interviewed. The authors identified the 15 most commonly used words and phrases and included these in random order in a questionnaire sent to all staff radiologists (n = 45) and to 158 referring physicians. Physicians were asked to rank the 15 phrases in order of the diagnostic certainty conveyed by each, from 1 (most certain) to 15 (least certain), using each number only once. The kappa statistic was used to assess agreement in rank order among physicians. RESULTS: The questionnaire response rate was 76% (n = 34) for radiologists and 49% (n = 78) for nonradiologists. There was excellent agreement among radiologists (kappa = 0.95) and nonradiologists (kappa = 0.93) in the rank order for the phrase diagnostic of. Although there was good agreement (kappa = 0.45) among radiologists for the word unlikely, agreement among nonradiologists was poor (kappa = 0.27). There was very poor agreement among all physicians for the rank order of the other 13 phrases. CONCLUSION: Among radiologists and nonradiologists, concordance was poor regarding the diagnostic certainty associated with phrases commonly used in radiology reports. Because poor agreement could lead to suboptimal quality of care, the standardization of terminology would benefit all parties.     

Turf wars in radiology: Other causes of overutilization and what can be done about it

The overutilization of noninvasive diagnostic imaging (NDI) is a complex problem with many other aspects aside from self-referral. This article discusses (1) other causes of overutilization, (2) the rationales used by nonradiologist physicians to justify self-referring their patients for NDI, (3) the extent of self-referral by radiologists (called “autoreferral” by some), and (4) steps that could be taken to curb the overutilization of NDI in the United States. It is important for radiologists to be familiar with these issues and to support efforts to control overutilization.     

The Impact of Nonphysician Providers on Diagnostic and Interventional Radiology Practices: Operational and Educational Implications

The numbers of nurse practitioners (NPs) and physician assistants (PAs) are increasing throughout the entire health care enterprise, and a similar expansion continues within radiology. The use of radiologist assistants is growing in some radiology practices as well. The increased volume of services rendered by this growing nonphysician provider subset of the health care workforce within and outside radiology departments warrants closer review, particularly with regard to their potential influence on radiology education and medical imaging resource utilization. In this article (the second in a two-part series), the authors review recent literature and offer recommendations for radiology practices regarding the impact NPs, PAs, and radiologist assistants may have on interventional and diagnostic radiology practices. Their potential impact on medical education is also discussed. Finally, staffing for radiology departments, as a result of an enlarging nonradiology NP and PA workforce ordering diagnostic imaging, is considered.     

The Imaging 3.0 Informatics Scorecard

Imaging 3.0 is a radiology community initiative to empower radiologists to create and demonstrate value for their patients, referring physicians, and health systems. In image-guided health care, radiologists contribute to the entire health care process, well before and after the actual examination, and out to the point at which they guide clinical decisions and affect patient outcome. Because imaging is so pervasive, radiologists who adopt Imaging 3.0 concepts in their practice can help their health care systems provide consistently high-quality care at reduced cost. By doing this, radiologists become more valuable in the new health care setting. The authors describe how informatics is critical to embracing Imaging 3.0 and present a scorecard that can be used to gauge a radiology group’s informatics resources and capabilities.     

Turf wars in radiology: The quality of interpretations of imaging studies by nonradiologist physicians—a patient safety issue?

Previous publications have demonstrated that in side-by-side testing, radiologists clearly outperform nonradiologist physicians at interpreting plain radiographs. Other articles, mostly in the nonradiologic literature, have shown that in actual practice settings, nonradiologist physicians make frequent errors in image interpretation. On the other hand, several other studies have concluded that such errors are infrequent and generally do not affect patient outcomes. However, most of the latter studies have had methodologic flaws. Radiologists need to be aware of the evidence that exists in the medical literature on errors made by nonradiologists in image interpretation and to bring it to the attention of hospital authorities or medical policy-making groups that are charged with improving patient safety.     

Current usage of nonionic contrast.

All physicians who had billed Pennsylvania Blue Shield for at least three intravenous contrast studies during 1989 were surveyed on their use of nonionic versus ionic contrast. This surveyed group represents a diversity of hospital sizes, practice types, and group sizes. Of the 383 physician groups surveyed, responses were obtained from 285. The majority of the responding groups were radiologists (94.0%). Nonionic contrast is utilized in 41.3% of all intravenous studies. Radiologists use nonionic contrast in a much greater proportion than nonradiologists (P < 0.0001), with 17.6% of radiologists utilizing nonionic contrast in all of their patients. Conversely, 75% of nonradiologists utilize ionic contrast in all of their patients. For all physician groups surveyed, 40.3% utilize nonionic for at least 50%, while 27.6% use nonionics for more than 75% of their patients. The routine use of steroid premedication prior to the injection of ionic contrast is not a common practice. The increased utilization of nonionic contrast found in this survey may reflect the cross-section of physicians and practice types surveyed or may represent changing practice patterns among physicians utilizing contrast material.     

Current usage of nonionic contrast

All physicians who had billed Pennsylvania Blue Shield for at least three intravenous contrast studies during 1989 were surveyed on their use of nonionic versus ionic contrast. This surveyed group represents a diversity of hospital sizes, practice types, and group sizes. Of the 383 physician groups surveyed, responses were obtained from 285. The majority of the responding groups were radiologists (94.0%). Nonionic contrast is utilized in 41.3% of all intravenous studies. Radiologists use nonionic contrast in a much greater proportion than nonradiologists (P < 0.0001), with 17.6% of radiologists utilizing nonionic contrast in all of their patients. Conversely, 75% of nonradiologists utilize ionic contrast in all of their patients. For all physician groups surveyed, 40.3% utilize nonionic for at least 50%, while 27.6% use nonionics for more than 75% of their patients. The routine use of steroid premedication prior to the injection of ionic contrast is not a common practice. The increased utilization of nonionic contrast found in this survey may reflect the cross-section of physicians and practice types surveyed or may represent changing practice patterns among physicians utilizing contrast material.     

Utilization of diagnostic medical imaging: comparison of radiologist referral versus same-specialty referral

PURPOSE: To retrospectively compare the frequency with which patients underwent diagnostic medical imaging procedures during episodes of outpatient medical care according to whether their physicians referred patients for imaging to themselves and/or physicians in their same specialty or to radiologists. MATERIALS AND METHODS: Institutional review board approval was not necessary for this HIPAA-compliant study. An insurance claims database from a large national employer-based health plan was obtained. Claims data from 1999-2003 were grouped into episodes of care for six conditions: cardiopulmonary disease, coronary and/or cardiac disease, extremity fracture, knee pain, intraabdominal malignancy, and stroke. For each condition, each referring physician's behavior was categorized as either "same-specialty referral" or "radiologist referral" on the basis of that physician's entire history of imaging referrals for the condition. The frequency with which patients underwent diagnostic medical imaging procedures during episodes of care was compared according to whether their physicians referred patients for imaging to themselves and/or same-specialty physicians or to radiologists. Rates were compared by using chi(2) tests, and logistic regression was used to compare utilization rates, with patient age and number of comorbidities as covariates. RESULTS: For the conditions evaluated, physicians who referred patients to themselves or to other same-specialty physicians for diagnostic imaging used imaging between 1.12 and 2.29 times as often, per episode of care, as physicians who referred patients to radiologists (P < .005 for all comparisons). Adjusting for patient age and comorbidity, the likelihood of imaging was 1.196-3.228 times greater for patients cared forby same-specialty-referring physicians. CONCLUSION: Same-specialty-referring physicians tend to utilize imaging more frequently than do physicians who refer their patients to radiologists. These results cannot be explained by differences in case mix (because analyses were performed within six specific conditions of interest), patient age, or comorbidity.     

Physician Self-Referral and Imaging Use Appropriateness: Negative Cervical Spine MRI Frequency as an Assessment Metric

BACKGROUND AND PURPOSE:Imaging self-referral is increasingly cited as a contributor to diagnostic imaging overuse. The purpose of this study was to determine whether ownership of MR imaging equipment by ordering physicians influences the frequency of negative cervical spine MR imaging findings.MATERIALS AND METHODS:A retrospective review was performed of 500 consecutive cervical spine MRIs ordered by 2 separate referring-physician groups serving the same geographic community. The first group owned the scanners used and received technical fees for their use, while the second group did not. Final reports were reviewed, and for each group, the percentage of negative study findings and the frequency of abnormalities were calculated. The number of concomitant shoulder MRIs was recorded.RESULTS:Five hundred MRIs meeting inclusion criteria were reviewed (250 with financial interest, 250 with no financial interest). Three hundred fifty-two had negative findings (190 with financial interest, 162 with no financial interest); there were 17.3% more scans with negative findings in the financial interest group (P = .006). Among scans with positive findings, there was no significant difference in the mean number of lesions per scan, controlled for age (1.90 with financial interest, 2.19 with no financial interest; P = .23). Patients in the financial interest group were more likely to undergo concomitant shoulder MR imaging (24 with financial interest, 11 with no financial interest; P = .02).CONCLUSIONS:Cervical spine MRIs referred by physicians with a financial interest in the imaging equipment used were significantly more likely to have negative findings. There was otherwise a highly similar distribution and severity of disease between the 2 patient samples. Patients in the financial interest group were more likely to undergo concomitant shoulder MR imaging.

United States health care expenditures grew 3.9% in 2011, reaching $2.7 trillion or an estimated 17.9% of the gross domestic product.¹ Health care spending is projected to continue to grow in 2012 and 2013 at 4.2% and 3.8%, respectively.² Diagnostic imaging costs remain a large component of annual health care expenditures and have, therefore, been targeted in an effort to contain costs. While the proportion of growth in health care expenditures attributable to diagnostic imaging use has decreased considerably in recent years, medical imaging use among nonradiologist physicians continues to increase at a growth rate twice that of radiologists and remains a significant contributor to higher imaging use and cost.³Imaging self-referral is defined as physicians referring their own patients for imaging to facilities in which they or their partners have financial interests.^4–6 In 1991, Medicare fraud-and-abuse legislation was passed in an effort to curb the rising tide of medical imaging self-referral. Commonly referred to as the “Stark II law” after the primary author Representative Fortney “Pete” Stark (Democrat, California), the legislation bans physician referrals to entities in which they have a financial relationship.⁷ However, the inclusion of an in-office ancillary services exception (created with patient convenience in mind) permits physicians to both order and provide advanced imaging services for patients in their office. As a result, despite the presence of the Stark law, physician self-referral of medical imaging has continued to grow substantially.⁸Critics of the practice of self-referral have asserted that it leads to overuse of diagnostic imaging and is, therefore, an important contributor to rising health care costs. In support of this argument, several previously published studies have demonstrated that the practice of imaging self-referral is increasing, that physicians who own diagnostic imaging equipment are more likely to refer their patients for imaging at facilities in which they have a financial interest, and that self-referral by nonradiologist physicians leads to higher overall imaging use.^9–18 However, despite the growing body of literature documenting these findings, the conclusion that self-referral leads to inappropriate medical imaging use, or overuse, remains a topic of debate. This is, in part, secondary to the inherent challenges researchers face in demonstrating the similarity between 2 compared groups of patients, particularly with regard to rates and severity of disease, insurance status, and clearly discerning the financial arrangements of imaging equipment ownership.Criticisms of prior studies linking imaging self-referral to overuse have focused on their inadequate consideration of use appropriateness. Determining the appropriateness of medical imaging use is a complex and challenging task confounded by multiple factors, including patient population (payer and insurance status and regional geographic differences), clinical setting (hospital versus outpatient practice), disease prevalence (young versus elderly), referral biases (eg, specialist versus primary care), diagnostic interpretation inhomogeneity (discordant “grading” of lesions) and terminology, or skill differences among interpreting radiologists. In many scenarios, these factors become uncontrollable variables that complicate attempts to compare the appropriateness of referrals for medical imaging between groups of physicians, including between groups with and without financial relationships to the medical imaging equipment. Prior effort has evaluated differences in the volume of patients referred for medical imaging between the 2 groups based on International Classification of Diseases-9 diagnosis codes and use per patient encounter. This approach has flaws because both the proportion of examinations with normal findings and the differences in prevalence and severity of disease between the 2 compared groups are not evaluated. Without this additional information, comparisons of relative use may be feasible, but not the appropriateness of imaging use.Comparing the proportion of imaging examinations with negative findings, after controlling for potential confounding variables, would allow an accurate assessment of the differences in imaging referral patterns between the 2 physician groups (financially incentivized and nonfinancially incentivized). This would not only validate previously published studies on imaging appropriateness but also add to the existing body of literature addressing the issue of self-referral. Furthermore, an analysis of the prevalence and severity of imaging-confirmed pathology between these groups may serve as a surrogate for disease prevalence and overall severity within the 2 different patient populations, because groups with equal disease prevalence and severity should manifest an equivalent number of positive imaging findings.The purpose of this study was to determine whether ownership of MR imaging equipment by an ordering physician group affects the use of cervical spine MR imaging. This was accomplished by comparing the likelihood of negative cervical spine MR imaging findings and the cervical spine MR imaging pathology rates between the 2 groups. We wished to test the null hypothesis that no such difference exists and that usage patterns are the same. This was accomplished via evaluation of 2 subordinate hypotheses: 1) There is no difference in the rate of examinations with negative findings between self-referred and non-self-referred MR imaging examinations, and 2) among examinations with positive findings, there are no differences in the prevalence of individual pathology subtypes between the 2 groups. We considered that no difference in the first would indicate that no excess ordering of examinations occurred in either group and that no difference in the second would mean that the 2 patient groups were highly similar with regard to the rate and type of pathology.     

Diagnostic and Interventional Imaging Services are Significant Sources of Medicare Revenue for Highly Reimbursed Nonradiologist Providers

IntroductionNonradiologist providers increasingly perform diagnostic imaging examinations and imaging-guided interventions traditionally performed by radiologists, which have raised concerns regarding appropriate utilization and self-referral. The purpose of this study was to assess the contribution of imaging studies to Medicare reimbursements for highly compensated nonradiologist providers in specialties often performing imaging studies.MethodsThe Medicare Provider Utilization and Payment Database was queried for provider information regarding overall reimbursement for providers in anesthesiology, cardiology, emergency medicine, neurology, obstetrics and gynecology, orthopedic surgery, neurology, and vascular surgery. Information regarding imaging studies reported and payment amounts were extracted for the 25 highest-reimbursed providers. Data were analyzed for relative contribution of imaging payments to overall medical Medicare payments.ResultsSignificant differences between numbers of imaging studies, types of imaging, and payment amounts were noted based on provider specialty (p < 0.001). Highest-reimbursed cardiologists received the greatest percentage of Medicare payments from imaging (18.3%) followed by vascular surgery (11.6%), obstetrics and gynecology (10.9%), orthopedic surgery (9.6%), emergency medicine (8.7%), neurology (7.8%), and anesthesiology (3.2%) providers. Mean imaging payments amongst highly reimbursed nonradiologists were greatest for cardiology ($578,265), vascular surgery ($363,912), and orthopedic surgery ($113,634). Amongst highly reimbursed specialists, most common nonradiologist imaging payments were from ultrasound (45%) and cardiac nuclear medicine studies (40%).ConclusionsNonradiologist performed imaging payments comprised substantial proportions of overall Medicare reimbursement for highly reimbursed physicians in several specialties, especially cardiology, vascular surgery, and orthopedic surgery. Further investigation is needed to better understand the wider economic implications of nonradiologist imaging study performance and self-referral beyond the Medicare population.     

The socioeconomic aspects of information technology for health care with emphasis on radiology

RATIONALE AND OBJECTIVES: Information technology is the key to cost effective and error free medical care in the United States and the only problem is that there is not enough of it yet. During the past 15 years, billions of dollars have been spent on information technology for health care with very little benefit but significant adverse effects on patients, physicians, and nurses. The truth about health care information technology (HIT) probably lies somewhere between these extreme statements, representing technophile and skeptical views, respectively. MATERIALS AND METHODS: There is no doubt that computer and communication hardware has reached a state of sophistication and availability in which any and all necessary information can be generated, stored, and distributed to health care workers in support of their patient care tasks. The barriers to rapid and widespread development and diffusion of cost effective and practically useful HIT are exclusively related to human factors. RESULTS: This article explores some of the organizational, cultural, cognitive, and economic forces that interact to influence success of HIT initiatives in health care organizations. A key point to be recognized is that the intrinsically handcrafted nature of health care work combined with high degrees of complexity and contingency make it impossible to "computerize" with the same ease and completeness of other industries. The major thrust of the argument is that designers of information systems and health care informatics managers must meet needs of patients and care providers. The software they create and implement should promote, support, and enhance the existing processes of health care rather than seeking to dictate how direct care providers should do their work. CONCLUSIONS: Instead of looking for "buy in" from physicians and nurses, the informatics community must return the authority over functional specification of patient care information systems to them--where it belonged in the first place. This same lesson about computer technology and organizational politics is also being learned in the business community, where executives are reclaiming responsibility for mission critical informatics decisions.     

Sources and resources for oncologists to help answer the question: is PET/CT appropriate for my patient?

Positron emission tomography (PET)/computed tomography (CT)-subsequently referred to as PET/CT is emerging as a critically important diagnostic tool in oncology. There has been a substantial increase in the utilization of this modality over the last decade. The optimal imaging protocols are, however, still not established which results in considerable confusion and uncertainty among referring physicians and providers. Oncologists, hematologists and other physicians managing oncologic patients frequently face the dilemma of whether or not to order a PET/CT scan for their patients. The large body of evidence from clinical research often overwhelms the ability of physicians to stay adequately informed on the disease specific performance of PET/CT. Moreover, regulatory agencies have changed their requirements for reimbursement of PET/CT scans in an effort to curtail health care expenditures. In this article we attempt to inform users and providers about the appropriate use of this technology.     

Racial and Ethnic Disparities in Radiology: A Call to Action

The US health care system is in the midst of incredible transformation. High-value, high-quality health care is the ultimate goal. Guided by the Institute of Medicine report “Crossing the Quality Chasm,” the focus is to deliver care that is safe, efficient, effective, timely, patient centered, and equitable. Equity is the principle that quality of care should not vary based on patient characteristics, such as race or ethnicity. Even with the same insurance and socioeconomic status and when comorbidities, stage of presentation, and other confounders are controlled for, minorities often receive a lower quality of health care than their white counterparts. These racial and ethnic disparities in quality of care contribute to disparities in health outcomes and higher costs. Radiology is not exempt from this issue, as disparities related to imaging services have been reported in the literature. The root causes of racial and ethnic disparities in health care are complex and include the negative impact of the social determinants of health, limited access to care, as well as health system, provider, and patient factors. The field of radiology has a unique opportunity to engage in efforts to improve quality, address disparities, and achieve equity. A call to action is necessary, with a focus on addressing social determinants of health; creating culturally, linguistically, and health literacy-appropriate outreach and services; investing in cross-cultural education; and diversifying the radiology workforce. Ultimately, radiologists can provide equitable access to radiology care and promote person-centered care solutions that are tailored to the needs of diverse populations.     

Effectiveness of resident-prepared conferences in teaching imaging utilization guidelines to radiology residents

RATIONALE AND OBJECTIVES: The authors evaluated the effectiveness of a resident-prepared conference series for teaching imaging utilization guidelines to radiology residents. MATERIALS AND METHODS: Brown University radiology residents (n = 17) gave 61 presentations on imaging utilization to their colleagues during 16 1-hour conferences. The residents were later examined on the topics presented and surveyed about their familiarity with the American College of Radiology appropriateness criteria, their exposure to issues of cost-effectiveness, and their degree of confidence in providing imaging consultation. The same examination and survey were administered to control residents from the University of Wisconsin (n = 14) and the Oregon Health Sciences University (n = 14). Scores were compared by using linear regression and Wilcoxon rank sum tests. RESULTS: Controlling for years in radiology residency, residents at Brown scored on average 16.0% (standard error = 2.2%) higher than residents at the other universities (P < .001). Controlling for institution, 3rd- and 4th-year residents scored on average 7.4% (standard error = 2.1%) higher than 1st- and 2nd-year residents (P = .001). Brown residents expressed more familiarity with American College of Radiology appropriateness criteria and appeared to have more exposure to cost-effectiveness issues in conferences than residents at Wisconsin or Oregon Health Sciences University (P < .005). Residents from the three universities did not differ in their level of confidence in providing imaging consultation. CONCLUSION: Resident-prepared conferences are an effective means of teaching imaging utilization guidelines to residents, but they do not affect the residents' perception of their ability to provide imaging consultation.     

Trends in Outpatient MRI Seem to Reflect Recent Reimbursement Cuts

PurposeTo determine whether recent reimbursement cuts have resulted in a shift of outpatient MRI from private offices to hospital outpatient departments (HOPDs); and to study office MRI utilization trends among radiologists and other specialists.MethodsThe Medicare Part B Physician/Supplier Procedure Summary Master Files were used. MRI codes were aggregated, and total MRI volumes from 2002 to 2012 were studied. Medicare place-of-service codes were used to identify studies performed in private offices and HOPDs and create trend lines. Specialty codes were used to categorize private office MRI users as radiologists, orthopedic surgeons, other physicians, and independent diagnostic testing facilities.ResultsMedicare office and HOPD utilization of MRI (all specialties) rose rapidly from 2002 to 2006, reaching 2,727,807 in offices and 2,355,641 in HOPDs. Thereafter, office volume steadily declined, whereas HOPD volume steadily increased. By 2012, more studies were done in HOPDs than in offices. Over the entire period from 2002 and 2012, office MRI volume among radiologists increased 27%, compared with 216% among orthopedic surgeons and 124% among other physicians.ConclusionsAlthough the majority of Medicare outpatient MRI studies had previously been performed in private offices, recent years brought a shift, with more now being performed in HOPDs. This change will increase costs to payers, because reimbursements to HOPDs are generally higher than those to offices. Although radiologists perform the majority of MRI exams that are conducted in private offices, the rate of growth for such exams from 2002 to 2012 was considerably higher among orthopedic surgeons and other physicians than among radiologists.