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.

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.

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.

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.

The Introduction and Development of the H-index for Imaging Utilizers: A Novel Metric for Quantifying Utilization of Emergency Department Imaging.

OBJECTIVE: The objective was to develop a novel metric for quantifying patient-level utilization of emergency department (ED) imaging. METHODS: Using 2009 to 2015 Truven Health MarketScan commercial claims and encounters database, all ED visits and associated imaging services were identified. To measure imaging resource intensity, total imaging relative value units (RVUs) were calculated for each patient per ED visit. An individual's annual imaging h-index is defined as the largest number, h, such that h ED visits by that individual in a given year is associated with total medical imaging RVUs of a value of at least h. RESULTS: Over 7 years, in a sample of 86,506,362 privately insured individuals (232,919,808 person-years) in all 50 states and the District of Columbia, 38,973,716 ED visits were identified. A total of 9.5% of person-years had one ED visit and 2.7% had two or more (the remainder had none). From 2009 to 2015, the percentage of ED patients undergoing imaging increased from 25.1% to 34.6%. Individuals with two or more ED visits each associated with two or more imaging RVUs (ED imaging h-index ≥ 2) comprised 0.2% of the sample and 1.4% of ED visitors; however, they accounted for 4.0% of ED visits and the use of 18.6% of imaging resources. From 2009 to 2015, imaging resource allocation for such patients increased from 16.5% to 21.0%. CONCLUSIONS: The ED imaging h-index allows identification of patients who undergo significant ED imaging, based on a single-digit patient-specific metric that incorporates both annual ED visit number and medical imaging resource intensity per visit. While ED patients with an ED imaging h-index ≥ 2 represented a minuscule fraction of privately insured individuals, they were associated with one-fifth of all ED imaging resources.

Increasing Use, Geographic Variation, and Disparities in Emergency Department CT for Suspected Urolithiasis.

PURPOSE: The aim of this study was to examine changing characteristics of utilization and potential disparities in US emergency department (ED) patients undergoing CT of the abdomen and pelvis (CTAP) for suspected urolithiasis. METHODS: A retrospective study was conducted among all patients from 2006 to 2015 with a primary diagnosis of suspected urolithiasis within the Nationwide Emergency Department Sample, the largest publicly available all-payer ED database in the United States. The annual numbers of ED visits for suspected urolithiasis and associated CTAP examinations per visit were determined. The compound annual growth rate for CTAP was calculated. Using multivariate logistic regression analyses, patient demographics and payer and hospital characteristics were evaluated as potential independent predictors of utilization. RESULTS: Nationwide, the number of ED visits per year for suspected urolithiasis increased from 1,057,119 in 2006 to 1,246,041 in 2014 (relative +17.9%), whereas the annual use of CTAP increased from 24.6% to 49.4% per visit (relative +100.8%; CAGR +8.0%). Multivariate analysis showed higher CTAP use associated with higher patient household income ZIP code quartile (odds ratio [OR] for wealthiest/poorest, 1.48), private payer (ORs, 1.21 versus Medicare and 1.22 versus Medicaid), Northeast geographic region (ORs, 5.07 versus Midwest, 4.16 versus West, and 1.77 versus South), hospital urban status (OR, 1.42), and nonteaching hospitals (OR, 1.20) (P < .05 for all). CONCLUSIONS: The relative use of CTAP in ED patients presenting with suspected urolithiasis doubled between 2006 and 2014 and showed marked geographic variation. Among ED patients with suspected urolithiasis, CTAP was more frequent in patients from higher household income ZIP codes, with private insurance, in the Northeast, and at urban and nonteaching hospitals.

The state of emergency radiology fellowships in North America and the development of a standardized curriculum.

BACKGROUND AND OBJECTIVES: The number of emergency radiology (ER) training programs in North America is small compared to the projected growth in demand for ER-trained radiologists. To date, there is no consensus-based training curriculum that sets a standard for all ER fellowship training programs. This study seeks to (1) identify the programmatic measures currently used in North American ER fellowship programs and (2) gather the perspectives of existing ER fellowship program directors (PD) and their recommendations for minimum and ideal curricular standards. METHODS: We distributed an 18-question survey to the PDs of every North American ER fellowship program (N = 15). Surveys were completed during the 2016-2017 academic year. We performed a cross-sectional analysis to gain an understanding of existing training curricula, expected areas of competency by the end-of-training, and PD opinions of what a standard ER training curriculum should contain. RESULTS: The data revealed heterogeneity in programmatic structure across the continent, as well as some areas of agreement. PD suggestions for a standard ER training curriculum showed consistency in many areas, including competency and proficiency expectations and clinical exposures, with some variability. These data were used to inform the creation of the first curricular standard for ER fellowship training. CONCLUSION: This study yielded the creation of a standard fellowship training resource for the field of ER. This deliverable serves as a curricular guideline for existing ER fellowships, as well as a model for new ER fellowship programs.

Diagnostic radiology resident perspectives on fellowship training and career interest in emergency radiology.

PURPOSE: (1) Evaluate radiology resident perception of emergency radiology (ER). (2) Identify potential barriers to pursuing fellowship training or a career in ER among radiology residents. MATERIALS AND METHODS: A 9-question digital survey was designed using Qualtrics Experience Management software (Qualtrics Inc., Provo, UT) and distributed to all US radiology residents via a multi-pronged distribution approach. RESULTS: Four hundred fifty-one residents responded out of an estimated national total of 4432 residents (10.2%). Gender proportion was nationally representative (female = 24.5%; p = 0.57), with a slight R1 predominance (p = 0.034). Of the residents, 88.8% were aware that an ER subspecialty exists, 82.0% were aware that ER fellowships exist, but only 51.7% were aware that the American Society of Emergency Radiology (ASER) exists. Nearly a quarter reported no ER division or ER resident rotation. Residents in a program without an ER division or rotation were nearly twice as likely to be unaware of the existence of ER subspecialty, ER fellowships, and ASER compared to others (p = 0.017). The presence of an ER division and rotation significantly increases the knowledge of ASER (65.5% vs. 40.7%, p < 0.001) and increases residents' ratings of their ER training (p < 0.001). The following factors were ranked as the most important for fellowship choice: (1) personal interest, (2) intellectually stimulating, and (3) work hours. When asked if ER had an appealing work schedule, the mean response was 56 out of 100 (0 = disagree, 100 = agree). CONCLUSION: US radiology residents with the greatest exposure to ER during residency are more familiar with ER training, ER career opportunities, and ASER and had a more favorable perception of the field. Subspecialty leaders should focus on ER's inherent intellectual appeal and reframe its nontraditional schedule as positive (flexible).

Creating and Sustaining a Successful Fellowship Program: Challenges and Solutions.

Subspecialty expertise and fellowship training are two of the most desirable attributes in new radiology hires and, not surprisingly, the vast majority of diagnostic radiologists entering the job market today have had fellowship training. Fellowship training imparts not only expertise beyond that which is attainable during residency, but also a unique opportunity for professional maturation. In this article, we offer guidance in planning, building and sustaining a successful fellowship. The key steps in this process include strategic planning, development of a curriculum that can be customized to meet the educational goals of any individual fellow, professional development and trainee preparation for the marketplace, and approaches to ensure program longevity and success through local, regional and national fellow recruitment efforts. While many of the ideas presented are framed from the perspective of their integration into a newly formed fellowship program, they can also be adapted for use by existing fellowship programs as opportunities for program growth and improvement.