ACR Appropriateness Criteria® Imaging After Total Knee Arthroplasty: 2023 Update.

Total knee arthroplasty is the most commonly performed joint replacement procedure in the United States. This manuscript will discuss the recommended imaging modalities for six clinical variants; 1. follow-up of symptomatic or asymptomatic patients with a total knee arthroplasty. Initial imaging, 2. Suspected infection after total knee arthroplasty. Additional imaging following radiographs, 3. Pain after total knee arthroplasty. Infection excluded. Suspect aseptic loosening or osteolysis or instability. Additional imaging following radiographs, 4. Pain after total knee arthroplasty. Suspect periprosthetic or hardware fracture. Additional imaging following radiographs, 5. Pain after total knee arthroplasty. Measuring component rotation. Additional imaging following radiographs, and 6. Pain after total knee arthroplasty. Suspect periprosthetic soft-tissue abnormality unrelated to infection, including quadriceps or patellar tendinopathy. Additional imaging following radiographs. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

The Remote Academic Radiologist: AJR Expert Panel Narrative Review.

The importance of developing a robust remote workforce in academic radiology has come to the forefront due to several converging factors. COVID-19, and the abrupt transformation it precipitated in terms of how radiologists worked, has been the biggest impetus for change; concurrent factors such as increasing examination volumes and radiologist burnout have also contributed. How to best advance the most desirable and favorable aspects of remote work while preserving an academic environment that fulfills the tripartite mission is a critical challenge that nearly all academic institutions face today. In this article, we discuss current challenges in academic radiology, including effects of the COVID-19 pandemic, from three perspectives-the radiologist, the learner, and the health system-addressing the following topics: productivity, recruitment, wellness, clinical supervision, mentorship and research, educational engagement, radiologist access, investments in technology, and radiologist value. Throughout, we focus on the opportunities and drawbacks of remote work, to help guide its effective and reliable integration into academic radiology practices.

Radiologist age and diagnostic errors.

PURPOSE: Previous investigations into the causes of error by radiologists have addressed work schedule, volume, shift length, and sub-specialization. Studies regarding possible associations between radiologist errors and radiologist age and timing of residency training are lacking in the literature, to our knowledge. The aim of our study was to determine if radiologist age and residency graduation date is associated with diagnostic errors. METHODS: Our retrospective analysis included 1.9 million preliminary interpretations (out of a total of 5.2 million preliminary and final interpretations) of imaging examinations by 361 radiologists in a US-based national teleradiology practice between 1/1/2019 and 1/1/2020. Quality assurance data regarding the number of radiologist errors was generated through client facility feedback to the teleradiology practice. With input from both the client radiologist and the teleradiologist, the final determination of the presence, absence, and severity of a teleradiologist error was determined by the quality assurance committee of radiologists within the teleradiology company using standardized criteria. Excluded were 3.2 million final examination interpretations and 93,963 (1.8%) of total examinations from facilities reporting less than one discrepancy in examination interpretation in 2019. Logistic regression with covariates radiologist age and residency graduation date was performed for calculation of relative risk of overall error rates and by major imaging modality. Major errors were separated from minor errors as those with a greater likelihood of affecting patient care. Logistic regression with covariates radiologist age, residency graduation date, and log total examinations interpreted was used to calculate odds of making a major error to that of making a minor error. RESULTS: Mean age of the 361 radiologists was 51.1 years, with a mean residency graduation date of 2001. Mean error rate for all examinations was 0.5%. Radiologist age at any residency graduation date was positively associated with major errors (p < 0.05), with a relative risk 1.021 for each 1-year increase in age and relative risk 1.235 for each decade as well as for minor errors (p < 0.05, relative risk 1.007 for each year, relative risk 1.082 for each decade). By major imaging modality, radiologist age at any residency graduation date was positively associated with computed tomography (CT) and X-ray (XR) major and minor error, magnetic resonance imaging (MRI) major error, and ultrasound (US) minor error (p < 0.05). Radiologist age was positively associated with odds of making a major vs. minor error (p < 0.05). CONCLUSIONS: The mean error rate for all radiologists was low. We observed that increasing age at any residency graduation date was associated with increasing relative risk of major and minor errors as well as increasing odds of a major vs. minor error among providers. Further study is needed to corroborate these results, determine clinical relevance, and highlight strategies to address these findings.

Are Academic Emergency Radiologists Systematically Disadvantaged Compared With Diagnostic Radiology Subspecialty Counterparts When It Comes to Promotion?

PURPOSE: The aim of this study was to assess academic rank differences between academic emergency and other subspecialty diagnostic radiologists. METHODS: Academic radiology departments likely containing emergency radiology divisions were identified by inclusively merging three lists: Doximity's top 20 radiology programs, the top 20 National Institutes of Health-ranked radiology departments, and all departments offering emergency radiology fellowships. Within departments, emergency radiologists (ERs) were identified via website review. Each was then matched on career length and gender to a same-institutional nonemergency diagnostic radiologist. RESULTS: Eleven of 36 institutions had no ERs or insufficient information for analysis. Among 283 emergency radiology faculty members from 25 institutions, 112 career length- and gender-matched pairs were included. Average career length was 16 years, and 23% were women. The mean h indices for ERs and non-ERs were 3.96 ± 5.60 and 12.81 ± 13.55, respectively (P < .0001). Non-ERs were twice as likely as ERs (0.21 versus 0.1) to be associate professors at h index < 5. Men had nearly 3 times the odds of advanced rank compared with women (odds ratio, 2.91; 95% confidence interval, 1.02-8.26; P = .045). Radiologists with at least one additional degree had nearly 3 times the odds of advancing rank (odds ratio, 2.75; 95% confidence interval, 1.02-7.40; P = .045). Each additional year of practice increased the odds of advancing rank by 14% (odds ratio, 1.14; 95% confidence interval, 1.08-1.21; P < .001). CONCLUSIONS: Academic ERs are less likely to achieve advanced rank compared with career length- and gender-matched non-ERs, and this persists even after adjusting for h index, suggesting that academic ERs are disadvantaged in current promotions systems. Longer term implications for staffing and pipeline development merit further attention as do parallels to other nonstandard subspecialties such as community radiology.

Time ratio disparities among ED patients undergoing head CT.

PURPOSE: To assess if patients who underwent head computed tomography (CT) experienced disparities in the emergency department (ED) and if the indication for head CT affected disparities. METHODS: This study employed a retrospective, IRB-approved cohort design encompassing four hospitals. All ED patients between January 2016 and September 2020 who underwent non-contrast head CTs were included. Furthermore, key time intervals including ED length of stay (LOS), ED assessment time, image acquisition time, and image interpretation time were calculated. Time ratio (TR) was used to compare these time intervals between the groups. RESULTS: A total of 45,177 ED visits comprising 4730 trauma cases, 5475 altered mental status cases, 11,925 cases with head pain, and 23,047 cases with other indications were included. Females had significantly longer ED LOS, ED assessment time, and image acquisition time (TR = 1.012, 1.051, 1.018, respectively, P-value < 0.05). This disparity was more pronounced in female patients with head pain complaints compared to their male counterparts (TR = 1.036, 1.059, and 1.047, respectively, P-value < 0.05). Black patients experienced significantly longer ED LOS, image acquisition time, and image assessment time (TR = 1.226, 1.349, and 1.190, respectively, P-value < 0.05). These disparities persisted regardless of head CT indications. Furthermore, patients with Medicare/Medicaid insurance also faced longer wait times in all the time intervals (TR > 1, P-value < 0.001). CONCLUSIONS: Wait times for ED head CT completion were longer for Black patients and Medicaid/Medicare insurance holders. Additionally, females experienced extended wait times, particularly when presented with head pain complaints. Our findings underscore the importance of exploring and addressing the contributing factors to ensure equitable and timely access to imaging services in the ED.

Are disparities in emergency department imaging exacerbated during high-volume periods?

PURPOSE: Evaluate if disparities in the emergency department (ED) imaging timeline exist, and if disparities are altered during high volume periods which may stress resource availability. METHODS: This retrospective study was conducted at a four-hospital healthcare system. All patients with at least one ED visit containing imaging from 1/1/2016 to 9/30/2020 were included. Peak hours were defined as ED encounters occurring between 5 pm and midnight, while all other ED encounters were non-peak hours. Patient-flow data points included ED length of stay (LOS), image acquisition time, and diagnostic image assessment time. RESULTS: 321,786 total ED visits consisted of 102,560 during peak hours and 219,226 during non-peak hours. Black patients experienced longer image acquisition and image assessment times across both time periods (TR = 1.030; p < 0.001 and TR = 1.112; p < 0.001, respectively); Black patients also had increased length of stay compared to White patients, which was amplified during peak hours. Likewise, patients with primary payer insurance experienced significantly longer image acquisition and image assessment times in both periods (TR > 1.00; p < 0.05 for all). Females had longer image acquisition and image assessment time and the difference was more pronounced in image acquisition time during both peak and non-peak hours (TR = 1.146 and TR = 1.139 respectively with p < 0.001 for both). CONCLUSION: When measuring radiology time periods, patient flow throughout the ED was not uniform. There was unequal acceleration and deceleration of patient flow based on racial, gender, age, and insurance status. Segmentation of patient flow time periods may allow identification of causes of inequity such that disparities can be addressed with targeted actions.

Artificial Intelligence/Machine Learning Education in Radiology: Multi-institutional Survey of Radiology Residents in the United States.

RATIONALE AND OBJECTIVES: To evaluate radiology residents' perspectives regarding inclusion of artificial intelligence/ machine learning (AI/ML) education in the residency curriculum. MATERIALS AND METHODS: An online anonymous survey was sent to 759 residents at 21 US radiology residency programs. Resident demographics, sub-specialty interests, educational background and research experiences, as well as the awareness, availability, and usefulness of various resources for AI/ML education were collected. RESULTS: The survey response rate was 27% (209/759). A total of 74% of respondents were male, 80% were training at large university programs, and only a minority (<20) had formal education or research experience in AI/ML. All four years of training were represented (range: 20%-38%). The majority of the residents agreed or strongly agreed (83%) that AI/ML education should be a part of the radiology residency curriculum and that such education should equip them with the knowledge to troubleshoot an AI tool in practice / determine whether a tool is working as intended (82%). Among the residency programs that offer AI/ML education, the most common resources were lecture series (43%), national informatics courses (28%), and in-house/institutional courses (26%). About 24% of the residents reported no AI/ML educational offerings in their residency curriculum. Hands on AI/ML laboratory (67%) and lecture series (61%) were reported as the most beneficial or effective. The majority of the residents preferred AI/ML education offered as a continuous course spanning the radiology residency (R1 to R4) (76%), followed by mini fellowship during R4 (32%) and as a course during PGY1 (21%). CONCLUSION: Residents largely favor the inclusion of formal AI/ML education in the radiology residency curriculum, prefer hands-on learning and lectures as learning tools, and prefer a continuous AI/ML course spanning R1-R4.

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.

Imaging of Soft Tissue Infections.

Although superficial infections can often be diagnosed and managed clinically, physical examination may lack sensitivity and specificity, and imaging is often required to evaluate the depth of involvement and identify complications. Depending on the area of involvement, radiography, ultrasound, CT, MR imaging, or a combination of imaging modalities may be required. Soft tissue infections can be nonnecrotizing or necrotizing, with the later having a morbid and rapid course. Infectious tenosynovitis most commonly affects the flexor tendon sheaths of the hand, characterized by thickened and enhancing synovium with fluid-filled tendon sheaths.

Comparative effectiveness of pelvic arterial embolization versus laparotomy in adults with pelvic injuries: A National Trauma Data Bank analysis.

PURPOSE: To compare the clinical outcomes and trends of arterial embolization (AE) versus laparotomy which are used in the management of pelvic trauma. MATERIALS AND METHODS: Adult patients with pelvic injuries were identified using the National Trauma Data Bank (NTDB) from 2007 to 2015. Patients with non-pelvic life-threatening injuries were excluded. Patients were grouped in operatively managed pelvic ring injuries, laparotomy ± fixation, AE ± fixation, and laparotomy and AE ± fixation. Using a linear mixed regression and logistic regression models, hospital length of stay (LOS), ICU days, ventilator days, and mortality for different therapies were compared. A propensity score weighting method was used to further eliminate treatment selection bias in the study sample and compare the outcomes between AE and laparotomy. RESULTS: Of 7473 pelvic trauma patients, 1226 (16.4%) patients were only operatively managed. 3730 patients (49.9%) underwent laparotomy, 2136 underwent AE (28.6%), and 381 (5.1%) patients underwent both laparotomy and AE. The year of injury, patient age, gender, race, severity of injury and presence of shock were found to be predictors of receipt of different therapies (P < 0.001 for all). When correcting for these confounding factors, the mortality rate was lower in the AE group compared to the laparotomy group 6.6% vs. 20.6% (P < 0.001). Additionally, LOS and ICU days were shorter for the AE group than the laparotomy group (P < 0.001). CONCLUSION: AE in patients with pelvic injuries is associated with lower mortality, as well as shorter LOS and ICU stays compared to laparotomy.

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.

ACR Appropriateness Criteria® Nontraumatic Chest Wall Pain.

Chest pain is a common reason that patients may present for evaluation in both ambulatory and emergency department settings, and is often of musculoskeletal origin in the former. Chest wall syndrome collectively describes the various entities that can contribute to chest wall pain of musculoskeletal origin and may affect any chest wall structure. Various imaging modalities may be employed for the diagnosis of nontraumatic chest wall conditions, each with variable utility depending on the clinical scenario. We review the evidence for or against use of various imaging modalities for the diagnosis of nontraumatic chest wall pain. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Disproportionate Use in Minor Trauma Is Driving Emergency Department Cervical Spine Imaging: An Injury Severity Score-Based Analysis.

PURPOSE: Clinical practice guidelines intended to reduce unnecessary cervical spine imaging have yielded mixed results. We aimed to assess evolving emergency department (ED) cervical spine imaging utilization in patients with trauma by injury severity. METHODS: Using 2009 to 2018 IBM MarketScan Commercial Databases, we identified ED trauma encounters, associated cervical spine imaging, and related diagnosis codes. We classified encounters by injury severity (minor, intermediate, major) using an International Classification of Disease code-derived Injury Severity Score algorithm and studied evolving imaging utilization using multivariable Poisson regression models. RESULTS: Of all 11,346,684 ED visits for trauma, 7,753,914 (68.3%), 3,524,250 (31.1%), and 68,520 (0.6%) involved minor, intermediate, and major injuries, respectively. Overall cervical spine imaging increased 5.7% annually (incidence rate ratio [IRR] 1.057, P < .001) with radiography decreasing 2.7% annually (IRR 0.973, P < .001) and CT increasing 10.5% annually (IRR 1.105, P < .001). Radiography utilization remained unchanged for minor injuries (IRR 0.994, P = .14) but decreased for intermediate (IRR 0.928 versus minor, P < .001) and major (IRR 0.931 versus minor, P < .001) injuries. Increases in CT utilization were greatest for minor injuries (IRR 1.109, P < .001) with smaller increases in intermediate (IRR 0.960 versus minor, P < .001) and major (IRR 0.987 versus minor, P = .022) injuries. CONCLUSIONS: Recent increases in cervical spine imaging in commercially insured patients with trauma seen in the ED have been largely related to increases in CT for patients with only minor injuries, in whom imaging utilization has been historically low. Further study is necessary to assess appropriateness, implications on costs and population radiation dose, and factors influencing ordering decision making.

Imaging Manifestations of Chest Trauma.

Trauma is the leading cause of death among individuals under 40 years of age, and pulmonary trauma is common in high-impact injuries. Unlike most other organs, the lung is elastic and distensible, with a physiologic capacity to withstand significant changes in contour and volume. The most common types of lung parenchymal injury are contusions, lacerations, and hematomas, each having characteristic imaging appearances. A less common type of lung injury is herniation. Chest radiography is often the first-line imaging modality performed in the assessment of the acutely injured patient, although there are inherent limitations in the use of this modality in trauma. CT images are more accurate for the assessment of the nature and extent of pulmonary injury than the single-view anteroposterior chest radiograph that is typically obtained in the trauma bay. However, the primary limitations of CT concern the need to transport the patient to the CT scanner and a longer processing time. The American Association for the Surgery of Trauma has established the most widely used grading scale to describe lung injury, which serves to communicate severity, guide management, and provide useful prognostic factors in a systematic fashion. The authors provide an in-depth exploration of the most common types of pulmonary parenchymal, pleural, and airway injuries. Injury grading, patient management, and potential complications of pulmonary injury are also discussed. ©RSNA, 2021.

Radiologist errors by modality, anatomic region, and pathology for 1.6 million exams: what we have learned.

PURPOSE: To evaluate the feasibility of adding pathology to recent radiologist error characterization schemes of modality and anatomic region and the potential of this data to more specifically inform peer review and peer learning. METHODS: Quality assurance data originating from 349 radiologists in a national teleradiology practice were collected for 2019. Interpretive errors were simply categorized as major or minor. Reporting or communication errors were classified as administrative errors. Interpretive errors were then divided by modality, anatomic region and placed into one of 64 pathologic categories. RESULTS: Out of 1,628,464 studies, the discrepancy rate was 0.5% (8181/1,634,201). The 8181 total errors consisted of 2992 major errors (0.18%) and 5189 minor errors (0.32%). Precisely, 3.1% (257/8181) of total errors were administrative. Of major interpretive errors, 75.5% occurred on CT, with CT abdomen and pelvis accounting for 40.4%. The most common pathologic discrepancy for all exams was in the category of mass, nodule, or adenopathy (1583/8181), the majority of which were minor (1315/1583). The most common pathologic discrepancy for the 2937 major interpretive errors was fracture or dislocation (27%; 793/2937), followed by bleed (10.7%; 315/2937). CONCLUSION: The addition of error-related pathology to peer review is both feasible and practical and provides a more detailed guide to targeted individual and practice-wide peer learning quality improvement efforts. Future research is needed to determine if there are measurable improvements in detection or interpretation of specific pathologies following error feedback and educational interventions.

Decreasing CT Acquisition Time in the Emergency Department through Lean Management Principles.

Background Emergency departments (EDs) rely on advanced imaging such as CT for diagnosis. Owing to increased ED volumes at the authors' institution, CT image acquisition became a significant bottleneck in ED patient throughput. Methods A multidisciplinary team was formed to solve this complex patient flow issue. Lean management principles were leveraged to identify process gaps and institute changes to achieve workflow improvements, remove process wastes, and improve patient throughput in the ED CT scanner. Process metrics such as percentage of CT examinations completed within 120 minutes and monthly median examination turnaround time (TAT) were tracked on a monthly basis. To measure impact, outcome metrics such as time savings from elimination of wasted steps were developed. Interventions Four projects including development of an ideal staffing model, a patient flow worksheet, revision of the CT patient screening form, and examination prioritization efforts were tested. Just-do-it activities such as revision of the CT angiography protocol ordering tool, optimizing scanner utilization, and improving communication and collaboration between the radiology department and ED were also attempted. Results After a phased rollout of changes over 6 months, the percentage of ordered ED CT examinations completed within 120 minutes increased by 10% (61%-71%); however, this improvement was sustained for only 6 weeks. Elimination of process inefficiencies resulted in a monthly median TAT reduction from 90-109 minutes to 82-106 minutes, and approximately 6 weeks (268 hours) of annualized full-time technologist time was saved. Conclusion Lean management tools can be leveraged to solve complex ED CT patient flow issues and reduce TAT. Online supplemental material is available for this article. ©RSNA, 2021.

The effect of COVID-19 on emergency department imaging: what can we learn?

PURPOSE: To investigate the effect of the COVID-19 pandemic on emergency department (ED) imaging. METHODS: This retrospective study included all ED visits at a four-hospital academic health system in two matched 5-week periods. Demographic information, COVID-19 status, and disposition were reviewed. Type of imaging, acquisition time, and radiology reports were analyzed. Significance level was set at p < 0.05. RESULTS: A 43.2% decrease in ED visits and 12% reduction in overall ED imaging occurred during the pandemic period. Mean age was unchanged, but a shift in gender and racial characteristics was observed (p < 0.001). In the pandemic period, COVID-19 ED patients were older (61.8 ± 16.9 years, p < 0.001) and more likely to be Black (64.2%; p < 0.001) than non-COVID-19 patients. Imaging per ED encounter increased to 2.4 ± 2.8 exams from 1.7 ± 1.1 (p < 0.001). Radiography increased (57.2% vs. 52.4%) as a fraction of total ED imaging, while computed tomography (23.4% vs. 27.2%) and ultrasound (8.5% vs. 9.6%) decreased (pre-pandemic vs. pandemic). COVID-19 ED patients underwent CT and US at a lower rate (11.5% and 5.4%) than non-COVID-19 patients (25.4% and 9.1%). The proportion of imaging study reports concluding "no disease" or "no acute disease" decreased from 56.7 to 40.6% (p < 0.001). CONCLUSION: The COVID-19 pandemic led to a significant reduction in ED visits, a shift in patient demographics, and a significant decrease in imaging volume. Additional impact included a significant increase in the proportion of positive imaging studies.

Doctorhood in Radiology: What Makes a Radiologist a Physician?

Because image interpretation occurs out of public view, the lay public does not always know what a radiologist is, or that a radiologist is even a physician. Despite the reality that many radiologists have little to no patient contact, all have considerable impact on patient care. As viewed through the lens of patient impact and in the context of the social contract that physicians enter, radiologists lay equal claim to the title "doctor" as any other physician. With titles come responsibilities: as physicians, radiologists are obligated through the social contract to provide humanistic and virtuous care, irrespective of time spent in close proximity with patients. This paper touches on ways in which radiologists can honor the social contract, providing care through a commitment to empathy, compassion, generosity, honesty and collaboration with nonradiologist colleagues. This invitation for introspection assumes special meaning for a profession that is undergoing an identity change at the behest of AI, serving as a reminder that radiologists ought to pay as much heed to maintaining virtuous physician character as they do to the fine points of image interpretation.

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.