Utilization Trends in Diagnostic Imaging for a Commercially Insured Population: A Study of Massachusetts Residents 2009 to 2013

PurposeTo report utilization trends in diagnostic imaging among commercially insured Massachusetts residents from 2009 to 2013.Materials and MethodsCurrent Procedural Terminology codes were used to identify diagnostic imaging claims in the Massachusetts All-Payer Claims Database for the years 2009 to 2013. We reported utilization and spending annually by imaging modality using total claims, claims per 1,000 individuals, total expenditures, and average per claim payments.ResultsThe number of diagnostic imaging claims per insured MA resident increased only 0.6% from 2009 to 2013, whereas nonradiology claims increased by 6% annually. Overall diagnostic imaging expenditures, adjusted for inflation, were 27% lower in 2009 than 2013, compared with an 18% increase in nonimaging expenditures. Average payments per claim were lower in 2013 than 2009 for all modalities except nuclear medicine. Imaging procedure claims per 1,000 MA residents increased from 2009 to 2013 by 13% in MRI, from 147 to 166; by 17% in ultrasound, from 453 to 530; and by 12% in radiography (x-ray), from 985 to 1,100. However, CT claims per 1,000 fell by 37%, from 341 to 213, and nuclear medicine declined 57%, from 89 claims per 1,000 to 38.ConclusionDiagnostic imaging utilization exhibited negligible growth over the study period. Diagnostic imaging expenditures declined, largely the result of falling payments per claim in most imaging modalities, in contrast with increased utilization and spending on nonimaging services. Utilization of MRI, ultrasound, and x-ray increased from 2009 to 2013, whereas CT and nuclear medicine use decreased sharply, although CT was heavily impacted by billing code changes.     

Knowledge of the Costs of Diagnostic Imaging: A Survey of Physician Trainees at a Large Academic Medical Center

PurposeTo study the awareness of postgraduate physician trainees across a variety of specialties regarding the costs of common imaging examinations.MethodsDuring early 2016, we conducted an online survey of all 1,238 physicians enrolled in internships, residencies, and fellowships at a large academic medical center. Respondents were asked to estimate Medicare national average total allowable fees for five commonly performed examinations: two-view chest radiograph, contrast-enhanced CT abdomen and pelvis, unenhanced MRI lumbar spine, complete abdominal ultrasound, and unenhanced CT brain. Responses within ±25% of published amounts were deemed correct. Respondents were also asked about specialty, postgraduate year of training, previous radiology education, and estimated number of imaging examinations ordered per week.ResultsA total of 381 of 1,238 trainees returned complete surveys (30.8%). Across all five examinations, only 5.7% (109/1,905) of responses were within the correct ±25% range. A total of 76.4% (291/381) of all respondents incorrectly estimated every examination’s cost. Estimation accuracy was not associated with number of imaging examinations ordered per week or year of training. There was no significant difference in cost estimation accuracy between those who participated in medical school radiology electives and those who did not (P = .14). Only 17.5% of trainees considered their imaging cost knowledge adequate. Overall, 75.3% desire integration of cost data into clinical decision support and/or computerized physician order entry systems.ConclusionsPostgraduate physician trainees across all disciplines demonstrate limited awareness of the costs of commonly ordered imaging examinations. Targeted medical school education and integration of imaging cost information into clinical decision support / computerized physician order entry systems seems indicated.     

Clinical Impact of a Quality Improvement Program Including Dedicated Emergency Radiology Personnel on Emergency Surgical Management: A Propensity Score-Matching Study

ObjectiveTo investigate the clinical impact of a quality improvement program including dedicated emergency radiology personnel (QIP-DERP) on the management of emergency surgical patients in the emergency department (ED).Materials and MethodsThis retrospective study identified all adult patients (n = 3667) who underwent preoperative body CT, for which written radiology reports were generated, and who subsequently underwent non-elective surgery between 2007 and 2018 in the ED of a single urban academic tertiary medical institution. The study cohort was divided into periods before and after the initiation of QIP-DERP. We matched the control group patients (i.e., before QIP-DERP) to the QIP-DERP group patients using propensity score (PS), with a 1:2 matching ratio for the main analysis and a 1:1 ratio for sub-analyses separately for daytime (8:00 AM to 5:00 PM on weekdays) and after-hours. The primary outcome was timing of emergency surgery (TES), which was defined as the time from ED arrival to surgical intervention. The secondary outcomes included ED length of stay (LOS) and intensive care unit (ICU) admission rate.ResultsAccording to the PS-matched analysis, compared with the control group, QIP-DERP significantly decreased the median TES from 16.7 hours (interquartile range, 9.4–27.5 hours) to 11.6 hours (6.6–21.9 hours) (p < 0.001) and the ICU admission rate from 33.3% (205/616) to 23.9% (295/1232) (p < 0.001). During after-hours, the QIP-DERP significantly reduced median TES from 19.9 hours (12.5–30.1 hours) to 9.6 hours (5.7–19.1 hours) (p < 0.001), median ED LOS from 9.1 hours (5.6–16.5 hours) to 6.7 hours (4.9–11.3 hours) (p < 0.001), and ICU admission rate from 35.5% (108/304) to 22.0% (67/304) (p < 0.001).ConclusionQIP-DERP implementation improved the quality of emergency surgical management in the ED by reducing TES, ED LOS, and ICU admission rate, particularly during after-hours.     

Evaluating the Impact of a Call Triage Assistant on Resident Efficiency,Errors, and Stress

ObjectiveThe aim of this study was to evaluate whether a call triage assistant, who answered telephone calls to the main reading room during the busiest hours of weekend call, would impact resident workflow efficiency, diagnostic errors, and stress level.MethodsThe call triage assistant answered all telephone calls to the main reading room from 12 pm to 7 pm on 6 weekend days over a 3-month period. We compared report turnaround times and resident discrepancy rates on these days with control days, when the same residents were on call without the assistant. We also surveyed residents to determine whether the assistants relieved anxiety associated with the call shift.ResultsWe recorded 168 telephone calls over the study period. We found the majority of telephone calls could be handled by the assistant without disturbing the on-call resident, resulting in a 71% reduction in interruptions. The mean turnaround time for studies read on the days the assistant was on duty was 44.3 min, compared with 75.2 min on the control days (P < .01). Resident major discrepancy rates (0.4% on the intervention days compared to 0.2% on the control days) were similar (P = .58), as were minor discrepancy rates (7.5% on the intervention days compared with 6.7% on the control days; P = .61). Residents reported fewer distractions, improved workflow efficiency, and decreased call-related stress when the assistant was on duty.ConclusionsA call triage assistant effectively improved workflow efficiency and reduced resident stress on call. Resident error rates were unaffected by the presence of the assistant.     

Spontaneous Rupture of the Hepatic Artery in a Patient with Type 1 Neurofibromatosis Treated by Embolization: A Case Report

We report the case of a 48-year-old man with neurofibromatosis presenting with sudden-onset abdominal pain, profound hypotension, and a drop in hemoglobin. CT scan demonstrated a massive hematoma within the right lobe of the liver with rupture into the peritoneal cavity. Angiography demonstrated diffuse abnormalities of the hepatic circulation with fusifom, ectatic, and stenotic segments. Acute extravasation from a peripheral branch of the right hepatic artery was identified and successfully embolized with subsequent hemodynamic stabilization of the patient. To the best of our knowledge this is the first case report of this kind in a patient with type I neurofibromatosis.     

Prospects of a Fellowship Match for Abdominal Imaging: A National Survey by the Society of Abdominal Radiology

PurposeAfter the Society of Chairs of Academic Radiology Departments timeline and guidelines were released for the 2021 through 2022 fellowship application cycle, the Society of Abdominal Radiology conducted a survey of residents, fellows, and abdominal imaging fellowship program directors (PDs) to assess stakeholders’ perceptions of changes in the fellowship application process.MethodsEligible study participants included fellowship PDs of all US abdominal imaging programs and Society of Abdominal Radiology members-in-training. A questionnaire was developed by content and survey experts, pilot-tested, and administered from August to October 2019.ResultsSurvey response rates were 51.4% among PDs (54 of 103) and 24.2% among trainees (67 of 279), with an overall response rate of 31.8%. Attitudes regarding the abdominal imaging fellowship application process were overall similar between PDs and trainees, including expressed support for a common application. Although trainees and PDs agreed that the Society of Chairs of Academic Radiology Departments 2021 through 2022 cycle timeline is preferable to the prior unstructured system, only 42.4% of PDs and 40.7% of trainees supported moving to a formal match, with a significant number of respondents undecided. Both PDs and trainees favored timing fellowship interviews during the fall of the third year of residency (R3 year), with a 1- to 2-month buffer between the start of interviews and offers.ConclusionsPDs and trainees demonstrate similar attitudes in support of the Society of Chairs of Academic Radiology Departments 2021 through 2022 cycle timeline and a common abdominal imaging fellowship application. Shifting the interview season from winter to fall of R3 year could be considered to meet the preferences of PDs and trainees alike. Moving to a formal match remains controversial.     

Perspectives on the Value of Advanced Medical Imaging: A National Survey of Primary Care Physicians

PurposeTo understand perceptions of primary care physicians (PCPs) about the value of advanced medical imaging.MethodsA national quantitative survey of 500 PCPs was conducted using an online self-administered questionnaire. Questions focused on advanced medical imaging (CT, MRI, and PET) and its perceived impact on the delivery of patient care. Responses were stratified by physician demographics.ResultsLarge majorities of the PCPs indicated that advanced imaging increases their diagnostic confidence (441; 88%); provides data not otherwise available (451; 90%); permits better clinical decision making (440; 88%); increases confidence in treatment choices (438; 88%), and shortens time to definitive diagnosis (430; 86%]). Most (424; 85%) believe that patient care would be negatively affected without access to advanced imaging. PCPs whose clinical careers predated the proliferation of advanced imaging modalities (>20 years of practice) assigned higher value to advanced imaging on several dimensions compared with younger physicians whose training overlapped widespread technology availability.ConclusionsBy a variety of metrics, large majorities of PCPs believe that advanced medical imaging provides considerable value to patient care. Those whose careers predated the widespread availability of advanced imaging tended to associate it with even higher value.     

Cancer Imaging at the Crossroads of Precision Medicine: Perspective From an Academic Imaging Department in a Comprehensive Cancer Center

The authors propose one possible vision for the transformative role that cancer imaging in an academic setting can play in the current era of personalized and precision medicine by sharing a conceptual model that is based on experience and lessons learned designing a multidisciplinary, integrated clinical and research practice at their institution. The authors’ practice and focus are disease-centric rather than imaging-centric. A “wall-less” infrastructure has been developed, with bidirectional integration of preclinical and clinical cancer imaging research platforms, enabling rapid translation of novel cancer drugs from discovery to clinical trial evaluation. The talents and expertise of medical professionals, scientists, and staff members have been coordinated in a horizontal and vertical fashion through the creation of Cancer Imaging Consultation Services and the “Adopt-a-Radiologist” campaign. Subspecialized imaging consultation services at the hub of an outpatient cancer center facilitate patient decision support and management at the point of care. The Adopt-a-Radiologist campaign has led to the creation of a novel generation of imaging clinician-scientists, fostered new collaborations, increased clinical and academic productivity, and improved employee satisfaction. Translational cancer research is supported, with a focus on early in vivo testing of novel cancer drugs, co-clinical trials, and longitudinal tumor imaging metrics through the imaging research core laboratory. Finally, a dedicated cancer imaging fellowship has been developed, promoting the future generation of cancer imaging specialists as multidisciplinary, multitalented professionals who are trained to effectively communicate with clinical colleagues and positively influence patient care.     

Deep learning in radiology: An overview of the concepts and a survey of the state of the art with focus on MRI

Deep learning is a branch of artificial intelligence where networks of simple interconnected units are used to extract patterns from data in order to solve complex problems. Deep‐learning algorithms have shown groundbreaking performance in a variety of sophisticated tasks, especially those related to images. They have often matched or exceeded human performance. Since the medical field of radiology mainly relies on extracting useful information from images, it is a very natural application area for deep learning, and research in this area has rapidly grown in recent years. In this article, we discuss the general context of radiology and opportunities for application of deep‐learning algorithms. We also introduce basic concepts of deep learning, including convolutional neural networks. Then, we present a survey of the research in deep learning applied to radiology. We organize the studies by the types of specific tasks that they attempt to solve and review a broad range of deep‐learning algorithms being utilized. Finally, we briefly discuss opportunities and challenges for incorporating deep learning in the radiology practice of the future. Level of Evidence: 3 Technical Efficacy: Stage 1 J. Magn. Reson. Imaging 2019;49:939–954.     

深化医学教学改革,加强介入放射学后备力量培养——医学生调查引起的反思

近年来介入放射学在疾病诊疗中的应用得到了广泛普及和认可,然而介入放射学科却面临着患者流失、人员缺乏等诸多挑战。本文着重从医学院校介入放射学教学现状和学生对本学科的认识上剖析其原因,以探求缓解供求矛盾的方法。     

Sclerosing Pneumocytoma with a Wax-and-Wane Pattern of Growth: A Case Report on Computed Tomography and Magnetic Resonance Imaging Findings and a Literature Review

Sclerosing pneumocytoma (SP) of the lung is a rare benign neoplasm. Here, we describe an unusual presentation of SP with a wax-and-wane pattern of growth in a 47-year-old woman. Tumor diameter decreased over a 3-year follow-up period and then increased on serial follow-up computed tomography scans. The mass showed high signal intensity on both T1- and T2-weighted chest magnetic resonance imaging (MRI) and early enhancement with a plateau on dynamic MRI. We speculate that intratumoral bleeding and resorption processes accounted for the changes in tumor size.     

Application of T1 Map Information Based on Synthetic MRI for Dynamic Contrast-Enhanced Imaging: A Comparison Study with the Fixed Baseline T1 Value Method

ObjectiveFor an accurate dynamic contrast-enhanced (DCE) MRI analysis, exact baseline T1 mapping is critical. The purpose of this study was to compare the pharmacokinetic parameters of DCE MRI using synthetic MRI with those using fixed baseline T1 values.Materials and MethodsThis retrospective study included 102 patients who underwent both DCE and synthetic brain MRI. Two methods were set for the baseline T1: one using the fixed value and the other using the T1 map from synthetic MRI. The volume transfer constant (K^trans), volume of the vascular plasma space (v_p), and the volume of the extravascular extracellular space (v_e) were compared between the two methods. The interclass correlation coefficients and the Bland-Altman method were used to assess the reliability.ResultsIn normal-appearing frontal white matter (WM), the mean values of K^trans, v_e, and v_p were significantly higher in the fixed value method than in the T1 map method. In the normal-appearing occipital WM, the mean values of v_e and v_p were significantly higher in the fixed value method. In the putamen and head of the caudate nucleus, the mean values of K^trans, v_e, and v_p were significantly lower in the fixed value method. In addition, the T1 map method showed comparable interobserver agreements with the fixed baseline T1 value method.ConclusionThe T1 map method using synthetic MRI may be useful for reflecting individual differences and reliable measurements in clinical applications of DCE MRI.     

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.     

颅后窝及松果体区占位性病变对小脑扁桃体位置影响的MRI研究

目的:探讨颅后窝及松果体区占位性病变对小脑扁桃体位置的影响。方法:搜集129例经临床、影像和手术 病理证实的颅后窝及松果体区占位性病变(病例组)和525例健康志愿者(正常对照组),对比研究颅后窝及松果体区不同 部位和不同大小的占位性病变与小脑扁桃体位置之间的关系。结果:正常人小脑扁桃体下缘至枕大孔前后唇连线的平均 距离为(0.6±1.8)mm,颅后窝及松果体区占位性病变组的平均距离为(-4.2±3.8)mm,两者间差异有极显著性意义 (χ2=13.82,P<0.01)。四脑室、小脑及桥小脑角区占位性病变对小脑扁桃体位置的影响有极显著性意义(P<0.01),且 占位性病变的大小与小脑扁桃体的位置有明显相关性;而位于松果体区和脑干的占位性病变对小脑扁桃体位置影响较小 (P>0.01)。结论:颅后窝占位性病变的部位和大小与小脑扁桃体的位置有明显相关性,根据占位性病变的大小可以预测 小脑扁桃体疝的发生。