Characteristics of COVID-19 Community Practice Declines in Noninvasive Diagnostic Imaging Professional Work

PurposeThe operational and financial impact of the widespread coronavirus disease 2019 (COVID-19) curtailment of imaging services on radiology practices is unknown. We aimed to characterize recent COVID-19-related community practice noninvasive diagnostic imaging professional work declines.MethodsUsing imaging metadata from nine community radiology practices across the United States between January 2019 and May 2020, we mapped work relative value unit (wRVU)-weighted stand-alone noninvasive diagnostic imaging service codes to both modality and body region. Weekly 2020 versus 2019 wRVU changes were analyzed by modality, body region, and site of service. Practice share χ² testing was performed.ResultsAggregate weekly wRVUs ranged from a high of 120,450 (February 2020) to a low of 55,188 (April 2020). During that −52% wRVU nadir, outpatient declines were greatest (−66%). All practices followed similar aggregate trends in the distribution of wRVUs between each 2020 versus 2019 week (P = .96-.98). As a percentage of total all-practice wRVUs, declines in CT (20,046 of 63,992; 31%) and radiography and fluoroscopy (19,196; 30%) were greatest. By body region, declines in abdomen and pelvis (16,203; 25%) and breast (12,032; 19%) imaging were greatest. Mammography (−17%) and abdominal and pelvic CT (−14%) accounted for the largest shares of total all-practice wRVU reductions. Across modality-region groups, declines were far greatest for mammography (−92%).ConclusionsSubstantial COVID-19-related diagnostic imaging work declines were similar across community practices and disproportionately impacted mammography. Decline patterns could facilitate pandemic second wave planning. Overall implications for practice workflows, practice finances, patient access, and payment policy are manifold.     

Increased per-patient imaging utilization in an emergency department setting during COVID-19

IntroductionCOVID-19 has resulted in decreases in absolute imaging volumes, however imaging utilization on a per-patient basis has not been reported. Here we compare per-patient imaging utilization, characterized by imaging studies and work relative value units (wRVUs), in an emergency department (ED) during a COVID-19 surge to the same period in 2019.MethodsThis retrospective study included patients presenting to the ED from April 1–May 1, 2020 and 2019. Patients were stratified into three primary subgroups: all patients (n = 9580, n = 5686), patients presenting with respiratory complaints (n = 1373, n = 2193), and patients presenting without respiratory complaints (n = 8207, n = 3493). The primary outcome was imaging studies/patient and wRVU/patient. Secondary analysis was by disposition and COVID status. Comparisons were via the Wilcoxon rank-sum or Chi-squared tests.ResultsThe total patients, imaging exams, and wRVUs during the 2020 and 2019 periods were 5686 and 9580 (−41%), 6624 and 8765 (−24%), and 4988 and 7818 (−36%), respectively, and the percentage patients receiving any imaging was 67% and 51%, respectively (p < .0001). In 2020 there was a 170% relative increase in patients presenting with respiratory complaints. In 2020, patients without respiratory complaints generated 24% more wRVU/patient (p < .0001) and 33% more studies/patient (p < .0001), highlighted by 38% more CTs/patient.ConclusionWe report increased per-patient imaging utilization in an emergency department during COVID-19, particularly in patients without respiratory complaints.     

Importance of First and Second Authorship in Assessing Citation-Based Scholarly Activity of US Radiation Oncology Residents and Subsequent Choice of Academic Versus Private Practice Career

PurposeThe Hirsch index (h-index) has been shown to correlate with radiation oncology residents’ having a first job in academics versus private practice, but it is limited by its inability to distinguish between the differing significance of coauthor roles in articles.MethodsA list of 2016 radiation oncology resident graduates and their postresidency career choices was compiled. The Scopus bibliometric citation database was then searched to collect h-index data for articles limited to first author only (h_f) and first or second-author only (h_s) for each resident.ResultsMean h_f was 2.06 for all resident graduates, and mean h_s was 2.77. Residents with PhDs had significantly higher h_f (3.11 versus 1.76, P < .01) and h_s (4.50 versus 2.28, P < .01). There was no statistically significant difference between male and female residents for h_f (2.19 versus 1.61, P = .11) or h_s (2.91 versus 2.25, P = .15). Residents choosing academia had higher h_f (2.72 versus 1.44, P < .01) and h_s (3.57 versus 2.01, P < 0.01) than those in private practice. Fewer than 20% of graduates with h_f = 0 and only 10% of graduates with h_s = 0 secured academic jobs.ConclusionThe average radiation oncology resident graduate has published a minimum of two first- and/or second-author articles cited at least twice. Graduates with PhDs and/or choosing academic careers were more likely to have higher h_f and h_s scores; there was no significant score difference by gender. Only 10% of graduates without any first- and/or second-author articles cited at least once secured academic jobs. These findings indicate that stratifying publications by first or second authorship when developing benchmarks for evaluating resident productivity and postresidency career type may be useful.     

COVID-19 and Breast Radiologist Wellness: Impact of Gender,Financial Loss,and Childcare Need

PurposeThe purpose of this study was to evaluate the emotional and financial impact of coronavirus disease 2019 (COVID-19) on breast radiologists to understand potential consequences on physician wellness and gender disparities in radiology.MethodsA 41-question survey was distributed from June to September 2020 to members of the Society of Breast Imaging and the National Consortium of Breast Centers. Psychological distress and financial loss scores were calculated on the basis of survey responses and compared across gender and age subgroups. A multivariate logistic model was used to identify factors associated with psychological distress scores.ResultsA total of 628 surveys were completed (18% response rate); the mean respondent age was 52 ± 10 years, and 79% were women. Anxiety was reported by 68% of respondents, followed by sadness (41%), sleep problems (36%), anger (25%), and depression (23%). A higher psychological distress score correlated with female gender (odds ratio [OR], 1.9; P = .001), younger age (OR, 0.8 per SD; P = .005), and a higher financial loss score (OR, 1.4; P < .0001). Participants whose practices had not initiated wellness efforts specific to COVID-19 (54%) had higher psychological distress scores (OR, 1.4; P = .03). Of those with children at home, 38% reported increased childcare needs, higher in women than men (40% versus 29%, P < .001). Thirty-seven percent reported that childcare needs had adversely affected their jobs, which correlated with higher psychological distress scores (OR, 2.2-3.3; P < .05).ConclusionsPsychological distress was highest among younger and female respondents and those with greater pandemic-specific childcare needs and financial loss. Practice-initiated COVID-19-specific wellness efforts were associated with decreased psychological distress. Policies are needed to mitigate pandemic-specific burnout and worsening gender disparities.     

Historic Physician Quality and Reporting System Reporting by Radiologists: A Wake-up Call to Avoid Penalties Under the Medicare Access and CHIP Reauthorization Act (MACRA)

PurposeThe Medicare Access and CHIP Reauthorization Act (MACRA) Quality performance category is the successor to the Physician Quality and Reporting System (PQRS) program and now contributes to physicians’ income adjustments based upon performance rates calculated for a minimum of six measures. We assess radiologists’ frequency of reporting PQRS measures as a marker of preparedness for MACRA.MethodsMedicare-participating radiologists were randomly searched through the Physician Compare website until identifying 1,000 radiologists who reported at least one PQRS measure. Associations were explored between the number of reported measures and radiologist characteristics.ResultsFor PQRS-reporting radiologists, the number of reported PQRS measures was 1 (25.2%), 2 (27.3%), 3 (18.2%), 4 (19.3%), 5 (8.3%), and 6 (1.7%). The most commonly reported measures were “documenting radiation exposure time for procedures using fluoroscopy” (64.3%) and “accurate measurement of carotid artery narrowing” (56.8%). Reporting at least two measures was significantly (P < .001) more likely for nonacademic (77.3%) versus academic (44.9%) radiologists, generalists (82.7%) versus subspecialists (59.1%), and radiologists in smaller (≤9 members) (84.7%) versus larger (≥100 members) (39.7%) practices. Reporting six measures was significantly (P < .05) more likely for generalists (2.6%) versus subspecialists (0.4%).ConclusionMost PQRS-reporting radiologists reported only one or two measures, well below MACRA’s requirement of six. Radiologists continuing such reporting levels will likely be disadvantaged in terms of potential payment adjustments under MACRA. Lower reporting rates for academic and subspecialized radiologists, as well as those in larger practices, may relate to such radiologists’ reliance on their hospitals or networks for PQRS reporting. Qualified clinical data registries should be embraced to facilitate more robust measure reporting.     

Trends in Medicare Reimbursement and Work Relative Value Unit Production in Radiation Oncology

PurposeMedicare payments to individual physicians are released annually by the CMS. The purpose of this study is to analyze trends in Medicare reimbursement and work relative value unit (wRVU) production to radiation oncologists.Materials and MethodsThe Medicare Physician Supplier and Other Provider Public Use File and the CMS Physician Fee Schedule Relative Value Files (to calculate wRVUs) for the calendar years 2012 to 2015 were used in this analysis. Medicare reimbursement was aggregated for each calendar year. Using the CMS Physician Fee Schedule Relative Value Files, the number of Medicare wRVUs was calculated for each radiation oncologist.ResultsIn 2015, 4,323 radiation oncologists produced 12,895,298 wRVUs compared with 11,352,286 wRVUs produced in 2012. These datasets include only Medicare reimbursements and do not include wRVUs from private insurance or other payers. In 2015, radiation oncologists produced a median of 2,486 wRVUs from Medicare (range 3 to 24,349). Billing to Healthcare Common Procedure Coding System Code 77427 (radiation treatment management, five treatments), a proxy for total radiation treatments, fell from 1,111,670 in 2012 to 1,039,403 in 2015, a decline of 7%.ConclusionThe total number of wRVUs produced by radiation oncologists has risen by 14% from 2012 to 2015. However, the number of external beam radiation fractions has declined by approximately 7% over this same period, likely due to a trend toward hypofractionated courses of treatment and use of special treatment modalities such as proton beam therapy or stereotactic body radiation therapy.     

Opportunities for Excellence in Interventional Radiology Training: A Qualitative Study

ObjectiveThe training experience in interventional radiology (IR) residency programs varies widely across the country. The introduction of an IR training pathway has provided the impetus for the specialty to better define outstanding IR education and for programs to rethink how their curricula prepare IR trainees for real-world practice. Although ACGME competencies define several training components that are necessary for independent practice, few quantitative or qualitative studies have explored current perceptions on what constitutes optimal IR training. Our goal was to qualitatively explore program training features deemed most important to adequately prepare IR physicians for practice and assess whether there were differences in perception between academic and nonacademic practices.MethodsSemistructured interviews were conducted with 71 IR attending physicians, trainees, and support staff across the United States. All interviews were performed over the telephone by a single researcher for consistency and systematically coded by two independent coders for common themes. Frequency and prevalence of themes and facilitating features were analyzed.ResultsThe most frequently perceived facilitating features included longitudinal patient care experience, practice-building education, interspecialty collaboration exposure, broad case mix, clinical decision-making exposure, diagnostic radiology training, procedural skills training, and graduated autonomy. Comparing nonacademic versus academic practice settings, significantly more nonacademic IR attending physicians expressed practice-building education (prevalence 72% versus 42%, frequency 2.2 versus 0.7, P < .01) as an important training experience.DiscussionAn understanding of perceived facilitating features for optimal IR trainee preparation, including potentially different needs between academic and nonacademic practices, can help programs prepare their trainees for a successful transition into practice.     

How Much Is That Head CT? Price Transparency and Variability in Radiology

PurposeTo extend the investigation of price transparency and variability to medical imaging.MethodsEighteen upper-tier academic hospitals identified by U.S. News & World Report and 14 of the 100 largest private radiology practices in the country identified by the Radiology Business Journal were contacted by telephone between December 2013 and February 2014 to determine the cash price for a noncontrast head CT. The price for a noncontrast head CT was chosen to assess price transparency in medical imaging because it represents a standard imaging examination with minimal differences in quality.ResultsFourteen upper-tier academic hospitals (78%) and 11 private practices (79%) were able to provide prices for a noncontrast head CT. There was no significant difference between the proportions of upper-tier academic hospitals and private practices that were able to provide prices for a noncontrast head CT (P = .96). The average total price for the upper-tier academic hospitals was $1,390.12 ± $686.13, with the price ranging from $391.62 to $2,015. The average total price for the private practices was $681.60 ± $563.58, with the total price ranging from $211 to $2,200.ConclusionsPrices for a noncontrast head CT study were readily available from the vast majority of upper-tier academic hospitals and private practices, although there was tremendous variation in the price estimates both within and between the upper-tier academic hospitals and private practices. Routine medical imaging thus appears to be more price transparent compared with other health care services.     

Prospectively ECG-triggered high-pitch coronary angiography with third-generation dual-source CT at 70 kVp tube voltage: Feasibility,image quality,radiation dose,and effect of iterative reconstruction

BackgroundLow tube voltage reduces radiation exposure in coronary CT angiography (CTA). Using 70 kVp tube potential has so far not been possible because CT systems were unable to provide sufficiently high tube current with low voltage.ObjectiveWe evaluated feasibility, image quality (IQ), and radiation dose of coronary CTA using a third-generation dual-source CT system capable of producing 450 mAs tube current at 70 kVp tube voltage.MethodsCoronary CTA was performed in 26 consecutive patients with suspected coronary artery disease, selected for body weight <100 kg and heart rate <60 beats/min. High-pitch spiral acquisition was used. Filtered back projection (FBP) and iterative reconstruction (IR) algorithms were applied. IQ was assessed using a 4-point rating scale (1 = excellent, 4 = nondiagnostic) and objective parameters.ResultsMean age was 62 ± 9 years (46% males; mean body mass index, 27.7 ± 3.8 kg/m²; mean heart rate, 54 ± 5 beats/min). Mean dose-length product was 20.6 ± 1.9 mGy × cm; mean estimated effective radiation dose was 0.3 ± 0.03 mSv. Diagnostic IQ was found in 365 of 367 (FBP) and 366 of 367 (IR) segments (P nonsignificant). IQ was rated “excellent” in 53% (FBP) and 86% (IR) segments (P = .001) and “nondiagnostic” in 2 (FBP) and 1 segment (IR) (P nonsignificant). Mean IQ score was lesser in FBP vs IR (1.5 ± 0.4 vs 1.1 ± 0.2; P < .001). Image noise was lower in IR vs FBP (60 ± 10 HU vs 74 ± 8 HU; P < .001).ConclusionIn patients <100 kg and with a regular heart rate <60 beats/min, third-generation dual-source CT using high-pitch spiral acquisition and 70 kVp tube voltage is feasible and provides both robust IQ and very low radiation exposure.     

Patient and Provider Perspectives of Telehealth and In-Person Interventional Radiology Clinic Visits

PurposeTo assess patient and provider satisfaction with interventional radiology (IR) outpatient telehealth and in-person clinic.Materials and MethodsThis institutional review board–approved study analyzed patient satisfaction with clinic via survey after an IR outpatient telehealth or in-person visit. A physician telehealth experience survey was completed by 8 IR physicians.ResultsDuring the initial survey period, 44 (83%) of 53 patients completed a survey via telephone compared with 37 (23%) of 158 patients who were offered an electronic survey during the second survey period. Of 81 respondents, 18 (22%) were in-person and 63 (78%) were via telehealth. Of the respondents, nearly all patients (97%) in the telehealth group reported satisfaction with their telehealth clinic visit, with similar rates of high patient satisfaction between in-person and telehealth visits (P = .51). Most patients (98%) in the telehealth group strongly agreed that their physician’s recommendations were clear in the telehealth visit and that their visit was private, similar to in-person visits (P = .13). A telehealth visit saved time for all patients (100%), with 78% reporting >1 hour of time-saving. All IR physicians (n = 8) reported greater efficiency with telehealth clinic than with in-person clinic and that follow-up patterns would change if telehealth was available. However, all providers (100%) found telephone visits less satisfying than in-person visits, with video visits being either equally satisfying (71%) or less satisfying (29%).ConclusionsPatient satisfaction with the in-person and telehealth outpatient IR clinic was high, with patients and providers reporting time-saving and greater efficiency with telehealth, suggesting that telehealth should remain an important component of outpatient IR clinic care.     

Chest Radiograph Reporting: Public Preferences and Perceptions

PurposeTo assess public preferences and perceptions regarding negative chest radiograph reports.MethodsUsing Amazon Mechanical Turk (Amazon Inc, Seattle, Washington), paid US English-speaking volunteers completed an 18-question survey. Participants were presented with the same two chest radiograph reports—one each in a freestyle and structured format—but randomized to one of four impression statements commonly used in our community. Participants were asked about content comprehension and confidence in the hypothetical interpreting radiologist.ResultsOver 15 days, 5,155 eligible participants completed the survey (of 6,363 respondents). Most reported prior chest radiography (68.9%) or any imaging (93.8%). Of those who underwent chest radiography, 77.6% reviewed their reports. Participants indicated structured reports were easier to comprehend (P < .001) but no difference in perceived confidence in the radiologist with freestyle versus structured reports (P = .21). No differences in comprehension were noted between different impressions with either freestyle (P = .077) or structured (P = .083) reports. Participants indicated higher confidence in radiologists when structured reports indicated “no acute disease” versus “unremarkable” (P = .049). When impressions stated “no acute disease,” participants indicated they would be more likely to do nothing, versus “negative chest” for which they indicated a higher likelihood of taking some action (P = .013, P = .04). Participant responses were similar for subgroups who previously underwent chest or other imaging and previously reviewed their imaging reports.ConclusionFor negative chest radiographs, structured reports are better comprehended by the public and less likely to prompt unnecessary follow-up. As patients increasingly access their medical records online, radiologist reporting should consider patient needs and behavior.     

Structured Reporting of IR Procedures: Effect on Report Compliance,Accuracy, and Satisfaction

Purpose

To compare effect of free-text versus structured reporting of IR procedures on report quality and report coding and value.

Outcomes of Stroke Thrombectomy Performed by Interventional Radiologists versus Neurointerventional Physicians

PurposeTo test the hypothesis that interventional radiologists (IRs) and neurointerventional (NI) physicians have similar outcomes of endovascular stroke thrombectomy (EVT), which could be used to improve the availability of thrombectomy.Materials and MethodsEight hospitals providing EVT performed by IRs and NI physicians at the same institution submitted sequential retrospective data limited to the era of modern devices. Good clinical outcomes (a 90-day modified Rankin score [mRS] of 0–2) and technically successful revascularization (a modified thrombolysis in cerebral infarction score of ≥2b) were compared between the specialties after adjusting for treating hospital, patient age, stroke severity, Alberta stroke program early computed tomography score, time from symptom onset to door, and clot location. Propensity score matching was used to compare the outcomes. A total of 1,009 patients were evaluated (622 treated by IRs and 387 treated by NI physicians).ResultsThe median time from stroke onset to puncture was 245 versus 253 minutes (P = .49), the technically successful revascularization rate was 81.8% versus 82.4% (P = .81), and the good clinical outcome rate was 45.5% versus 50.1% (P = .16). After adjusting, the physician specialty was not a significant predictor of good clinical outcomes (odds ratio, 1.028; 95% confidence interval, 0.760–1.390; P = .86). After matching, an mRS of 0–2 was present in 47.7% of IR treated patients and 51.1% of NI treated patients (P = .366).ConclusionsThere were no significant differences in the successful revascularization rate and good clinical outcomes between IRs and NI physicians. The outcomes of EVT performed by IRs were similar to those of EVT performed by NI physicians, as determined using previously published trials and registries. This may be useful for addressing coverage and access to stroke interventions.     

Assessment of the Radiology Support,Communication and Alignment Network to Reduce Medical Imaging Overutilization: A Multipractice Cohort Study

PurposeThe aim of this study was to determine whether participation in Radiology Support, Communication and Alignment Network (R-SCAN) results in a reduction of inappropriate imaging in a wide range of real-world clinical environments.MethodsThis quality improvement study used imaging data from 27 US academic and private practices that completed R-SCAN projects between January 25, 2015, and August 8, 2018. Each project consisted of baseline, educational (intervention), and posteducational phases. Baseline and posteducational imaging cases were rated as high, medium, or low value on the basis of validated ACR Appropriateness Criteria®. Four cohorts were generated: a comprehensive cohort that included all eligible practices and three topic-specific cohorts that included practices that completed projects of specific Choosing Wisely topics (pulmonary embolism, adnexal cyst, and low back pain). Changes in the proportion of high-value cases after R-SCAN intervention were assessed for each cohort using generalized estimating equation logistic regression, and changes in the number of low-value cases were analyzed using Poisson regression.ResultsUse of R-SCAN in the comprehensive cohort resulted in a greater proportion of high-value imaging cases (from 57% to 79%; odds ratio, 2.69; 95% confidence interval, 1.50-4.86; P = .001) and 345 fewer low-value cases after intervention (incidence rate ratio, 0.45; 95% confidence interval, 0.29-0.70; P < .001). Similar changes in proportion of high-value cases and number of low-value cases were found for the pulmonary embolism, adnexal cyst, and low back pain cohorts.ConclusionsR-SCAN participation was associated with a reduced likelihood of inappropriate imaging and is thus a promising tool to enhance the quality of patient care and promote wise use of health care resources.     

National Trends in Oncologic Diagnostic Imaging

ObjectiveTo characterize national trends in oncologic imaging (OI) utilization.MethodsThis retrospective cross-sectional study used 2004 and 2016 CMS 5% Carrier Claims Research Identifiable Files. Radiologist-performed, primary noninvasive diagnostic imaging examinations were identified from billed Current Procedural Terminology codes; CT, MRI, and PET/CT examinations were categorized as “advanced” imaging. OI examinations were identified from imaging claims’ primary International Classification of Diseases-9 and International Classification of Diseases-10 codes. Imaging services were stratified by academic practice status and place of service. State-level correlations of oncologic advanced imaging utilization (examinations per 1,000 beneficiaries) with cancer prevalence and radiologist supply were assessed by Spearman correlation coefficient.ResultsThe national Medicare sample included 5,051,095 diagnostic imaging examinations (1,220,224 of them advanced) in 2004 and 5,023,115 diagnostic imaging examinations (1,504,608 of them advanced) in 2016. In 2004 and 2016, OI represented 4.3% and 3.9%, respectively, of all imaging versus 10.8% and 9.5%, respectively, of advanced imaging. The percentage of advanced OI done in academic practices rose from 18.8% in 2004 to 34.1% in 2016, leaving 65.9% outside academia. In 2016, 58.0% of advanced OI was performed in the hospital outpatient setting and 23.9% in the physician office setting. In 2016, state-level oncologic advanced imaging utilization correlated with state-level radiologist supply (r = +0.489, P < .001) but not with state-level cancer prevalence (r = −0.139, P = .329).DiscussionOI usage varied between practice settings. Although the percentage of advanced OI done in academic settings nearly doubled from 2004 to 2016, the majority remained in nonacademic practices. State-level oncologic advanced imaging utilization correlated with radiologist supply but not cancer prevalence.     

Radiologist-Practice Separation: Recent Trends and Characteristics

PurposeTo assess recent trends and characteristics in radiologist-practice separation across the United States.MethodsUsing the Medicare Physician Compare and Medicare Physician and Other Supplier Public Use File data sets, we linked all radiologists to associated group practices annually between 2014 and 2018 and assessed radiologist-practice separation over a variety of physician and group characteristics. Multivariate logistic regression modeling was used to estimate the likelihood of radiologist-practice separation.ResultsOf 25,228 unique radiologists associated with 4,381 unique group practices, 41.1% separated from at least one group practice between 2014 and 2018, and annual separation rates increased 38.4% over time (13.8% from 2014 to 2015 to 19.2% from 2017 to 2018). Radiologist-practice separation rates ranged from 57.4% in Utah to 26.3% in Virginia. Separation rates were 42.8% for general radiologists versus 38.2% for subspecialty radiologists. Among subspecialists, separation rates ranged from 43.0% for breast imagers to 33.5% for cardiothoracic radiologists. Early career status (odds ratio [OR] = 1.286) and late (OR = 1.554) career status were both independent positive predictors of radiologist-practice separation (both P < .001). Larger practice size (OR = 0.795), radiology-only (versus multispecialty) group (OR = 0.468), academic (versus nonacademic) practice (OR = 0.709), and abdominal (OR = 0.820), musculoskeletal (OR = 0.659), and neuroradiology (OR = 0.895) subspecialization were independent negative predictors (all P < .05).ConclusionsWith over 40% of radiologists separating from at least one practice in recent years, the US radiologist workforce is highly and increasingly mobile. Because reasons for separation (eg, resignation, practice acquisition) cannot be assessed using administrative data, further attention is warranted given the manifold financial, operational, and patient care implications.     

Characteristics of Radiologists Serving as Medical Malpractice Expert Witnesses for Defense Versus Plaintiff

PurposePrevious studies have reported higher qualification characteristics for anesthesiologists, neurosurgeons, orthopedic surgeons, and otolaryngologists serving as defense (versus plaintiff) medical malpractice expert witnesses. We assessed such characteristics for radiologist expert witnesses.MethodsUsing the Westlaw legal research database, we identified radiologists serving as experts in all indexed medical malpractice cases between 2010 and 2019. Online databases were used to identify years of practice experience and scholarly bibliometrics. Using Medicare claims, individual radiologist practice types and mixes were ascertained. Radiologists testifying at least once each for defense and plaintiff were excluded from our defense-only versus plaintiff-only comparative analysis.ResultsInitial Boolean searches yielded 1,042 potential cases; subsequent manual review identified 179 radiologists testifying in 231 lawsuits: 143 testified in one case (58 defense, 85 plaintiff) and 36 testified in multiple cases (10 defense-only, 14 plaintiff-only, 12 both). The 68 defense-only experts had fewer years of practice experience than the 99 plaintiff-only experts (28.3 versus 31.8 years, P = .02), but the two groups were otherwise similar in both practice type (44.6% versus 54.9% academic, P = .62) and mix (63.8% versus 65.8% practiced as subspecialists, P = .37) and as well as numbers of publications (60.5 versus 62.8, P = .86), citations (1,994.1 versus 2,309.2, P = .56), and h-indices (17.2 versus 16.8, P = .89).ConclusionsIn contrast to other specialists, radiologists serving as medical malpractice expert witnesses for defense and plaintiff display similar qualifications across various characteristics. Published practice parameter guidelines and experts’ ability to blindly review archived original images might together explain this interspecialty discordance.     

Radiologists’ Contribution to Variation in Detecting Clinically Significant Prostate Cancer in Men With Prostate MRI

ObjectiveAssess radiologists’ contribution to variation in clinically significant prostate cancer (csPCa) detection in patients with elevated prostate-specific antigen (PSA) and multiparametric MRI (mpMRI).MethodsThis institutional review board–approved, retrospective cohort study was performed at a tertiary, academic, National Cancer Institute–designated Comprehensive Cancer Center with a multidisciplinary prostate cancer program. Men undergoing mpMRI examinations from January 1, 2015, to December 31, 2019, with elevated PSA (≥4 ng/mL) and biopsy within 6 months pre- or post-MRI or prostatectomy within 6 months post-mpMRI were included. Univariate and multivariable hierarchical logistic regression assessed impact of patient, provider, mpMRI examination, mpMRI report, and pathology factors on the diagnosis of Grade Group ≥ 2 csPCa.ResultsStudy cohort included 960 MRIs in 928 men, mean age 64.0 years (SD ± 7.4), and 59.8% (555 of 928) had csPCa. Interpreting radiologist was not significant individually (P > .999) or combined with mpMRI ordering physician and physician performing biopsy or prostatectomy (P = .41). Prostate Imaging Reporting and Data System (PI-RADS) category 2 (odds ratio [OR] 0.18, P = .04), PI-RADS category 4 (OR 2.52, P < .001), and PI-RADS category 5 (OR 4.99, P < .001) assessment compared with no focal lesion; PSA density of 0.1 to 0.15 ng/mL/cc (OR 2.46, P < .001), 0.15 to 0.2 ng/mL/cc (OR 2.77, P < .001), or ≥0.2 ng/mL/cc (OR 4.52, P < .001); private insurance (reference = Medicare, OR 0.52, P = .001), and unambiguous extraprostatic extension on mpMRI (OR 2.94, P = .01) were independently associated with csPCa. PI-RADS 3 assessment (OR 1.18, P = .56), age (OR 0.99, P = .39), and African American race (OR 0.90, P = .75) were not.DiscussionAlthough there is known in-practice variation in radiologists’ interpretation of mpMRI, in our multidisciplinary prostate cancer program we found no significant radiologist-attributable variation in csPCa detection.     

Low-Volume and High-Volume Readers of Neurological and Musculoskeletal MRI: Achieving Subspecialization in Radiology

ObjectiveDifferentiate high- versus low-volume radiologists who interpret neurological (Neuro) MRI or musculoskeletal (MSK) MRI and measure the proportion of Neuro and MSK MRIs read by low-volume radiologists.MethodsWe queried the 2015 Medicare Physician and Other Supplier Public Use File for radiologists who submitted claims for Neuro or MSK MRIs. Radiologists were classified as high-volume versus low-volume based on their work relative value units (wRVUs) focus or volume of studies interpreted using three different methodologies: Method 1, percentage of wRVUs in Neuro or MSK MRI; Method 2, absolute number of Neuro or MSK MRIs interpreted; and Method 3, both percentage and absolute number. Multiple thresholds with each methodology were tested, and the percentage of Neuro or MSK MRIs interpreted by low-volume radiologists was calculated for each threshold.ResultsWith Method 1, 33% of Neuro MRI and 50% of MSK MRI studies were interpreted by a radiologist whose wRVUs in Neuro or MSK MRI were less than 20% (Method 1). With Method 2, 22% of Neuro MRIs and 37% of MSK MRIs were interpreted by radiologists who read fewer than the mean number of Neuro or MSK MRIs interpreted by an “average full-time radiologist” whose wRVUs in Neuro or MSK MRI were approximately 20%. With Method 3, 38% of Neuro MRIs and 57% of MSK MRIs were interpreted by “low-volume” radiologists. If instead a 50% wRVU threshold is used for Methods One, Two, and Three, then 70%, 58%, and 77% of Neuro MRIs and 86%, 80%, and 90% of MSK MRIs are read by low-volume radiologists.DiscussionA large number of radiologists read a low volume of Neuro or MSK MRIs; these low-volume Neuro or MSK MRI radiologists read a substantial portion of Neuro or MSK MRIs. It is unknown which of the methods for distinguishing low-volume radiologists, combined with which threshold, may best correlate with high-performing or low-performing radiologists.     

Unplanned 30-Day Readmissions after Management of Submassive and Massive Acute Pulmonary Embolism: Catheter-Directed versus Systemic Thrombolysis

PurposeTo compare 30-day readmission and in-hospital outcomes from the Nationwide Readmissions Database (NRD) for catheter-directed thrombolysis (CDT) versus systemic intravenous thrombolysis (IVT) as treatments for acute submassive or massive pulmonary embolism (PE).Materials and MethodsThe NRD was queried from 2016 to 2019 for adult patients with nonseptic acute PE who underwent IVT or CDT. Massive PE was distinguished from submassive PE if patients had concurrent International Classification of Diseases (ICD-10) codes corresponding to mechanical ventilation, vasopressors, or shock. Propensity score–matched analysis was conducted to infer the association of CDT versus IVT in unplanned 30-day readmissions, nonroutine discharge, gastrointestinal bleeding (GIB), and intracranial hemorrhage (ICH). These results are demonstrated as average treatment effects (ATEs) of IVT compared with those of CDT.ResultsA total of 37,116 patients with acute PE were studied; 18,702 (50.3%) underwent CDT, and 18,414 (49.7%) underwent IVT. A total of 2,083 (11.1%) and 3,423 (18.6%) were massive PEs in the 2 groups, respectively (P < .001). The ATE of IVT was higher than that of CDT regarding unplanned 30-day readmissions (ATE, 0.019; P < .001), GIB (ATE, 0.012; P < .001), ICH (ATE, 0.003; P = .017), and nonroutine discharge (ATE, 0.022; P = .006). The subgroup analysis of patients with submassive PE demonstrated that IVT had a higher ATE regarding unplanned 30-day readmission (ATE, 0.028; P < .001), GIB (ATE, 0.008; P = .003), ICH (ATE, 0.002; P = .035), and nonroutine discharge (ATE, 0.019; P = .022) than CDT.ConclusionsCDT had a lower likelihood of unplanned 30-day readmissions, including when stratified by a submassive PE subtype. Additionally, adverse events, including ICH and GIB, were more likely among patients who received IVT than among those who received CDT.