Pediatric Outpatient Noncontrast Brain MRI: A Time-Driven Activity-Based Costing Analysis at Three U.S. Hospitals.

BACKGROUND. MRI utilization and the use of sedation or anesthesia for MRI have increased in children. Emerging alternative payment models (APMs) require a detailed understanding of the health system costs of performing these examinations. OBJECTIVE. The purpose of this study was to use time-driven activity-based costing (TDABC) to assess health system costs for outpatient noncontrast brain MRI examinations across three children's hospitals. METHODS. Direct costs for outpatient noncontrast brain MRI examinations at three academic free-standing pediatric hospitals were calculated using TDABC. Examinations were categorized as sedated MRI (i.e., sedation or anesthesia), nonsedated MRI, or limited MRI. Process maps were created to describe patient workflows based on input from key personnel and direct observation. Time durations for each process activity were determined; time stamps from retrospective EMR review were used when possible. Capacity cost rates were calculated for resource types within three cost categories (labor, equipment, and space); cost was calculated in a fourth category (supplies). Resources were allocated to each activity, and the cost of each process step was determined by multiplying step-specific capacity costs by the time required for each step. The costs of all steps were summed to yield a base-case total examination cost. Sensitivity analysis for sedated MRI was performed using minimum and maximum time duration inputs for each activity to yield minimum and maximum costs by hospital. RESULTS. The mean base-case cost for a sedated brain MRI examination was $842 (range, $775-924 across hospitals), for a nonsedated brain MRI examination was $262 (range, $240-285), and for a limited brain MRI examination was $135 (range, $127-141). For all examination types, the largest cost category as well as the largest source of difference in cost between hospitals was labor. Sensitivity analysis found that the greatest influence on overall cost at each hospital was the duration of the MRI acquisition. CONCLUSION. The health system cost of performing a sedated MRI examination was substantially greater than that of performing a nonsedated MRI examination. However, the cost of each individual examination type did not vary substantially among hospitals. CLINICAL IMPACT. Health systems operating within APMs can use this comparative cost information for purposes of cost reduction efforts and establishment of bundled prices.

Turnaround time and efficiency of pediatric outpatient brain magnetic resonance imaging: a multi-institutional cross-sectional study.

BACKGROUND: Aside from single-center reports, few data exist across pediatric institutions that examine overall MRI turnaround time (TAT) and the determinants of variability. OBJECTIVE: To determine average duration and determinants of a brain MRI examination at academic pediatric institutions and compare the duration to those used in practice expense relative value units (RVUs). MATERIALS AND METHODS: This multi-institutional cross-sectional investigation comprised four academic pediatric hospitals. We included children ages 0 to < 18 years who underwent an outpatient MRI of the brain without contrast agent in 2019. Our outcome of interest was the overall MRI TAT derived by time stamps. We estimated determinants of overall TAT using an adjusted log-transformed multivariable linear regression model with robust standard errors. RESULTS: The average overall TAT significantly varied among the four hospitals. A sedated brain MRI ranged from 158 min to 224 min, a non-sedated MRI from 70 min to 112 min, and a limited MRI from 44 min to 70 min. The most significant predictor of a longer overall TAT was having a sedated MRI (coefficient = 0.71, 95% confidence interval [CI]: 0.66-0.75; P < 0.001). The median MRI scan time for a non-sedated exam was 38 min and for a sedated exam, 37 min, approximately double the duration used by the Relative Value Scale (RVS) Update Committee (RUC). CONCLUSION: We found considerable differences in the overall TAT across four pediatric academic institutions. Overall, the significant predictors of turnaround times were hospital site and MRI pathway (non-sedated versus sedated versus limited MRI).

Prospective cost implications with a clinical decision support system for pediatric emergency head computed tomography.

BACKGROUND: Unnecessary imaging is a potential cost driver in the United States health care system. OBJECTIVE: Using a clinical decision support tool, we determined the percentage of low-utility non-contrast head computed tomography (CT) examinations on emergency patients and calculated the prospective cost implications of providing low-value imaging using time-driven activity-based costing at an academic quaternary pediatric hospital. MATERIALS AND METHODS: A clinical decision support tool for imaging, CareSelect (National Decision Support Co., Madison, WI), was integrated in silent mode into the electronic health record from September 2018 through August 2019. Each non-contrast head CT order received a score from the clinical decision support tool based on the American College of Radiology Appropriateness Criteria. Descriptive statistics for all levels of appropriateness scores were compiled with an emphasis on low-utility exams. A micro-costing assessment was conducted using time-driven activity-based costing on head CT without contrast examinations. RESULTS: Within the 11-month time period, 3,186 head CT examinations without contrast were ordered for emergency center patients. Among these orders, 28% (896/3,186) were classified as low-utility studies. The base case CT pathway time was 43 min and base case total cost was $193.35. The base case opportunity cost of these low-utility exams extrapolated annually amounts to $188,902 for our institution. CONCLUSION: Silent mode implementation of a clinical decision support tool resulted in 28% of head CT non-contrast exams on emergency patients being graded as low-utility studies. Prospective cost implications resulted in an annual base case cost of $188,902 to Texas Children's Hospital.

Out-of-Pocket Costs for Vesicoureteral Reflux Imaging in Commercially Insured Children From 2012 to 2021.

Among commercially insured children nationally from 2012 to 2021, imaging for urinary tract infection or suspected vesicoureteral reflux required cost sharing by 55.6­71.2% of families. In a multivariable model, the total out-of-pocket cost was not significantly associated with imaging modality, although it was associated with patient demographics, insurance plan type, and calendar quarter.

Vesicoureteral Reflux Imaging: A National Analysis in Commercially Insured Children From 2012 to 2021.

In this national commercial claims database analysis, the number of outpatient pediatric VUR imaging examinations decreased from 48,843 in 2012­2016 to 31,423 in 2017­2021. Imaging modalities' distribution varied over time, with increased use of VCUG (> 90% of examinations in both periods), decreased use of nuclear cystography, and emergence of ceVUS.

Pediatric percutaneous renal biopsies: comparison of complications between real-time ultrasound guidance and pre-procedure ultrasound-aided skin-marking techniques.

BACKGROUND: Percutaneous renal biopsy is a commonly performed procedure that guides decision-making for children with renal disease. OBJECTIVE: To compare complications from renal biopsies using real-time ultrasound (US) guidance versus pre-procedure US-aided skin-marking in children. MATERIALS AND METHODS: We conducted a priori power analysis using a risk-adjusted model, which indicated we needed a sample size of 643-714 procedures (effect size: 0.8). Then we retrospectively identified consecutive patients who underwent a percutaneous renal biopsy from Jan. 1, 2012, to Dec. 31, 2016. We categorized complications according to the Society of Interventional Radiology (SIR) criteria and compared rates using the Fisher exact test. We analyzed complication predictors using multivariate regression. RESULTS: The study consisted of 701 percutaneous renal biopsies in 553 patients: 313 used real-time US guidance and 388 used pre-procedure US-aided skin-marking. Among the 254/701 (36%) complications, 56/313 (18%) resulted from real-time US guidance and 198/388 (51%) from pre-procedure US-aided skin-marking (P<0.001). In the US real-time guidance group, 39/56 (70%) complications were SIR A, 8/56 (14%) SIR B, 6/56 (11%) SIR C and 3/56 (5%) SIR D. Among the pre-procedure US-aided skin-marking group, 139/198 (70%) complications were SIR A, 47/198 (24%) SIR B, 11/198 (6%) SIR C and 1/198 (1%) SIR D. Complications between the two groups were significantly different regarding SIR A (P<0.001) and SIR B complications (P<0.001) but not major complications. Multivariate regression demonstrated that complications were higher using US-aided pre-procedure skin-marking (odds ratio [OR]=6.30; 95% confidence interval [CI]=3.86, 10.27) than with US real-time guidance. CONCLUSION: Children and young adults who underwent real-time US-guided percutaneous renal biopsies had significantly fewer minor complications, including those requiring follow-up medical care, compared to those who underwent percutaneous renal biopsies with pre-procedure US-aided skin-marking. No difference was detected in the incidence of major complications.

Meeting the Needs of Patient Preferences in Imaging.

Healthcare continues to transition toward a patient-centered paradigm, where patients are active in medical decisions. Fully embracing this new paradigm means updating how clinical guidelines are formulated, accounting for patient preferences for medical care. Recently, several societies have incorporated patient preference evidence in their updated clinical practice guidelines, and patients in their expert panels. To fully transition to a patient-centered-paradigm, imaging organizations should rethink the formulation of clinical guidelines, accounting for patient preference evidence.

Communicating Risk in Imaging: A Scoping Review of Risk Presentation in Patient Decision Aids.

RATIONALE AND OBJECTIVES: Best practices exist for communicating medical information to patients, however there is less emphasis on methods to communicate risks, especially in medical imaging. We conducted a scoping review of patient decision aids in medical imaging and characterized the presentation methods of imaging risks. METHODS: Embase, Medline, CINAHL, and PsychINFO were searched to identify studies involving patient decision aids utilized in diagnostic imaging that communicated the risks. Study characteristics included the number and types of risks included, as well as the presentation type and how the probability of risks were communicated. RESULTS: The final study included 46 articles encompassing 27 distinct patient decision aids. Mammography was the most common imaging scenario (22/46), lung cancer screening (18/46), traumatic brain injury (5/46), and urolithiasis (1/46). All patient decision aids included risks associated with imaging, however the number of risk types varied from 2 to 9 (mean: 4, SD: 2). We identified 12 risks across the 27 decision aids, however no single study included all risks. Overall, most risks (65%) were communicated with text, and the presentation mode varied by type of risk. False positive risks were most commonly communicated using a visual format while radiation risk was most commonly communicated using text format. CONCLUSION: There was no consistent manner of communicating risk to patients and visual methods such as icon arrays were not consistently used. The variability of both included risks and the risk presentation modes in the PDAs may affect decision-making, especially in patients and caregivers with lower health literacy and numeracy.

Patient Preferences in Diagnostic Imaging: A Scoping Review.

BACKGROUND: As new diagnostic imaging technologies are adopted, decisions surrounding diagnostic imaging become increasingly complex. As such, understanding patient preferences in imaging decision making is imperative. OBJECTIVES: We aimed to review quantitative patient preference studies in imaging-related decision making, including characteristics of the literature and the quality of the evidence. METHODS: The Pubmed, Embase, EconLit, and CINAHL databases were searched to identify studies involving diagnostic imaging and quantitative patient preference measures from January 2000 to June 2022. Study characteristics that were extracted included the preference elicitation method, disease focus, and sample size. We employed the PREFS (Purpose, Respondents, Explanation, Findings, Significance) checklist as our quality assessment tool. RESULTS: A total of 54 articles were included. The following methods were used to elicit preferences: conjoint analysis/discrete choice experiment methods (n = 27), contingent valuation (n = 16), time trade-off (n = 4), best-worst scaling (n = 3), multicriteria decision analysis (n = 3), and a standard gamble approach (n = 1). Half of the studies were published after 2016 (52%, 28/54). The most common scenario (n = 39) for eliciting patient preferences was cancer screening. Computed tomography, the most frequently studied imaging modality, was included in 20 studies, and sample sizes ranged from 30 to 3469 participants (mean 552). The mean PREFS score was 3.5 (standard deviation 0.8) for the included studies. CONCLUSIONS: This review highlights that a variety of quantitative preference methods are being used, as diagnostic imaging technologies continue to evolve. While the number of preference studies in diagnostic imaging has increased with time, most examine preventative care/screening, leaving a gap in knowledge regarding imaging for disease characterization and management.

Trends in Pediatric Appendicitis and Imaging Strategies During Covid-19 in the United States.

RATIONALE AND OBJECTIVES: To determine if, during the first wave of the COVID-19 pandemic, 1) the proportion of complicated appendicitis changed, and 2) if imaging strategies for appendicitis in children changed. MATERIALS AND METHODS: Retrospective cross-sectional study using administrative data from the Pediatric Health Information System, inclusive of pediatric patients diagnosed with appendicitis from March to May in 2017, 2018, 2019 and 2020. We compared trends during COVID-19 pandemic (March-May 2020) with corresponding pre-COVID-19 periods in 2017-201.9 Study outcomes were the proportion of complicated appendicitis and trends in imaging for appendicitis explained by patient-level variables. RESULTS: The proportion of complicated appendicitis cases increased by 4.4 percentage points, from 46.5% pre-COVID-19 (2017-2019) to 50.9% during COVID-19 (2020), p < 0.001. Mean count of uncomplicated acute appendicitis cases decreased from pre-COVID-19 to the 2020 COVID-19 period (2017: n = 2555; 2018: n = 2679; 2019: n = 2722; 2020: n = 2231). Mean count of complicated appendicitis was unchanged between study periods (2017: n = 2189; 2018: n = 2302, 2019: n = 2442; 2020: n = 2311). Imaging approaches were largely unchanged between study periods; ultrasound was the most utilized modality in both study periods (68.3%, 70.2%; p = 0.033). CONCLUSION: During the first wave of the COVID-19 pandemic, the proportion of complicated appendicitis cases increased without an absolute increase in the number of complicated appendicitis cases, but instead a decrease in the number of uncomplicated acute appendicitis diagnoses.

Time-Driven Activity-Based Costing in Radiology: An Overview.

Time-driven activity-based costing (TDABC) is a cost-accounting method to assess operational costs at a process-specific level. The purpose of this review is to provide a foundational methodologic overview of TDABC and offer insights from lessons we have learned by applying TDABC in radiology. Understanding these principles can help radiology practice leaders maintain local cost-stewardship while delivering the highest quality of clinical care.

Value Assessment of Evolving Pediatric Appendicitis Imaging Strategies Between 2004 and 2018.

OBJECTIVE: To assess diagnostic imaging utilization and the proportion of negative appendectomies for pediatric appendicitis at US children's hospitals between 2004 and 2018. METHODS: This was a retrospective study using data from the Pediatric Health Information System (PHIS) database. Pediatric patients (age: 0-17 years) who underwent an appendectomy at one of 32 children's hospitals from January 1, 2004, through September 30, 2018, were included. Patients were identified based on International Classification of Diseases, 9th revision and International Classification of Diseases, 10th revision procedure codes. Patient demographics, imaging performed, and the frequency of negative appendectomy were analyzed. RESULTS: The final study population consisted of 104,033 children. From 2004 to 2018, CT utilization decreased from 56.8% (2,951 of 5,198) to 18.6% (1,201 of 6,455; P < .001). Ultrasound utilization increased from 26.4% (1,371 of 5,198) to 63.4% (4,093 of 6,455; P < .001). Radiography utilization remained stable at 16.7% (870 of 5,198) and 15.8% (1,018 of 6,455; P = .160). MRI use increased from 0.1% (6 of 5,198) to 2.2% (143 of 6,455; P < .001). During the study period, the negative appendectomy rate slightly decreased, from 3.74% (4,742 of 126,778 in 2004-2011) to 3.14% (4,258 of 135,561 in 2012-2018; P < .001). CONCLUSION: There has been a shift in imaging of children with appendicitis over 15 years in the United States, because the use of CT has decreased and ultrasound use has increased. This shift has likely added value to the health care system without adversely affecting outcomes (negative appendectomy rate).

Cost Comparison of In-Suite Versus Portable Tunneled Femoral Central Line Placements in Children Using Time-Driven Activity-Based Costing.

OBJECTIVE: Compare the cost of placing tunneled femoral central lines in the interventional radiology suite to portable bedside placement using time-driven activity-based costing. METHODS: Detailed process maps were created using information generated from interviews with frontline staff, direct shadowing of patient procedures (19 patients-8 in-suite, 11 portable; patient age 4 days to 37 months; 6 males, 13 females), and electronic medical record review (80 patients-44 in-suite, 36 portable; patient age 1 day to 20 months; 42 males, 38 females) who underwent a tunneled femoral central line placement at a tertiary care pediatric hospital from January 1, 2018, to June 30, 2018. Procedures were conducted in-suite using fluoroscopy guidance or portably at the patient's bedside using ultrasound. Capacity cost rates for each resource in the process maps were calculated for personnel, equipment, facilities, and supply costs. Costs for each process step were then calculated by multiplying the capacity cost rate by the mean duration of each step. Stepwise costs were summed for the entire process to generate a cost for each tunneled femoral central line placement pathway. RESULTS: Total pathway time for tunneled femoral central lines placement in-suite was 123 to 134 min (nonsedated) and 120 to 131 min (sedated) for a cost of $923 to $990 and $1,262 to $1,386, respectively. Total pathway time for tunneled femoral central lines placed portably were 117 to 119 min (nonsedated) and 115 to 147 min (sedated) for a cost of $1,060 to $1,066 and $1,379 to $1,393, respectively. CONCLUSION: Total costs of tunneled femoral central lines placed in-suite were similar to total costs for lines placed portably. Cost should not be a primary consideration when deciding upon tunneled femoral central line approach in these patients.

Time-Driven Activity-Based Cost Comparison of Three Imaging Pathways for Suspected Midgut Volvulus in Children.

OBJECTIVE: To use time-driven activity-based costing to compare the costs of pathways for evaluating suspected pediatric midgut volvulus using either fluoroscopic upper gastrointestinal examination (UGI) or focused abdominal ultrasound (US). METHODS: Process maps were created through patient shadowing, medical record review, and frontline staff interviews. Using time-driven activity-based costing methodology, practical capacity cost rates were calculated for personnel, equipment, and facility costs. Supply costs were included at institutional purchase prices. The cost of each process substep was determined by multiplying step-specific capacity costs by the median time required for each step, and substep costs were summed to generate total pathway cost. Multivariate sensitivity analyses were performed applying minimum and maximum labor costs. Assuming UGI would be used to troubleshoot nondiagnostic US, a break-even analysis was performed to determine the cost impact of varying frequencies of UGI on the total cost of the US-based pathway. RESULTS: Process maps were created from 105 (48 girls, 57 boys) patient encounters. Base case pathway times were 90 min (UGI) and 55 min (US). Base case cost for UGI was $282.74 (range: $170.86-$800.82) when performed by a radiology practitioner assistant and $545.66 (range: $260.97-$1,974.06) when performed by a radiologist. Base case cost for US was $155.67 (range: $122.94-$432.29) when performed by a sonographer and $242.64 (range: $147.46-$1,330.05) when performed by a radiologist. For a US-based pathway, the total cost break-even pathway mix (percent UGI required for troubleshooting) was 57%. CONCLUSION: US can be a faster and less costly alternative to UGI in pediatric patients with suspected midgut volvulus.

Cost Comparison of Ultrasound Versus MRI to Diagnose Adolescent Female Patients Presenting with Acute Abdominal/Pelvic Pain Using Time-Driven Activity-Based Costing.

RATIONALE AND OBJECTIVES: To compare the cost of ultrasound (US) versus magnetic resonance imaging (MRI) using time-driven activity-based costing in adolescent female patients with suspected appendicitis. MATERIALS AND METHODS: Process maps were created using data from electronic medical record review and patient shadowing for adolescent female patients undergoing US or noncontrast MRI exams of the abdomen and pelvis for suspected appendicitis. Capacity cost rates for all personnel, equipment, facilities, and supplies in each exam pathway were established from institutional accounting data. The cost of each process step was determined by multiplying step-specific capacity cost rates by the mean time required to complete the step. Total pathway costs for US and MRI were computed by summing the costs of all steps through each pathway, and a direct cost comparison was made between the two modalities. RESULTS: Process maps for US and MRI pathways were generated from 231 and 52 patient encounters, respectively. Patients undergoing US exams followed one of six pathways depending on exam order (abdomen versus pelvis performed first) and whether additional time was needed for bladder filling. Mean total US pathway time was 91 minutes longer than for MRI (US = 166 minutes; MRI = 75 minutes). Total MRI pathway cost was $209.97 compared to a mean US cost of $258.33 (range = $163.21-$293.24). CONCLUSION: MRI can be a faster and less costly alternative to US for evaluating suspected appendicitis in adolescent female patients. While precise costs will vary by institution, MRI may be a viable and at times preferable alternative to US in this patient population.

Trends in Anesthesia/Sedation for Computed Tomography and Magnetic Resonance Imaging Encounters in Pediatric Emergency Departments, 2012-2022.

This cross-sectional study assesses trends over time in sedation/anesthesia use for computed tomography (CT) and magnetic resonance imaging (MRI) across pediatric emergency departments (EDs).