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

PURPOSE: The 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. METHODS: This 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. RESULTS: Use 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. CONCLUSIONS: R-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.

Anticipated Supply and Demand for Independent Interventional Radiology Residency Positions: A Survey of Department Chairs.

PURPOSE: The first participants in the independent interventional radiology (IR) residency match will begin prerequisite diagnostic radiology (DR) residencies before the anticipated launch of the independent IR programs in 2020. The aim of this study was to estimate the competitiveness level of the first independent IR residency matches before these applicants have already committed to DR residencies and possibly early specialization in IR (ESIR) programs. METHODS: The Society of Chairs of Academic Radiology Departments (SCARD) Task Force on the IR Residency distributed a survey to all active SCARD members using SurveyMonkey. The survey requested the number of planned IR residency and ESIR positions. The average, minimum, and maximum of the range of planned independent IR residency positions were compared with the average, maximum, and minimum, respectively, of the range of planned ESIR positions, to model matches of average, high, and low competitiveness. RESULTS: Seventy-four active SCARD members (56%) answered at least one survey question. The respondents' programs planned to fill, in total, 98 to 102 positions in integrated IR residency programs, 61 to 76 positions in independent IR residency programs, and 50 to 77 positions in ESIR DR residency programs each year. The ranges indicate the uncertainty of some programs regarding the number of positions. CONCLUSIONS: The survey suggests that participating programs will fill sufficient independent IR residency positions to accommodate all ESIR applicants in a match year of average or low competitiveness, but not in a match year of high competitiveness. This suggestion does not account for certain difficult-to-predict factors that may affect the independent IR residency match.

Managing incidental findings on abdominal and pelvic CT and MRI, Part 2: white paper of the ACR Incidental Findings Committee II on vascular findings.

This white paper describes vascular incidental findings found on CT and MRI of the abdomen and pelvis. Recommendations for management are included. This represents the second of 4 such papers from the ACR Incidental Findings Committee II, which used a consensus method based on repeated reviews and revisions and a collective review and interpretation of relevant literature. Topics include definitions and recommended management for abdominal aortic, iliac, splenic, renal, and visceral artery aneurysms. Other incidentally discovered aortic conditions, systemic venous anomalies, compression syndromes, abdominal venous thrombosis, and gonadal and pelvic venous conditions are also discussed. A table is provided for reference.

2013 appropriate utilization of cardiovascular imaging: a methodology for the development of joint criteria for the appropriate utilization of cardiovascular imaging by the American College of Cardiology Foundation and American College of Radiology.

The American College of Radiology (ACR) and the American College of Cardiology Foundation (ACCF) have jointly developed a method to define appropriate utilization of cardiovascular imaging. The primary role of this method is to create a series of documents to define the utility of cardiovascular imaging procedures in relation to specific clinical questions, with the aim of defining what, if any, imaging tests are indicated to help to determine diagnosis, treatment, or outcome. The methodology accomplishes this aim through the application of systematic evidence reviews integrated with expert opinion by means of a rigorous Delphi process. By obtaining broad input during the development process from radiologists, cardiologists, primary care physicians, and other stakeholders, these documents are intended to provide practical evidence-based guidance to ordering providers, imaging laboratories, interpreting physicians, patients, and policymakers as to optimal cardiovascular imaging utilization. This document details the history, rationale, and methodology for developing these joint documents for appropriate utilization of cardiovascular imaging.

2013 appropriate utilization of cardiovascular imaging: a methodology for the development of joint criteria for the appropriate utilization of cardiovascular imaging by the American College of Cardiology Foundation and American College of Radiology.

The American College of Radiology (ACR) and the American College of Cardiology Foundation (ACCF) have jointly developed a method to define appropriate utilization of cardiovascular imaging. The primary role of this method is to create a series of documents to define the utility of cardiovascular imaging procedures in relation to specific clinical questions, with the aim of defining what, if any, imaging tests are indicated to help to determine diagnosis, treatment, or outcome. The methodology accomplishes this aim through the application of systematic evidence reviews integrated with expert opinion by means of a rigorous Delphi process. By obtaining broad input during the development process from radiologists, cardiologists, primary care physicians, and other stakeholders, these documents are intended to provide practical evidence-based guidance to ordering providers, imaging laboratories, interpreting physicians, patients, and policymakers as to optimal cardiovascular imaging utilization. This document details the history, rationale, and methodology for developing these joint documents for appropriate utilization of cardiovascular imaging.

ACR Appropriateness Criteria(®) on suspected lower extremity deep vein thrombosis.

Lower extremity deep vein thrombosis (DVT) is a common clinical concern, with an incidence that increases with advanced age. DVT typically begins below the knee but may extend proximally and result in pulmonary embolism. Pulmonary embolism can occur in 50% to 60% of patients with untreated DVT and can be fatal. Although clinical examination and plasma d-dimer blood evaluation can often predict the presence of DVT, imaging remains critical for the diagnostic confirmation and treatment planning of DVT. Patients with above-the-knee or proximal DVT have a high risk for pulmonary embolism and are recommended to receive anticoagulation therapy. On the other hand, patients with below-the-knee or distal DVT rarely experience pulmonary embolism, and anticoagulation therapy in these patients remains controversial. However, one sixth of patients with distal DVT may experience extension of their thrombus above the knee and therefore are recommended to undergo serial imaging assessment at 1 week to exclude proximal DVT extension if anticoagulation therapy is not initiated. Ultrasound is the preferred imaging method for evaluation of patients with newly suspected lower extremity DVT. Magnetic resonance and CT venography can be especially helpful for the evaluation of suspected DVT in the pelvis and thigh. Contrast x-ray venography, the historic gold standard for DVT assessment, is now less commonly performed and primarily reserved for patients with more complex presentations such as those with suspected recurrent acute DVT.

ACR Appropriateness Criteria® on upper gastrointestinal bleeding.

Upper gastrointestinal bleeding is a significant cause of morbidity and mortality, affecting 36 to 48 per 100,000 persons annually. Aggressive resuscitation and upper endoscopy remain the cornerstones of therapy; however, in cases refractory to endoscopic diagnosis and management, radiology plays an increasingly vital and often lifesaving role, thanks to improvements in both imaging and interventional techniques. The various etiologies of upper gastrointestinal bleeding are discussed along with specific management recommendations based on an extensive literature review of current radiographic methods.

ACR appropriateness criteria on recurrent symptoms following lower-extremity angioplasty.

Lower-extremity arteriopathy patients can be managed nonsurgically, but there is no standard algorithm for follow-up. The authors present a consensus on appropriate postangioplasty studies in the setting of claudication or a threatened limb. Physical examination with measurements of the ankle-brachial index should be the first step in patients with recurrent symptoms. When there is high clinical suspicion for a threatened limb, the patient should proceed directly to catheter angiography for possible reintervention. However, in the setting of claudication alone, segmental Doppler pressures and pulse volume recordings are the initial test of choice. Magnetic resonance angiography or ultrasound can be used in conjunction to further characterize lesions with more detail. Computed tomographic angiography may also be used to image lower-extremity vasculature but is limited by the presence of large amounts of vascular calcifications. Novel techniques, including dual-energy computed tomographic angiography and noncontrast magnetic resonance angiography, may provide clinicians with alternative approaches in patients with large amounts of vascular calcifications and renal insufficiency, respectively.

Improved characterization of atherosclerotic plaques by gadolinium contrast during intravascular magnetic resonance imaging of human arteries.

OBJECTIVES: To determine whether gadolinium-DTPA (Gd-DTPA) facilitates discrimination of fibrous, lipid or calcified constituents during intravascular magnetic resonance imaging (IVMRI) of human atherosclerotic arteries. BACKGROUND: Atherosclerotic plaques that cause fatal thrombosis due to rupture have high content of lipid relative to fibrous tissue. We recently demonstrated that IVMRI identifies lipid, fibrous, and calcified components within atherosclerotic human arteries with favorable sensitivity and specificity. Gd-DTPA, a T1-shortening agent, selectively amplifies the signal from fibrous tissue on T1 weighted (T1w) surface MRI. METHODS: A 0.030 in. diameter receiver coil coupled to a 1.5T MR scanner was positioned in iliac arteries of nine subjects with atherosclerosis. Previously validated multi-parametric analysis of T1w and moderate T2w images identified 137 fibrous, lipid and calcified regions of interest within 37 arterial segments. T1w imaging was repeated following 0.1 mmol/kg IV Gd-DTPA infusion. RESULTS: Computer-derived mean gray value in fibrous regions increased by 34.2% with Gd-DTPA (95% CI 24.3-43.5%, p=0.0001) while lipid and calcified regions showed only a non-significant increase of 4.3% (95% CI -0.6 to 9.2%, p=0.0825) and 3.8% (95% CI -1.1 to 7.7%, p=0.103), respectively. The increase in mean gray value with Gd-DTPA was greater for fibrous than for lipid or calcified regions (p=0.0001). CONCLUSIONS: Gd-DTPA selectively enhances signal intensity of fibrous constituents during IVMRI of human atherosclerotic arteries and thus identifies key tissue characteristics associated with plaque stability. These findings have important implications for the assessment of plaque-stabilizing therapies and ultimately for reducing cardiovascular events.

Two-dimensional assessment of right ventricular function: an echocardiographic-MRI correlative study.

BACKGROUND: While echocardiography is used most frequently to assess right ventricular (RV) function in clinical practice, echocardiography is limited in its ability to provide an accurate measure of RV ejection fraction (RVEF). Hence, quantitative estimation of RV function has proven difficult in clinical practice. OBJECTIVE: We sought to determine which commonly used echocardiographic measures of RV function were most accurate in comparison with an MRI-derived estimate of RVEF. METHODS: We analyzed RV function in 36 patients who had cardiac MRI studies and echocardiograms within a 24 hour period. 2D parameters of RV function-right ventricular fractional area change (RVFAC), tricuspid annular motion (TAM), and transverse fractional shortening (TFS) were obtained from the four-chamber view. RV volumes and EFs were derived from volumetric reconstruction based on endocardial tracing of the RV chamber from the short axis images. Echocardiographic assessment of RV function was correlated with MRI findings. RESULTS: RVFAC measured by echocardiography correlated best with MRI-derived RVEF (r = 0.80, P < 0.001). Neither TAM (r = 0.17; P = 0.30) nor TFC (r = 0.12; p< 0.38) were significantly correlated with RVEF. CONCLUSIONS: RVFAC is the best of commonly utilized echocardiographic 2D measure of RV function and correlated best with MRI-derived RV ejection fraction. CONDENSED ABSTRACT: While echocardiography is used most frequently to assess RV function in clinical practice, echocardiography is limited in its ability to provide an accurate measure of RV ejection fraction (RVEF). Using cardiac MRI, RV fractional area change (RVFAC), determined either by MRI or echocardiography, was found to correlate best with MRI-derived RVEF.

A summary of safety of gadofosveset (MS-325) at 0.03 mmol/kg body weight dose: Phase II and Phase III clinical trials data.

OBJECTIVE: We sought to summarize the Phase II and Phase III clinical trials safety data for gadofosveset (Vasovist, MS-325), a new magnetic resonance angiography contrast agent. MATERIALS AND METHODS: Subjects with known or suspected vascular disease were administered 0.03 mmol/kg gadofosveset (767 subjects) or placebo (49 subjects) in phase II and phase III studies. Overall safety data were pooled from 8 studies and included adverse event monitoring, clinical laboratory assays, vital signs, oxygen saturation, physical examination, and electrocardiography. The safety was monitored for 72 to 96 hours postinjection (PI), and safety comparison with x-ray angiography using iodinated contrast media also was performed in 318 subjects. In the phase II trial, 5 doses of gadofosveset and placebo were evaluated. In this study, 38 patients were administered placebo and 39 patients received 0.03 mmol/kg gadofosveset. RESULTS: In pooled data, treatment related adverse events were reported by 176 (22.9%) patients receiving gadofosveset and by 16 (32.7%) patients receiving placebo. In phase II trial, treatment-related adverse events were reported by 13 of the 39 (33.3%) patients receiving gadofosveset and 9 of the 38 (23.7%) patients receiving placebo. No severe or serious adverse events were reported in either gadofosveset or placebo groups in this phase II trial. Pooled data revealed no clinically significant trends in adverse events, laboratory assays, vital signs, or oxygen saturation. A QTc prolongation of 2.8 milliseconds was observed at 45 minutes after MS-325 injection; however, this trend was similar to that of the placebo group at the same time point (3.2 milliseconds). CONCLUSION: Gadofosveset has exhibited a good safety profile and can be safely administered as an intravenous bolus injection. The overall rate and experience of adverse events was similar to that of placebo. The safety profile of gadofosveset is comparable with that of other gadolinium contrast agents as reported in the literature.

ACR practice guideline for the performance and interpretation of cardiac magnetic resonance imaging (MRI).

Magnetic resonance imaging (MRI) is an established imaging modality, recognized for its value in the assessment and monitoring of a wide range of cardiac pathology. It can provide physiologic as well as anatomic information. Image interpretation requires both well-developed MRI skills and knowledge of cardiac pathology. Radiologists, because of their extensive experience in MRI, have an important role in its application in the heart. The guidelines presented here are an educational tool designed to assist practitioners in providing the best possible patient care via the diagnostic methods of cardiac MRI. American College of Radiology requirements for physicians and personnel performing and interpreting cardiac MRI, which will become applicable by July 1, 2008, are also presented.