Contemporary Management of Blunt Liver Trauma: An Analysis of the Trauma Quality Improvement Program Registry (2007-2019).

PURPOSE: To evaluate the effectiveness of management strategies for blunt liver injuries in adult patients. MATERIALS AND METHODS: Patients aged ≥18 years with blunt liver injuries registered via the Trauma Quality Improvement Program (2007-2019) were identified. Management strategies initiated within 24 hours of hospital presentation were classified as nonoperative management (NOM), embolization, surgery, or combination therapy. Patients were stratified by injury grade. Linear models estimated each strategy's effect on hospital length of stay (LOS), intensive care unit (ICU) LOS, ventilator dependence, and mortality. RESULTS: Of 78,127 included patients, 88.7%, 8.7%, 1.8%, and 0.8% underwent NOM, surgery, embolization, and combination therapy, respectively. Among patients with low-grade (n = 62,237) and high-grade (n = 15,890) injuries and compared with all other management strategies, NOM was associated with the shortest hospital LOS and ICU LOS. Among patients with low-grade injuries and compared with surgery, embolization was associated with a shorter hospital LOS (9.7 days; P < .001; Cohen d = 0.32) and ICU LOS (5.3 days; P < .001; Cohen d = 0.36). Among patients with high-grade injuries and compared with surgery, embolization was associated with a shorter ICU LOS (6.0 days; P < .01; Cohen d = 0.24). Among patients with low- and high-grade injuries and compared with embolization, surgery was associated with higher odds of mortality (P < .001). CONCLUSIONS: Among patients presenting with blunt liver injuries and compared with surgery, embolization was associated with a shorter ICU LOS and lower risk of mortality.

Utilization of Chest and Abdominopelvic CT for Traumatic Injury From 2011 to 2018: Evaluation Using a National Commercial Database.

BACKGROUND. Increases in the use of CT to evaluate patients presenting with trauma have raised concern about inappropriate imaging. The evolving utilization of CT for trauma evaluation may be impacted by injury severity. OBJECTIVE. The purpose of this study was to explore patterns in utilization of chest and abdominopelvic CT among trauma-related emergency department (ED) visits across the United States. METHODS. This retrospective study was conducted with national commercial claims information extracted from the MarketScan Commercial Database. Trauma-related ED encounters were identified from the 2011-2018 MarketScan database files and classified by injury severity score (minor, intermediate, and major injuries) on the basis of International Classification of Diseases codes. ED encounters were also assessed for chest CT, abdominopelvic CT, and single-encounter chest and abdominopelvic CT examinations. Utilization per 1000 trauma-related ED encounters was determined. Multivariable Poisson regression models were used to determine incidence rate ratios (IRRs) as a measure of temporal changes in utilization. RESULTS. From 2011 to 2018, 8,369,092 trauma-related ED encounters were identified (5,685,295 for minor, 2,624,944 for intermediate, and 58,853 for major injuries). Utilization of chest CT per 1000 trauma-related ED encounters increased from 4.9 to 13.5 examinations (adjusted IRR, 1.15 per year; minor injuries, from 2.2 to 7.7 [adjusted IRR, 1.17]; intermediate injuries, from 8.5 to 21.5 [adjusted IRR, 1.16]; major injuries, from 117.8 to 200.1 [adjusted IRR, 1.08]). Utilization of abdominopelvic CT per 1000 trauma-related ED encounters increased from 7.5 to 16.4 (adjusted IRR, 1.12; minor injuries, 4.8 to 12.2 [adjusted IRR, 1.13]; intermediate injuries, 10.6 to 21.7 [adjusted IRR, 1.13]; major injuries, 134.8 to 192.6 [adjusted IRR, 1.07]). Utilization of single-encounter chest and abdominopelvic CT per 1000 trauma-related ED encounters increased from 3.4 to 8.9 [adjusted IRR, 1.16; minor injuries, 1.1 to 4.6 [adjusted IRR, 1.18]; intermediate injuries, 6.4 to 16.4 [adjusted IRR, 1.16]; major injuries, 99.6 to 179.9 [adjusted IRR, 1.08]). CONCLUSION. National utilization of chest and abdominopelvic CT for trauma-related ED encounters increased among commercially insured patients from 2011 to 2018, particularly for single-encounter chest and abdominopelvic CT examinations and for minor injuries. CLINICAL IMPACT. Given concerns about increased cost and detection of incidental findings, further investigation is warranted to explore the potential benefit of single-encounter chest and abdominopelvic CT examinations of patients with minor injuries and to develop strategies for optimizing appropriateness of imaging orders.

Utilization and Comparative Effectiveness of Uterine Artery Embolization versus Hysterectomy for Severe Postpartum Hemorrhage: A National Inpatient Sample Study.

PURPOSE: To identify differences in mortality or length of hospital stay for mothers treated with uterine artery embolization (UAE) or hysterectomy for severe postpartum hemorrhage (PPH), as well as to analyze whether geographic or clinical determinants affected the type of therapy received. MATERIALS AND METHODS: This National Inpatient Sample study from 2005 to 2017 included all patients with live-birth deliveries. Severe PPH was defined as PPH that required transfusion, hysterectomy, or UAE. Propensity score weighting-adjusted demographic, maternal, and delivery risk factors were used to assess mortality and prolonged hospital stay. RESULTS: Of 9.8 million identified live births, PPH occurred in 31.0 per 1,000 cases. The most common intervention for PPH was transfusion (116.4 per 1,000 cases of PPH). Hysterectomy was used more frequently than UAE (20.4 vs 12.9 per 1,000 cases). The following factors predicted that hysterectomy would be used more commonly than UAE: previous cesarean delivery, breech fetal position, placenta previa, transient hypertension during pregnancy without pre-eclampsia, pre-existing hypertension without pre-eclampsia, pre-existing hypertension with pre-eclampsia, unspecified maternal hypertension, and gestational diabetes (all P < .001). Delivery risk factors associated with greater utilization of hysterectomy over UAE included postterm pregnancy, premature rupture of membranes, cervical laceration, forceps vaginal delivery, and shock (all P < .001). There was no difference in mortality between hysterectomy and UAE. After balancing demographic, maternal, and delivery risk factors, the odds of prolonged hospital stay were 0.38 times lower with UAE than hysterectomy (P < .001). CONCLUSIONS: Despite similar mortality and shorter hospital stays, UAE is used far less than hysterectomy in the management of severe PPH.

Spending on Medical Imaging by Age and Gender in the U.S. Population With Employer-Sponsored Insurance.

Demographic changes in the population are an under-studied driving force of imaging utilization and associated spending. This study used national databases to characterize variations in spending on medical imaging among individuals with primary or secondary employer-sponsored insurance. Spending on imaging generally increased with age until individuals were approximately 80-85 years old, and among those who were 14-70 years old, spending was higher among women than men. The findings provide insight into how demographic changes could impact future spending on medical imaging.

Clinical Characteristics of Most Frequent Use of Iodinated Contrast Media for CT.

Given the integral role of CT in patient care, the current global contrast media shortage creates profound and manifold patient care implications. We used a large insurance dataset to highlight examinations (abdominopelvic and chest CT), delivery settings (emergency department and outpatient hospital), and clinical indications (acute abdominopelvic and chest disease and cancer surveillance) for which contrast-enhanced CT is most commonly used. Such information may help inform emerging national guidelines and institutional policies.

Increasing Utilization of Emergency Department Neuroimaging From 2007 Through 2017.

BACKGROUND. The volume of emergency department (ED) visits and the number of neuroimaging examinations have increased since the start of the century. Little is known about this growth in the commercially insured and Medicare Advantage populations. OBJECTIVE. The purpose of our study was to evaluate changing ED utilization of neuroimaging from 2007 through 2017 in both commercially insured and Medicare Advantage enrollees. METHODS. Using patient-level claims from Optum's deidentified Clinformatics Data Mart database, which annually includes approximately 12-14 million commercial and Medicare Advantage health plan enrollees, annual ED utilization rates of head CT, head MRI, head CTA, neck CTA, head MRA, neck MRA, and carotid duplex ultrasound (US) were assessed from 2007 through 2017. To account for an aging sample population, utilization rates were adjusted using annual relative proportions of age groups and stratified by patient demographics, payer type, and provider state. RESULTS. Between 2007 and 2017, age-adjusted ED neuroimaging utilization rates per 1000 ED visits increased 72% overall (compound annual growth rate [CAGR], 5%). This overall increase corresponded to an increase of 69% for head CT (CAGR, 5%), 67% for head MRI (CAGR, 5%), 1100% for head CTA (CAGR, 25%), 1300% for neck CTA (CAGR, 27%), 36% for head MRA (CAGR, 3%), and 52% for neck MRA (CAGR, 4%) and to a decrease of 8% for carotid duplex US (CAGR, -1%). The utilization of head CT and CTA of the head and neck per 1000 ED visits increased in enrollees 65 years old or older by 48% (CAGR, 4%) and 1011% (CAGR, 24%). CONCLUSION. Neuroimaging utilization in the ED grew considerably between 2007 and 2017, with growth of head and neck CTA far outpacing the growth of other modalities. Unenhanced head CT remains by far the dominant ED neuroimaging examination. CLINICAL IMPACT. The rapid growth of head and neck CTA observed in the fee-for-service Medicare population is also observed in the commercially insured and Medicare Advantage populations. The appropriateness of this growth should be monitored as the indications for CTA expand.

Federal Out-of-Network Balance Billing Legislation: Context and Implications for Radiology Practices.

Out-of-network (OON) balance billing, commonly known as surprise billing but better described as a surprise gap in health insurance coverage, occurs when an individual with private health insurance (vs a public insurer such as Medicare) is administered unanticipated care from a physician who is not in their health plan's network. Such unexpected OON care may result in substantial out-of-pocket costs for patients. Although ending surprise billing is patient centric, patient protective, and noncontroversial, passing federal legislation was challenging given its ability to disrupt insurer-physician good-faith negotiations and thus impact in-network rates. Like past proposals, the recently passed No Surprises Act takes patients out of the middle of insurer-physician OON reimbursement disputes, limiting patients' expense to standard in-network cost-sharing amounts. The new law, based on arbitration, attempts to protect good-faith negotiations between physicians and insurance companies and encourages network contracting. Radiology practices, even those that are fully in network or that never practiced surprise billing, could nonetheless be affected. Ongoing rulemaking processes will have meaningful roles in determining how the law is made operational. Physician and stakeholder advocacy has been and will continue to be crucial to the ongoing evolution of this process. © RSNA, 2021.

Radiologist Characteristics Associated with Interpretive Performance of Screening Mammography: A National Mammography Database (NMD) Study.

Background Factors affecting radiologists' performance in screening mammography interpretation remain poorly understood. Purpose To identify radiologists characteristics that affect screening mammography interpretation performance. Materials and Methods This retrospective study included 1223 radiologists in the National Mammography Database (NMD) from 2008 to 2019 who could be linked to Centers for Medicare & Medicaid Services (CMS) datasets. NMD screening performance metrics were extracted. Acceptable ranges were defined as follows: recall rate (RR) between 5% and 12%; cancer detection rate (CDR) of at least 2.5 per 1000 screening examinations; positive predictive value of recall (PPV1) between 3% and 8%; positive predictive value of biopsies recommended (PPV2) between 20% and 40%; positive predictive value of biopsies performed (PPV3) between the 25th and 75th percentile of study sample; invasive CDR of at least the 25th percentile of the study sample; and percentage of ductal carcinoma in situ (DCIS) of at least the 25th percentile of the study sample. Radiologist characteristics extracted from CMS datasets included demographics, subspecialization, and clinical practice patterns. Multivariable stepwise logistic regression models were performed to identify characteristics independently associated with acceptable performance for the seven metrics. The most influential characteristics were defined as those independently associated with the majority of the metrics (at least four). Results Relative to radiologists practicing in the Northeast, those in the Midwest were more likely to achieve acceptable RR, PPV1, PPV2, and CDR (odds ratio [OR], 1.4-2.5); those practicing in the West were more likely to achieve acceptable RR, PPV2, and PPV3 (OR, 1.7-2.1) but less likely to achieve acceptable invasive CDR (OR, 0.6). Relative to general radiologists, breast imagers were more likely to achieve acceptable PPV1, invasive CDR, percentage DCIS, and CDR (OR, 1.4-4.4). Those performing diagnostic mammography were more likely to achieve acceptable PPV1, PPV2, PPV3, invasive CDR, and CDR (OR, 1.9-2.9). Those performing breast US were less likely to achieve acceptable PPV1, PPV2, percentage DCIS, and CDR (OR, 0.5-0.7). Conclusion The geographic location of the radiology practice, subspecialization in breast imaging, and performance of diagnostic mammography are associated with better screening mammography performance; performance of breast US is associated with lower performance. ©RSNA, 2021 Online supplemental material is available for this article.

Patient-reported financial toxicity in multiple sclerosis: Predictors and association with care non-adherence.

BACKGROUND: Multiple sclerosis (MS) results in considerable financial burdens due to expensive treatment and high rates of disability, which could both impact care non-adherence. OBJECTIVE: To measure financial toxicity in MS patients, identify its predictors and association with care non-adherence. METHODS: Adult MS patients visiting neurology clinic (June 2018 to February 2019) were consented to complete a survey. Financial toxicity was measured using Comprehensive Score for Financial Toxicity (COST) (range: 0-44, the lower the score, the worse the financial toxicity). Independent predictors of financial toxicity were identified using linear regression. Associations of COST score with patient outcomes were assessed. RESULTS: The mean COST score in 243 recruited patients was 17.4 ± 10.2. In response to financial burdens, 66.7% and 34.7% reported life-style altering behaviors or care non-adherence, respectively. Higher financial self-efficacy was associated with less financial toxicity (coefficient, 1.33 (95% confidence interval (CI), 1.02-1.64); p < 0.001). At least one relapse in the last 3 months was associated with greater financial toxicity (coefficient, -3.34 (95% CI, -6.66 to -0.01); p = 0.049). Greater financial toxicity correlated with life-style-altering coping strategy use (p < 0.001), care non-adherence (p = 0.001), and worse health-related quality of life (HRQOL) (p = 0.03). CONCLUSION: MS patients with lower financial self-efficacy and prior relapse history are at higher risk for financial toxicity, with associated care non-adherence and lower HRQOL.

Contemporary Management of Pediatric Blunt Splenic Trauma: A National Trauma Databank Analysis.

PURPOSE: To quantify changes in the management of pediatric patients with isolated splenic injury from 2007 to 2015. MATERIALS AND METHODS: Patients under 18 years old with registered splenic injury in the National Trauma Data Bank (2007-2015) were identified. Splenic injuries were categorized into 5 management types: nonoperative management (NOM), embolization, splenic repair, splenectomy, or a combination therapy. Linear mixed models accounting for confounding variables were used to examine the direct impact of management on length of stay (LOS), intensive care unit (ICU) days, and ventilator days. RESULTS: Of included patients (n = 24,128), 90.3% (n = 21,789), 5.6% (n = 1,361), and 2.7% (n = 640) had NOM, splenectomy, and embolization, respectively. From 2007 to 2015, the rate of embolization increased from 1.5% to 3.5%, and the rate of splenectomy decreased from 6.9% to 4.4%. Combining injury grades, NOM was associated with the shortest LOS (5.1 days), ICU days (1.9 days), and ventilator days (0.5 day). Moreover, splenectomy was associated with longer LOS (10.1 days), ICU days (4.5 days), and ventilator days (2.1 days) than NOM. The average failure rate of NOM was 1.5% (180 failures/12,378 cases). Average embolization failure was 1.3% (6 failures/456 cases). Splenic artery embolization was associated with lower mortality than splenectomy (OR: 0.10, P <.001). No statistically significant difference was observed in mortality between embolization and NOM (OR: 0.96, P = 1.0). CONCLUSIONS: In pediatric splenic injury, NOM is the most utilized and associated with favorable outcomes, most notably in grades III to V pediatric splenic injury. If intervention is needed, embolization is effective and increasingly utilized most significantly in lower grade injuries.

Defining the Value of Interventional Radiology to Healthcare Stakeholders: Proceedings from a Society of Interventional Radiology Research Consensus Panel.

Interventional radiology (IR) has collectively struggled to articulate and prove its value to several external stakeholders. The goal of this research consensus panel was to provide a summary of the existing knowledge, identify current gaps in knowledge, identify the strengths and weaknesses in existing data, and prioritize research needs related to the value of IR. Panelists were asked to identify the critical relationships/alliances that should be fostered to advance the prioritized research and determine how the Society of Interventional Radiology and the Society of Interventional Radiology Foundation can further support these initiatives. Following presentations and discussions, it was determined that proving and quantifying how IR decreases the length of stay and prevents hospital admissions are the most salient, value-related research topics to pursue for the specialty.

Brain Imaging in Patients With Dementia Visiting U.S. Emergency Departments.

OBJECTIVE. This article aimed to assess changing use of brain imaging tests among patients with Alzheimer disease and vascular dementia who visited U.S. emergency departments (EDs) between 2006 and 2014. MATERIALS AND METHODS. Using the largest publicly available all-payer ED database, the Nationwide Emergency Department Sample, we identified a weighted cohort of 427,705 individuals with Alzheimer disease and 33,743 individuals with vascular dementia who visited U.S. EDs between 2006 and 2014. Logistic regression analyses were performed to identify factors associated with use. RESULTS. Between 2006 and 2014, ED visits among patients with Alzheimer disease and vascular dementia declined by 24.7% and 20.3%, respectively. However, there was a significant increase in utilization rates of head CT (from 4.4% to 11.1% in patients with Alzheimer disease and from 1.5% to 2.9% in patients with vascular dementia) and brain MRI (from 0.04% to 0.5% in patients with Alzheimer disease and 0.0% to 0.1% in those with vascular dementia) in the same time period. Among patients with Alzheimer disease, age, median income in patient ZIP code, day of the week of the ED visit, hospital teaching status, and hospital geographic region were significant predictors of imaging use. Among patients with vascular dementia, insurance type and hospital classification (urban vs rural) were significant predictors of imaging use. CONCLUSION. Despite declining ED visits, ED brain imaging in patients with Alzheimer disease and vascular dementia has increased. Various patient-specific and hospital-specific factors contribute to differential utilization rates.

The Medical Malpractice Deposition: A Review for Radiologist-Defendants.

Depositions are critical components of any medical malpractice lawsuit and seek to help uncover the facts of the case to allow justice to be served. Depositions often create considerable anxiety for physician-defendants, including radiologists. Defendants unfamiliar with the rules of questioning or interviewing techniques used by plaintiffs' attorneys may fail to appreciate important and nuanced details of questions from the plaintiff's attorney, which in turn could impact the outcome of the case. Thorough and informed deposition preparation is thus essential. Highlighting issues relevant to radiologist-defendants, we discuss the role and structure of medical malpractice depositions as well as common scenarios, lines of questioning, and attorney strategies.

Teaching Physician Supervision: Medicare's Ongoing Imperative for Academic Radiologists.

OBJECTIVE. Medicare permits radiologists to bill for trainee work but only in narrowly defined circumstances and with considerable consequences for noncompliance. The purpose of this article is to introduce relevant policy rationale and definitions, review payment requirements, outline documentation and operational considerations for diagnostic and interventional radiology services, and offer practical suggestions for academic radiologists striving to optimize regulatory compliance. CONCLUSION. As academic radiology departments advance their missions of service, teaching, and scholarship, most rely on residents and fellows to support expanding clinical demands. Given the risks of technical noncompliance, institutional commitment and ongoing education regarding teaching supervision compliance are warranted.

Disparities in the Use of Emergency Department Advanced Imaging in Medicare Beneficiaries.

OBJECTIVE. The purpose of our study was to assess potential disparities in the utilization of advanced imaging during emergency department (ED) visits. MATERIALS AND METHODS. This retrospective study was conducting using 5% Research Identifiable Files. All CT and MRI (together defined as "advanced imaging") examinations associated with ED visits in 2015 were identified for continuously enrolled Medicare beneficiaries. Individuals with medical claims 30 days before the index ED event were excluded, and encounters that occurred in hospitals without advanced imaging capabilities were also excluded. Patient characteristics were identified using Medicare files and hospital characteristics using the American Hospital Association Annual Survey of Hospitals. Multivariate logistic regression was used for the analysis. RESULTS. Of 86,976 qualifying ED encounters, 52,833 (60.74%) ED encounters were for female patients; 29.03% (n = 25,245) occurred at rural hospitals and 15.81% (n = 13,750) at critical access hospitals. Race distribution was 83.13% White, 11.05% Black, and 5.82% Other. Compared with ED patients at urban hospitals, those at rural and critical access hospitals were 6.9% less likely (odds ratio [OR] = 0.931, p = 0.015) and 18.0% less likely (OR = 0.820, p < 0.0001), respectively, to undergo advanced imaging. Compared with White patients, Black patients were 31.6% less likely (OR = 0.684, p < 0.0001) to undergo advanced imaging. Relative to their urban counterparts, both White (OR = 0.941, p = 0.05) and Black (OR = 0.808, p = 0.047) rural ED patients were less likely to undergo advanced imaging. CONCLUSION. Among Medicare beneficiaries receiving care in U.S. EDs, significant disparities exist in advanced imaging utilization. Although imaging appropriateness was not investigated, these findings suggest inequity. Further research is necessary to understand why consistent health benefits do not translate into consistent imaging access among risk-adjusted ED patients.

Increasing and disparate use of neuroimaging for adults and children with non-traumatic headaches in the US emergency departments: Opportunities for improvement.

BACKGROUND: Optimization of neuroimaging practices for headache is considered a national priority; however, nationwide patterns and predictors of neuroimaging use for headache in the US emergency departments (EDs) are unknown. OBJECTIVE: To analyze temporal neuroimaging utilization trends for adults and children with non-traumatic headache in the US EDs and identify factors predictive of neuroimaging use in this patient population. METHODS: Retrospective cross-sectional study using the Healthcare Cost and Utilization Project Nationwide Emergency Department Sample database for administrative encounter-level data analysis of a nationwide group of adult and pediatric patients with primary diagnosis of headache (ICD-9CM codes 784.0x, 339.xx, 346.xx) visited the US EDs between January 1, 2006 and December 31, 2014. Temporal trends and independent predictors of neuroimaging use (e.g., patient and hospital characteristics, primary payment sources) were determined. RESULTS: In 2006-2014, a weighted group of 18,146,302 patients with a primary diagnosis of non-traumatic headache visited US EDs. Advanced neuroimaging utilization increased from 18.6% (n = 350,777) to 34.8% (n = 756,895) in the total group, from 18.8% (n = 314,646) to 36.5% (n = 698,080) in the adult subgroup (+94.1%), and from 16.9% (n = 36,131) to 22.0% (n = 58,815) (+30.2%) in the pediatric subgroup (+87.0%) between 2006 and 2014. The strongest predictors of higher neuroimaging utilization were hospital location in the Northeast (OR 3.17, 95% CI 2.67-3.76) or South (OR 2.42, 95% CI 2.03-2.88) regions. Lower utilization of imaging was associated with weekend ED visits (OR 0.92, 95% CI 0.92-0.93), female gender (OR 0.82, 95% CI 0.81-0.83), and Medicare, Medicaid, or self-pay (vs. private insurance) encounters. CONCLUSION: Neuroimaging utilization in patients with headache in US EDs nearly doubled in 2006-2014, and was used in 34.8% of all ED encounters in 2014. Utilization was higher and increased at faster rates for adults than children. In US EDs, imaging for headache is preferentially performed on commercially insured and male patients, at urban hospitals, in certain geographic regions, and on weekdays, raising concerns regarding disparate imaging use.

Increasing emergency department utilization of brain imaging in patients with primary brain cancer.

PURPOSE: To study changing emergency department (ED) brain imaging utilization in patients with primary brain cancers. METHODS: Using 2006-2014 data from the Nationwide Emergency Department Sample (NEDS), we identified all patients with primary brain cancers visiting EDs and evaluated trends of head CT and brain MRI utilization. Multivariable logistic regression analyses were used to determine patient- and hospital-specific factors associated with brain imaging utilization. RESULTS: A weighted cohort of 40,862 ED visits were included (mean age 55; 54% male), increasing from 3932 in 2006 to 5625 in 2014 (+ 43%). A total of 14.4% underwent brain imaging, with 13.2% undergoing CT, 2.3% undergoing MRI, and 1.1% undergoing both modalities. Between 2006 and 2014, there was a 104% increase in the rate of ED brain imaging (from 9.7% in 2006 to 19.8% in 2014). Factors associated with higher utilization of ED brain imaging in adults were non-teaching hospital status and Midwest and Northeast hospital regions (compared with the West). In pediatric patients, higher utilization was associated with older age, higher median household income of patient's ZIP code, and visits in rural, non-teaching hospitals located in the Midwest, South, and Northeast (compared with the West). CONCLUSION: In US patients with primary brain cancer, the number of ED visits increased annually, and the utilization of ED head imaging examinations doubled in a recent 9-year period. A variety of sociodemographic characteristics are associated with a higher likelihood of imaging in both adult and pediatric patients.

Cost Analysis of Dialysis Access Maintenance Interventions across Physician Specialties in U.S. Medicare Beneficiaries.

Background Dialysis maintenance interventions account for billions of dollars in U.S. Medicare spending and are performed by multiple medical specialties. Whether Medicare costs differ by physician specialty is, to the knowledge of the authors, not known. Purpose To assess patency-adjusted costs of endovascular dialysis access maintenance by physician specialty. Materials and Methods In this retrospective longitudinal cohort study, patients who were beneficiaries of Medicare undergoing their first arteriovenous access placement in 2009 were identified by using billing codes in the 5% Limited Data Set. By tracking their utilization data through 2014, postintervention primary patency and aggregate payments associated with maintenance interventions were calculated. Unadjusted payments per year of access patency gain were compared across physician specialty. A general linear mixed-effects model adjusted for covariates was used, as follows: patient characteristics, access type (fistula vs graft), clinical severity, type of intervention (angioplasty, stent, thrombolysis), clinical location (hospital outpatient vs office-based laboratory), and resource utilization (operating room use, anesthesia use). Results First arteriovenous access was performed in 1479 beneficiaries (mean age, 63 years ± 15 [standard deviation]; 820 men) in 2009. Through 2014, 8166 maintenance interventions were performed in this cohort. Unadjusted mean Medicare payments for each incremental year of patency were as follows: $71 000 for radiologists, $89 000 for nephrologists, and $174 000 for surgeons. Billing for operating room (41.8% [792 of 1895], surgery; 10.2% [277 of 2709], nephrology; and 31.1% [1108 of 3562], radiology) and anesthesia (19.9% [377 of 1895], surgery; 2.6% [70 of 2709], nephrology; 4.7% [170 of 3562], radiology) varied by specialty and accounted for 407% and 132% higher payments, respectively. After adjusting for clinical severity and location, type of intervention, and resource utilization, nephrologists and surgeons had 59% (95% confidence interval: 44%, 73%; P < .001) and 57% (95% confidence interval: 43%, 72%; P < .001) higher payments, respectively, for the same patency gain compared with radiologists. Operating room use and anesthesia services were major drivers of higher cost, with 407% (95% confidence interval: 374%, 443%; P < .001) and 132% (95% confidence interval: 116%, 150%; P < .001) higher costs, respectively. Conclusion Patency-adjusted payments for hemodialysis access maintenance differed by physician specialty, driven partly by discrepant rates of billing for operating room and anesthesia use. © RSNA, 2020 Online supplemental material is available for this article. See also the editorial by White in this issue.

Clinical Practice Characteristics of Radiologists Based on American Board of Radiology Interventional Radiology Certification Status.

OBJECTIVE. The objective of this study was to assess clinical practice characteristics of radiologists on the basis of American Board of Radiology (ABR) interventional radiology (IR) certification status. MATERIALS AND METHODS. Medicare-participating radiologists were linked with ABR diplomates using the ABR's public search engine. Radiologists with an interventional radiology/diagnostic radiology (IR/DR) certificate (offered since 2017) were deemed currently IR-certified (n = 2840), and those assigned a vascular and interventional radiology subspecialty certificate (now defunct by the ABR) were deemed previously IR-certified (n = 900). Physician characteristics were obtained from Centers for Medicare & Medicaid Services (CMS) data. RESULTS. Overall, the mean percentage work effort in IR was higher for radiologists currently IR-certified than it was for radiologists who were previously IR-certified (65.9% vs 30.6%). Although 41.2% of currently IR-certified diplomates had more than 90% IR work effort, 35.7% had 50% or less IR work effort. Radiologists with current IR certification versus those with previous IR certification were more likely to be in an academic practice (25.1% vs 8.4%), a larger practice (in a practice with ≥ 100 members, 41.2% vs 22.4%), and earlier career stages (≤ 20 years in practice, 46.5% vs 0.6%). Of the 10 services most commonly billed by currently versus previously IR-certified radiologists, two and zero, respectively, were invasive procedures. Of identified CMS-participating radiologists with more than 50% IR effort, 27.2% (727/2670) were neither previously nor currently IR-certified. CONCLUSION. Although radiologists maintaining IR certification have higher IR work effort than those whose IR certification has lapsed, they are heterogeneous with overall sizable noninvasive diagnostic imaging practices. Approximately one-quarter of radiologists with predominant IR practices have never obtained IR certification. Because current IR/DR maintenance of certification testing exclusively addresses IR practice, attention is warranted to ensure certification is relevant to all IR diplomates.

Emerging Challenges and Opportunities in the Evolution of Teleradiology.

OBJECTIVE. In recent decades, teleradiology has expanded considerably, and many radiology practices now engage in intraorganizational or extraorganizational teleradiology. In this era of patient primacy, optimizing patient care and care delivery is paramount. This article provides an update on recent changes, current challenges, and future opportunities centered around the ability of teleradiology to improve temporal and geographic imaging access. We review licensing and regulations and discuss teleradiology in providing services to rural areas and assisting with disaster response, including the response to the coronavirus disease (COVID-19) pandemic. CONCLUSION. Teleradiology can help increase imaging efficiency and mitigate both geographic and temporal discrepancies in imaging care. Technologic limitations and regulatory hurdles hinder the optimal practice of teleradiology, and future attention to these issues may help ensure broader patient access to high-quality imaging across the United States.