Survival following thrombotic thrombocytopenic purpura in pregnancy.

When thrombotic thrombocytopenic purpura (TTP) occurs in pregnancy, survival of either the mother or fetus is exceedingly rare. A patient is reported who developed this disease in the 17th week of pregnancy and recovered after treatment with antiplatelet drugs (aspirin, dipyridamole) and corticosteroids. The rationale and potential hazards of antiplatelet therapy in TTP are discussed.

Financial impact of the Medicare Fee Schedule on a large multispecialty faculty practice in an academic medical center.

Although there have been preliminary studies of the financial impact of the Medicare Fee Schedule (MFS) on specialty-specific groups of practicing physicians in an academic setting, there has been no published report of the financial impact of the MFS on an entire multispecialty academic faculty practice. This 1992 study reports the estimated financial impact of the MFS on the faculty practice at the University of Michigan Medical School (UMMS). The authors calculated the difference between the Medicare payments to be received when the MFS is completely implemented in 1996 and the payments received in 1991, and then repeated this process for each year of the transition period, 1992-1996. The UMMS will experience a $1.2 million (-4.7%) loss under the fully implemented MFS. The medical departments project an 8% gain, while substantial losses are projected for the surgical departments (-10%) and hospital-based departments (-15%). Projections indicate that obstetrics-gynecology and ophthalmology will lose nearly 20% and that surgery will lose 9%. But large percentage gains are projected for neurology (+43%), physical medicine (+25%), and family practice (+17%). Analysis of the MFS transition's effects shows an abrupt and unpredictable financial impact in the first year. Faculty practice plans may be more disadvantaged under the MFS than other physician groups, yet the uncertain impact of the MFS in the first year (1992) may inhibit accurate financial planning for all physician groups.

The use of volume standards in health services.

The ways in which volume standards are implemented by health services organizations are not clear. Therefore, the authors sought to evaluate the extent of use of volume standards, the purposes for which such standards were developed, and the sources of the standards in a sample of health services organizations. The authors found that volume standards were used widely by accrediting organizations, professional societies, and hospitals in their sample, but almost never by health maintenance organizations. Volume standards were used for ensuring adequate experience among residents, providing guidelines to residency programs, and privileging and credentialing physicians. Expert consensus appeared to be the usual source of volume standards.

Radiology groups' workload in relative value units and factors affecting it.

PURPOSE: To measure diagnostic radiology groups' workload in physician work relative value units (RVUs) and identify factors affecting it. MATERIALS AND METHODS: In 1996 and 1997, the authors surveyed diagnostic radiology and radiation oncology groups regarding finances, workload, and basic characteristics. The study was based on approximately 100 diagnostic radiology groups. The authors analyzed the distribution of workload in different categories of groups, conducting multiple statistical analyses. RESULTS: The annual numbers of procedures were approximately 10%-15% lower than those in a comparison survey with a good response rate. The annual number of RVUs per full-time equivalent (FTE) diagnostic radiologist was highly variable in every group category, as was the number of RVUs per clinical work hour. Multivariate regression analysis indicated that variation in the annual number of hours worked did not explain variation in annual workload. RVUs per FTE radiologist were higher the greater the percentage of a group's workload from interventional, computed tomographic, and magnetic resonance imaging procedures. CONCLUSION: Given the likely response bias, the annual workload per FTE radiologist probably averaged approximately 4,000 RVUs in academic groups and approximately 6,000 in nonacademic groups, but the large, unexplained variance means the average values should not be taken as norms.

Utilization of radiologic services in different payment systems and patient populations.

PURPOSE: To report population-based utilization rates and their variability across and within populations, geographic areas, and different payment systems for diagnostic radiology and radiation oncology procedures. MATERIALS AND METHODS: Aggregated claims data were obtained from four sources for up to nine radiologic modalities. The data cover Medicare, health maintenance organizations (HMOs), and conventional insurance. For some sources, the data were separated into four age groups. All radiologic services, including those provided by nonradiologists, were included. RESULTS: Average annual ambulatory diagnostic radiology utilization rates ranged from 570 procedures per 1,000 nonelderly persons in an HMO setting to 1,970 per 1,000 for Medicare enrollees. Radiation oncology utilization rate added 11 procedures per 1,000 to the HMO population rate and 260 per 1,000 to the Medicare population rate. In the Medicare data, the diagnostic radiology utilization rate in the 25th percentile state was 78% of the rate in the 75th percentile state. In a small sample of HMOs, the 25th percentile HMO rate was 45% of the 75th percentile HMO rate. CONCLUSION: Much variability exists in utilization rates. National or regional averages are not a good guide to the utilization rates in a specific patient population and should not be taken as norms. Only actual data from a patient population are likely to provide radiologists with fairly accurate predictions of their future utilization rates.

Core-needle and surgical breast biopsy: comparison of three methods of assessing cost.

PURPOSE: To compare and evaluate the measures of costs for core-needle and surgical breast biopsies. MATERIALS AND METHODS: Three measures of costs were evaluated: (a) input resources, (b) actual payments, and (c) billed charges. A combination of methods were used for data collection from 10 sites enrolled in a large-scale, multiinstitutional, randomized controlled clinical trial. RESULTS: Input resource cost data (42 core-needle and eight surgical biopsies) were the most difficult to obtain. Actual payments and billed charges data collection (32 core-needle and 44 surgical biopsies) was hampered by the difficulty of obtaining data from all providers involved in the procedures. Average direct input resource costs for surgical biopsy (including needle localization) were almost three times as high as those for core-needle biopsy ($698 vs $243). Actual payments ($2,398 vs $799) and billed charges ($3,764 vs $1,496) for surgical biopsy averaged two and a half to three times higher than those for core biopsy (P < .001). CONCLUSION: There was remarkable consistency in relative costs. Input resource costs were much more difficult to obtain than were either actual payments or billed charges. However, input resource costs present a more reliable indication of the actual costs of a procedure than do the other measures. Given the difficulty in obtaining input resource costs, analyses by using actual payments may be preferred.

Practice costs in diagnostic radiology.

PURPOSE: To report on practice costs and their variation. MATERIALS AND METHODS: In 1996 and 1997, practices were surveyed, and data on costs and other operational characteristics were obtained from approximately 170 practices. Several components of practice costs (eg, physician-related costs, administrative and business costs) were calculated separately for different group types (eg, academic, private hospital-only), each on four bases: per full-time equivalent (FTE) radiologist, per relevant procedure, per relevant relative value unit (RVU), and as a percentage of revenue. RESULTS: Median total practice costs per FTE radiologist ranged from approximately $90,000 to $190,000, depending on group type. Per procedure, the median ranged from $9 to $21; and as a percentage of revenue, it ranged from 27% to 41%. Median technical costs were approximately $36 per technical RVU in private hospital-and-office groups. Within any category of group, for every cost category, there was substantial variation among groups. CONCLUSION: The sizable variation implies that means or medians should not be regarded as norms. Nonetheless, the data on 75th and 25th percentile costs can show a radiology group where savings and inadequate resources, respectively, are relatively likely to be found. Physician-related costs are best measured per FTE. Technical costs and administrative and business costs are best measured per RVU or for categories of groups defined by having similar percentages of nonhospital services.

The employment market for 1996 diagnostic radiology and radiation oncology graduates: training program directors' point of view.

OBJECTIVE: In light of concerns about the job market, we describe the employment situation for 1996 graduates and the status and plans of training programs. MATERIALS AND METHODS: In April-May 1996, and in a December follow-up, we surveyed all radiation oncology residency directors and a 50% random sample of diagnostic radiology residency directors about the employment situation of their 1996 residency and fellowship graduates and about their programs. One hundred percent of those surveyed responded. We compared findings with similar 1995 surveys. Differences were assessed with t tests, with a p value less than or equal to .05 as the test of significance. RESULTS: Unemployment 6 months after graduation was 0.8% for diagnostic fellows and less for other categories. Approximately 91% of graduates had positions that reasonably matched their training and personal employment goals. Our survey showed that programs have reduced beginning residency slots by 6% in diagnostic radiology and 4% in radiation oncology over the last 3 years. Program directors plan additional reductions of 3% and 29%, respectively, for total reductions in diagnostic radiology of 9% and in radiation oncology of 33%. Many observers were dismayed because of the low percentage of available slots that filled in the 1996 National Resident Matching Program. However, as in previous years, by late April to mid May 1996, more than 92% of beginning-year residency slots were filled. CONCLUSION: Unemployment continues to be low. "Soft" indicators such as the percentage of graduates with unsuitable positions show no deterioration. However, if major surpluses of diagnostic radiologists or radiation oncologists are pending, both the reductions in program size and the failure to fill all available slots are, to date, too minor to offer significant relief. Given the small size of actual reductions so far, the reported plans for large reductions of radiation oncologists seem questionable.

The employment market for diagnostic radiologists and radiation oncologists: an update.

OBJECTIVE: In response to concern throughout the profession about the employment market for radiologists in the United States, the American College of Radiology, through several information-gathering activities, is monitoring the situation, including the amount of hiring done, job vacancies, and unemployment. To provide context, we compare our findings with data for earlier years and for all physicians. MATERIALS AND METHODS: The American College of Radiology undertook systematic sample surveys of approximately 60 training program directors with regard to their graduates; 3000 radiologists with regard to unemployment; and 400 radiology groups with regard to hiring. Good response rates (> or = 70%) were achieved; separate data for radiation oncology and diagnostic radiology are generally available. Data on use of the College's placement service also are presented. RESULTS: Among trainees completing a diagnostic radiology fellowship or a radiation oncology residency in 1994, 1% (standard error = 1%) were unemployed in December 1994 and 15% (standard error = 4%) were working in jobs not in keeping with their training and employment goals. Among all radiologists, the 1994 unemployment rate was 0.5% (standard error = 0.2%). Radiology groups were hiring for approximately 1600 positions in 1994, of which about three fifths were replacements and two fifths were expansions. After hiring was completed, remaining vacancies numbered approximately 400, or 2% of the radiology workforce. In early 1995, program directors reported that trainees completing a residency or fellowship in 1995 were having greater difficulty finding positions than had their 1994 counterparts. CONCLUSION: The unemployment rate for radiologists was similar to that for all physicians and lower than that for other persons with advanced degrees (1.5-2%). In 1994, expansion positions for which groups were hiring nearly equaled the growth of the radiology workforce. However, 1994 hiring (and vacancy) rates were only approximately 70% of 1991 levels. It is clear that the employment market is weakening; however, contrary to some anecdotal reports, a large-scale collapse has not occurred.

The employment market for 1995 graduates of diagnostic radiology and radiation oncology training.

OBJECTIVE: Despite widespread concern that a major surplus of non-primary-care physicians is developing, little nonanecdotal information has been available. Therefore, we developed and applied a methodology for appraising the situation of new graduates. Graduates should be particularly vulnerable because, unlike seasoned physicians. they all must find employment. MATERIALS AND METHODS: In April-May 1995, and in a December follow-up, we surveyed diagnostic radiology and radiation oncology training program directors about the status of their 1995 residency and fellowship graduates, their programs, and the employment market. More than 90% responded. We compared findings with similar 1994 surveys. Differences were assessed with t tests or multiple regression analyses, with a p value of less than or equal to .05 as the test of significance. RESULTS: Directors reported unemployment 6 months after graduation was 0.6% (+/- 0.3%) for diagnostic radiology fellows and less for others. They said approximately 90% of graduates had positions reasonably matching their training and personal employment goals. Reported unemployment rates and percentages of graduates in desired positions did not differ from 1994. However, training directors generally were more pessimistic in 1995, overwhelmingly reporting the employment market was more difficult than in recent years. Few statistically significant differences among subgroups--including diagnostic subspecialties--were found. Net planned changes in program size will generate reductions of at most a few percent in the annual number of graduates, and more than 98% of beginning year residency slots were filled. CONCLUSION: Unemployment was remarkably low. Also, surprisingly, even "soft" indicators such as undesired positions or difficulties during the process of employment search (i.e., in April-May) did not show deterioration. Projections of pending physician surpluses may be exaggerated. Given our findings, program directors' growing pessimism is puzzling. This pessimism has not called forth sizable cuts in program size and, if major surpluses are pending, neither reductions in program size nor failure to fill all available slots offer significant relief, at least to date. The employment market is about equally good (or equally difficult) across diagnostic subspecialties. The absence of regional differences indicates graduates are effectively reaching beyond the locality where they trained in their employment search.

Power Doppler imaging: initial evaluation as a screening examination for carotid artery stenosis.

PURPOSE: To evaluate power Doppler imaging as a possible screening examination for carotid artery stenosis. MATERIALS AND METHODS: In the principal pilot study, a prospective, blinded comparison of power Doppler imaging with duplex Doppler imaging, the reference-standard method, was conducted in 100 consecutive patients routinely referred for carotid artery imaging at a large, private multispecialty clinic. In the validation pilot study, a prospective, blinded comparison of power Doppler imaging with digital subtraction angiography, the reference-standard method, was conducted in 20 consecutive patients routinely referred at a teaching hospital. Using conservative assumptions, the authors performed cost-effectiveness analysis. RESULTS: Power Doppler imaging produced diagnostic-quality images in 89% of patients. When the images of the patients with nondiagnostic examinations were regarded as positive, power Doppler imaging had an area under the receiver operating characteristic curve, A(z), of 0.87, sensitivity of 70%, and specificity of 91%. The validation study results were very similar. The cost-effectiveness of screening and, as indicated, duplex Doppler imaging as the definitive diagnostic examination and endarterectomy was $47,000 per quality-adjusted life-year. CONCLUSION: The A(z) value for power Doppler imaging compares well with that for mammography, a generally accepted screening examination, and with most other imaging examinations. Power Doppler imaging is likely to be a reasonably accurate and cost-effective screening examination for carotid artery stenosis in asymptomatic populations.