Interpretations of Examinations Outside of Radiologists' Fellowship Training: Assessment of Discrepancy Rates Among 5.9 Million Examinations From a National Teleradiology Databank.

BACKGROUND. In community settings, radiologists commonly function as multispecialty radiologists, interpreting examinations outside of their area of fellowship training. OBJECTIVE. The purpose of this article was to compare discrepancy rates for preliminary interpretations of acute community-setting examinations that are concordant versus discordant with interpreting radiologists' area of fellowship training. METHODS. This retrospective study used the databank of a U.S. teleradiology company that provides preliminary interpretations for client community hospitals. The analysis included 5,883,980 acute examinations performed from 2012 to 2016 that were preliminarily interpreted by 269 teleradiologists with a fellowship of neuroradiology, abdominal radiology, or musculoskeletal radiology. When providing final interpretations, client on-site radiologists voluntarily submitted quality assurance (QA) requests if preliminary and final interpretations were discrepant; the teleradiology company's QA committee categorized discrepancies as major (n = 8444) or minor (n = 17,208). Associations among examination type (common vs advanced), relationship between examination subspecialty and the teleradiologist's fellowship (concordant vs discordant), and major and minor discrepancies were assessed using three-way conditional analyses with generalized estimating equations. RESULTS. For examinations with a concordant subspecialty, the major discrepancy rate was lower for common than for advanced examinations (0.13% vs 0.26%; relative risk [RR], 0.50, 95% CI, 0.42-0.60; p < .001). For examinations with a discordant subspecialty, the major discrepancy rate was lower for common than advanced examinations (0.14% vs 0.18%; RR, 0.81; 95% CI, 0.72-0.90; p < .001). For common examinations, the major discrepancy rate was not different between examinations with concordant versus discordant subspecialty (0.13% vs 0.14%; RR, 0.90; 95% CI, 0.81-1.01; p = .07). For advanced examinations, the major discrepancy rate was higher for examinations with concordant versus discordant subspecialty (0.26% vs 0.18%; RR, 1.45; 95% CI, 1.18-1.79; p < .001). The minor discrepancy rate was higher among advanced examinations for those with concordant versus discordant subspecialty (0.34% vs 0.29%; RR, 1.17; 95% CI, 1.00-1.36; p = .04), but not different for other comparisons (p > .05). CONCLUSION. Major and minor discrepancy rates were not higher for acute community-setting examinations outside of interpreting radiologists' fellowship training. Discrepancy rates increased for advanced examinations. CLINICAL IMPACT. The findings support multispecialty radiologist practice in acute community settings. Efforts to match examination and interpreting radiologist sub-specialty may not reduce diagnostic discrepancies.

Percutaneous Image-guided Cryoneurolysis: Applications and Techniques.

The expansion and dissemination of interventional cryoneurolysis in recent years has been fueled by the integration of advanced imaging guidance, the evolution of our understanding of neuropathologic processes after exposure of nerves to cold, and opportunities for its use beyond pain management. The clinical translation of cryoneurolysis through interventional radiology requires consideration of many factors, including (a) the supply and composition of target nerves, (b) the value of diagnostic injection with imaging guidance for confirmation, (c) the integration of advanced imaging guidance that allows safe ablation, (d) the difference between neoplastic and nonneoplastic causes of pain, (e) the phenomenon of percutaneously induced neuroregeneration, (f) the potential to manage conditions other than pain, (g) the consideration of protocols, (h) the limitations of current technology, and (i) the potential complications and adverse effects. Cryoneurolysis has societal and legislative endorsement as an effective nonopioid option for pain palliation. The Centers for Medicare and Medicaid Services (CMS) approved three new category III Current Procedural Terminology (CPT) codes specifically for the cryoablation of nerves with advanced imaging guidance. Interventional radiologists who are aware of nerve-directed strategies see eligible patients in their daily practice and have opportunities to bundle procedures (eg, celiac plexus block at the time of a biliary drain for pancreatic cancer with low bile duct obstruction), offering an avenue to serve the patient, reduce opioid dependence, allow faster discharge, and establish name recognition of interventional radiologists. Also, the ability to use CT to target deep structures accurately and swiftly, often with only local anesthesia, compared with the usual monitored anesthesia care in a surgical setting, may provide another avenue to build a cryoneurolysis practice. ©RSNA, 2022.

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.

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.

Generalist versus Subspecialist Workforce Characteristics of Invasive Procedures Performed by Radiologists.

Purpose To explore subspecialty workforce considerations surrounding invasive procedures performed by radiologists. Materials and Methods The 2015 Centers for Medicare & Medicaid Services Physician and Other Supplier Public Use File was used to identify all invasive procedures (Current Procedural Terminology code range, 10000-69999) billed by radiologists for Medicare fee-for-service beneficiaries. Radiologists were categorized by subspecialty according to the majority of their billable work-relative value units (wRVUs). Those without a single subspecialty majority work effort were deemed generalists. Procedures were categorized into three tiers of complexity (high, ≥4.0 wRVUs; mid, 1.6-3.9 wRVUs; low, ≤1.5 wRVUs). Total and tiered generalist versus subspecialist workforce composition was assessed. Results Just 25 unique services comprised more than 75% of invasive procedures performed by radiologists. Of radiologists who performed procedures, 57.5% were generalists, 15.8% were interventionalists, and 26.8% were other subspecialists. Of the radiologists who performed low-, mid-, and high-complexity procedures, generalists accounted for 46.3%, 30.9%, and 23.1%, respectively; interventionalists accounted for 35.4%, 30.9%, and 75.2%, respectively; and other subspecialists accounted for 18.3%, 14.6%, and 1.7%, respectively. Generalists were the dominant providers of six of the top 10 low-complexity and seven of the top 10 midcomplexity procedures. Interventionalists were the dominant providers of all top 10 high-complexity procedures. Nationally, over twice as many U.S. counties had local access to generalists (869 counties) for invasive procedures versus interventionalists (347 counties) or other subspecialists (380 counties). Conclusion Among radiologists, generalists perform far more procedures in more geographic locations and are more likely to serve patients with less complex service needs than are interventionalists or other subspecialists. Practices and professional societies must remain vigilant to ensure that the subspecialty evolution in radiology does not exacerbate patient access disparities. © RSNA, 2018 Online supplemental material is available for this article.

Percutaneous Image-Guided Cryoneurolysis.

OBJECTIVE: The aim of this article is to review the available evidence regarding image-guided percutaneous cryoneurolysis, with a focus on indications, technique, efficacy, and potential complications. CONCLUSION: Percutaneous image-guided cryoneurolysis is safe and effective for the management of several well-described syndromes involving neuropathic pain. Additional rigorous prospective study is warranted to further define the efficacy and specific role of these interventions.

Assessment of arterial supply to the stomach after bariatric surgery using multidetector CT arteriography.

PURPOSE: To describe residual arterial supply to the stomach after bariatric surgery via a systematic arterial-phase CT assessment approach that can aid in diagnosis and treatment of postoperative complications and facilitate planning for future procedures. METHODS: Arterial-phase CT of 46 patients who underwent Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) at 3 academic institutions were retrospectively reviewed to assess patency of left gastric artery (LGA), right gastric artery (RGA), gastroepiploic artery (GEA), and left inferior phrenic artery (LIPA) and presence of gastric perforators. RESULTS: In 25 RYGB and 21 SG patients, mean diameters were LGA 2.2 ± 0.4 mm, RGA 1.6 ± 0.5 mm, and GEA 1.7 ± 0.4 mm. On RYGB scans, all LGAs, RGAs, and 24/25 (96%) of GEAs were identified. Excellent to good patency was seen in 20/25 (80%) LGAs, 21/25 (84%) RGAs, and 23/24 (96%) GEAs. On SG scans, all LGAs, 18/21 (86%) of RGAs, and 20/21 (95%) GEAs were identified. Excellent to good patency was seen in 17/21 (81%) LGAs, 15/18 (83%) RGAs, and 20/20 (100%) GEAs. In terms of gastric perforators, LGA supply was seen on 23/25 (92%) of RYGB and 17/17 (100%) of SG scans. RGA supply was seen on 13/21 (62%) RYGB and 9/18 (50%) SG scans. GEA supply was seen on 19/23 (83%) RYGB scans. No gastric supply via GEA was seen on SG scans. CONCLUSION: In this study, arterial supply to the stomach through the LGA was consistently identified in all RYGB and SG cases, indicating an uncomplicated surgical approach with regard to preserving the LGA. Dedicated CT angiography protocol or catheter-directed angiography is recommended for accurate and comprehensive assessment of the gastric blood supply, particularly before surgical re-intervention.

Osteopathic Versus Allopathic Radiologist Workforce Characteristics: A Medicare Administrative and Claims Data Analysis.

PURPOSE: Radiologist medical school pathways have received little attention in recent workforce investigations. With osteopathic enrollment increasing, we assessed the osteopathic versus allopathic composition of the radiologist workforce. METHODS: Linking separate Medicare Doctors and Clinicians Initiative databases and Physician and Other Supplier Files from 2014 through 2019, we assessed (descriptively and using multivariate panel logistic regression modeling) individual and practice characteristics of radiologists who self-reported medical degrees. RESULTS: Between 2014 and 2019, as the number of osteopathic radiologists increased 46.0% (4.7% to 6.0% of total radiologist workforce), the number of allopathic radiologists increased 12.1% (representing a relative workforce decrease from 95.3% to 94.0%). For each year since completing training, practicing radiologists were 3.7% less likely to have osteopathic (versus allopathic) degrees (odds ratio [OR] = 0.96 per year, P < .01). Osteopathic radiologists were less likely to work in urban (versus rural) areas (OR = 0.95), and compared with the Midwest, less likely to work in the Northeast (OR = 0.96), South (OR = 0.95), and West (OR = 0.94) (all P < .01). Except for cardiothoracic imaging (OR = 0.78, P = .24), osteopathic radiologists were more likely than allopathic radiologists to practice as general (rather than subspecialty) radiologists (range OR = 0.37 for nuclear medicine to OR = 0.65 for neuroradiology, all P < .01). CONCLUSIONS: Osteopathic physicians represent a fast-growing earlier-career component of the radiologist workforce. Compared with allopathic radiologists, they more frequently practice as generalist radiologists, in rural areas, and in the Midwest. Given recent calls for greater general and rural radiology coverage, increasing osteopathic representation in the national radiologist workforce could improve patient access.

What's in a Name? Report of the ACR Task Force on General Radiology and Multi-Subspecialization.

The ACR Council passed Resolution 47 at its 2020 annual meeting establishing a representative task force (TF) to explore the concept of the "multispecialty radiologist," previously proposed in 2012. The TF held eight virtual meetings over 8 months, considered data from a 2020 ACR Membership Tracking Survey, conducted a review of current literature, and collected anecdotal experience from TF members and ACR leadership. ACR legal counsel and a cross-section of ACR Commissions and Committees also provided input. The TF concluded that there is scant interest from the radiology community in the multispecialty radiologist title and no agreed-upon definition for the term. Radiologists may identify as diagnostic or subspecialty radiologists; however, the roles they fill in clinical practice include general, multispecialty, and subspecialized radiology. The TF proposes definitions for each of these terms to support radiologist recruitment aligned with optimal patient care in the practice community and to improve the quality of data collection about the field. To reduce ambiguity, the TF proposes adoption of the defined terms by the radiology community, including radiologist recruiters and employers, and suggests ways in which resident training and the ABR board examination can be adapted to support this new structure. Additionally, as part of an exploration of hyperspecialization and trainee preparedness for clinical practice, the TF discussed the challenges faced by community-based practices seeking to provide a full range of high-quality, radiologist-delivered diagnostic and interventional services to their patient populations.

Practice Characteristics of the United States General Radiologist Workforce: Most Generalists Work as Multispecialists.

RATIONALE AND OBJECTIVES: While subspecialty radiologists' practice patterns have received recent attention, little is known about the practice patterns of general radiologists. We aim to characterize this group (which represents most US radiologists). MATERIALS AND METHODS: US radiologists' individual work efforts were assessed using the 2017 Medicare Provider and Other Supplier Public Use File and a previously validated wRVU-weighted claims-based classification system. Using prior criteria, radiologists without >50% work efforts in a single subspecialty were deemed generalists. For this study, a >25% subspecialty work effort threshold was deemed a subspecialty "focus area," and generalists with ≥2 subspecialty focus areas were deemed "multispecialists." Practice characteristics were summarized using various parameters. RESULTS: Among 12,438 radiologists meeting existing claims-based criteria to be deemed generalists, 85.0% had ≥2 subspecialty focus areas of >25% work effort (i.e., multispecialists), 14.6% had one focus area, and 0.4% had no focus area. The fraction of generalists meeting multispecialist criteria was similar across radiologists' years in practice (range 84.7% to 85.4%), academic vs. nonacademic status (84.9% to 86.6%), and practice size (83.3% to 87.0%). Although general radiologist multispecialization varied geographically, a majority were multispecialists in all states (range 57.6% in VT to 93.9% in WY) and percentages were not associated with state-level population density (r = 0.013; p = 0.926). CONCLUSION: The large majority of US general radiologists practice as multispecialists, and nearly all have at least one subspecialty focus area. The predominance of general radiologists' multispecialty focus across various practice types and locations supports their role in facilitating patient access to a range of radiologist subspecialties.

Access to Interventional Radiology Services in Small Hospitals and Rural Communities: An ACR Membership Intercommission Survey.

PURPOSE: To evaluate the status of interventional radiology (IR) staffing, recruitment, and retention in the United States, specifically as they apply to small hospitals and rural communities. MATERIALS AND METHODS: A 22-question survey was created by an ACR intercommission workgroup and circulated via e-mail to ACR members who self-identified as a "group practice leader," "general radiologist," "interventional radiologist," or "abdominal radiologist." Contingency tables were constructed, and bivariate analyses were performed to assess overall responses and the distribution of responses among specific groups of respondents. RESULTS: A total of 1,005 e-mail recipients completed the survey. A statistically significant greater proportion of responders from rural hospitals (versus nonrural hospitals) answered that (1) their group falls short or far short of meeting demand for IR services (29.1% versus 14.3%), (2) they had difficulty recruiting IR physicians to their practice (67% versus 40.6%), and (3) they had difficulty retaining IR physicians (40% versus 29%). The most frequently reported reasons for difficulty recruiting were that IR-trained physicians "do not want to do diagnostic work" (56.2%) and "do not want to practice in a small or rural setting" (48.8%). A greater proportion of respondents from rural hospitals perceived that they had difficulty retaining IR physicians because of perceived inadequate "complexity of case mix" (67.5%) or "number of cases" (66.1%). CONCLUSION: Small hospitals and rural communities experience greater difficulty recruiting and retaining IR physicians and meeting IR service demands compared with their nonrural counterparts.

The Current State of Teleradiology Across the United States: A National Survey of Radiologists' Habits, Attitudes, and Perceptions on Teleradiology Practice.

PURPOSE: To explore the current state of teleradiology practice, defined as the interpretation of imaging examinations at a different facility from where the examination was performed. METHODS: A national survey addressing radiologists' habits, attitudes, and perceptions regarding teleradiology was distributed by e-mail to a random sample of ACR members in early 2019. RESULTS: Among 731 of 936 respondents who indicated a non-teleradiologist primary work setting, 85.6% reported performing teleradiology within the past 10 years and 25.4% reported that teleradiology represents a majority of their annual imaging volumes; 84.4% performed teleradiology for internal examinations and 45.7% for external examinations; 46.2% performed teleradiology for rural areas and 37.2% for critical access hospitals; 91.3% performed teleradiology during weekday normal business hours and 44.5% to 79.6% over evening, overnight, and weekend hours. In all, 76.9% to 86.2% perceived value from teleradiology for geographic, after-hours, and multispecialty coverage, as well as reduced interpretation turnaround times. The most common challenges for teleradiology were electronic health record access (62.8%), quality assurance (53.8%), and technologist proximity (48.4%). The strategy most commonly considered useful for improving teleradiology was technical interpretation standards (33.3%). Radiologists in smaller practices were less likely to perform teleradiology or performed teleradiology for lower fractions of work, were less likely to experience coverage advantages of teleradiology, and reported larger implementation challenges, particularly relating to electronic health records and prior examination access. CONCLUSION: Despite historic concerns, teleradiology is widespread throughout modern radiology practice, helping practices achieve geographic, after-hours, and multispecialty coverage; reducing turnaround times; and expanding underserved access. Nonetheless, quality assurance of offsite examinations remains necessary. IT integration solutions could help smaller practices achieve teleradiology's benefits.

Emergency Radiology: Current Challenges and Preparing for Continued Growth.

The escalation of imaging volumes in the emergency department and intensifying demands for rapid radiology results have increased the demand for emergency radiology. The provision of emergency radiology is essential for nearly all radiology practices, from the smallest to the largest. As our radiology specialty responds to the challenge posed by the triple threat of providing 24-7 coverage, high imaging volumes, and rapid turnaround time, various questions regarding emergency radiology have emerged, including its definition and scope, unique operational demands, quality and safety concerns, impact on physician well-being, and future directions. This article reviews the current challenges confronting the subspecialty of emergency radiology and offers insights into preparing for continued growth.

Unifying the Silos of Subspecialized Radiology: The Essential Role of the General Radiologist.

As radiology becomes increasingly subspecialized, conversations focus on whether the general radiologist is trending toward extinction. Current data indicate that the vast majority of graduating radiology residents now seek fellowship training. Practicing entirely within the narrow confines of one's fellowship subspecialty area, however, is uncommon, with recent data indicating that more than half of all radiologists spend the majority of their work effort as generalists. From the traditional concept of the generalist as the non-fellowship-trained radiologist who interprets everything to the multispecialty-trained radiologist to the emergency radiologist who is a subspecialist but reads across the traditional anatomic divisions, the general radiologist of today and the future is one who remains broadly skilled and equipped to provide a wide spectrum of radiologic services. The successful future of many practices of all types and the specialty as a whole will require ongoing collaborative partnerships that include both general and subspecialized radiologists. This review article highlights various scenarios in which general radiologists provide value to different types of radiology practices.

ACR 2016 Open-Microphone Session: ACR Membership 3.0-Moving From Member Volume to Value.

This report of the 2016 ACR Council Open Microphone session reviews the discussion around interests and concerns of council members and state chapter leaders as to the perceived and real value of their ACR membership, and how the ACR might further enhance membership value and meaningful engagement with members.

2017 ACR Annual Meeting Open-Microphone Session: Navigating the Landscape of Changing Practice Models: Private Practice, Corporate Radiology, and Enterprise Systems.

Many practice groups are considering adopting new practice models, primarily to secure their practices by adapting to new payment models, government compliance and regulation, and increasing IT and infrastructure costs. As we move toward value-based care and capitation, the value equation (value = quality/cost) will lead us to also compete on cost to improve value. No matter what payment models ultimately dominate, we need to be prepared to lead in a value-based care environment. Measures of value will either be defined by radiologists or imposed by outside entities. It is critical to our continued success that practices and practice leaders continue to fully and strongly support the ACR to avoid the possibility of a decline in membership that may accompany a lack of practice engagement. Consolidation appears inevitable, but with the help of the ACR, radiologists should have a vibrant future if investments are made now in determining appropriate radiology-specific value measures that are meaningful in consolidated health care environments.