Balancing the Scales: An Analysis of Social Determinants of Health, Radiology Report Acuity, and Radiology Staffing Models in an Academic Health System.

PURPOSE: Social determinants of health, including race and insurance status, contribute to patient outcomes. In academic health systems, care is provided by a mix of trainees and faculty members. The optimal staffing ratio of trainees to faculty members (T/F) in radiology is unknown but may be related to the complexity of patients requiring care. Hospital characteristics, patient demographics, and radiology report findings may serve as markers of risk for poor outcomes because of patient complexity. METHODS: Descriptive characteristics of each hospital in an urban five-hospital academic health system, including payer distribution and race, were collected. Radiology department T/F ratios were calculated. A natural language processing model was used to classify multimodal report findings into nonacute, acute, and critical, with report acuity calculated as the fraction of acute and critical findings. Patient race, payer type, T/F ratio, and report acuity score for hospital 1, a safety net hospital, were compared with these factors for hospitals 2 to 5. RESULTS: The fraction of patients at hospital 1 who are Black (79%) and have Medicaid insurance (28%) is significantly higher than at hospitals 2 to 5 (P < .0001), with the exception of hospital 3 (80.1% black). The T/F ratio of 1.37 at hospital 1 as well as its report acuity (28.9%) were significantly higher (P < .0001 for both). CONCLUSIONS: T/F ratio and report acuity are highest at hospital 1, which serves the most at-risk patient population. This suggests a potential overreliance on trainees at a site whose patients may require the greatest expertise to optimize care.

Development and Implementation of an Integrated Imaging Informatics Track for Radiology Residents: Our 3-Year Experience.

RATIONALE AND OBJECTIVES: Imaging Informatics is an emerging and fast-evolving field that encompasses the management of information during all steps of the imaging value chain. With many information technology tools being essential to the radiologists' day-to-day work, there is an increasing need for qualified professionals with clinical background, technology expertise, and leadership skills. To answer this, we describe our experience in the development and implementation of an Integrated Imaging Informatics Track (I3T) for radiology residents at our institution. MATERIALS AND METHODS: The I3T was created by a resident-driven initiative funded by an intradepartmental resident grant. Its curriculum is delivered through a combination of monthly small group discussions, operational meetings, recommended readings, lectures, and early exposure to the National Imaging Informatics Course. The track is steered and managed by the I3T Committee, including trainees and faculty advisors. Up to two first-year residents are selected annually based on their curriculum vitae and an interest application. Successful completion of the program requires submission of a capstone project and at least one academic deliverable (national meeting presentation, poster, exhibit, manuscript and/or grant). RESULTS: In our three-year experience, the seven I3T radiology residents have reported a total of 58 scholarly activities related to Imaging Informatics. I3T residents have assumed leadership roles within our organization and nationally. All residents have successfully carried out their clinical responsibilities. CONCLUSION: We have developed and implemented an I3T for radiology residents at our institution. These residents have been successful in their clinical, scholarship and leadership pursuits.

Secondary Interpretations of Diagnostic Imaging Examinations: Patient Liabilities and Out-of-Pocket Costs.

BACKGROUND: Secondary interpretations of diagnostic imaging examinations are increasingly performed to improve care for complex patients. We sought to determine associated patient-billed liabilities and out-of-pocket payments and to identify patient and imaging study characteristics that correlate with higher patient bills and out-of-pocket payments. METHODS: Data extracted for 7,740 secondary imaging interpretations performed across our large metropolitan health system over 25 months included total professional charges, insurance payments, patient-billed liabilities, and patient out-of-pocket payments. Multivariable linear regression analyses were performed to identify patient and imaging factors associated with higher patient bills and out-of-pocket payments. RESULTS: Mean secondary interpretation professional charges, insurance payments, patient-billed liabilities, and patient out-of-pocket payments were $306.50, $108.02, $27.80, and $14.55, respectively. Patients received bills for 47.5% of services and made out-of-pocket payments for 17.1%. Patient-billed liabilities and out-of-pocket payments were higher for patients who were younger and uninsured and for secondary interpretations requested for patients seen in outpatient (versus inpatient) settings. Patient-billed liabilities and out-of-pocket payments were lower for patients who were Black (versus White) and had government-sponsored (versus commercial) insurance and for secondary interpretations performed during the second, third, or fourth (versus first) quarter of each calendar year. CONCLUSION: Observed differences between patient-billed liabilities and out-of-pocket payments suggest that secondary interpretations of diagnostic imaging examinations can result in small but real patient financial burdens. Improved price transparency and enhanced patient communication about the value of secondary interpretations could reduce potential surprises when patients receive these bills.

Improving Billing Accuracy Through Enterprise-Wide Standardized Structured Reporting With Cross-Divisional Shared Templates.

OBJECTIVE: We describe our experience in implementing enterprise-wide standardized structured reporting for chest radiographs (CXRs) via change management strategies and assess the economic impact of structured template adoption. METHODS: Enterprise-wide standardized structured CXR reporting was implemented in a large urban health care enterprise in two phases from September 2016 to March 2019: initial implementation of division-specific structured templates followed by introduction of auto launching cross-divisional consensus structured templates. Usage was tracked over time, and potential radiologist time savings were estimated. Correct-to-bill (CTB) rates were collected between January 2018 and May 2019 for radiography. RESULTS: CXR structured template adoption increased from 46% to 92% in phase 1 and to 96.2% in phase 2, resulting in an estimated 8.5 hours per month of radiologist time saved. CTB rates for both radiographs and all radiology reports showed a linearly increasing trend postintervention with radiography CTB rate showing greater absolute values with an average difference of 20% throughout the sampling period. The CTB rate for all modalities increased by 12%, and the rate for radiography increased by 8%. DISCUSSION: Change management strategies prompted adoption of division-specific structured templates, and exposure via auto launching enforced widespread adoption of consensus templates. Standardized structured reporting resulted in both economic gains and projected radiologist time saved.

Assessing the Training Costs and Work of Diagnostic Radiology Residents Using Key Performance Indicators - An Observational Study.

RATIONALE AND OBJECTIVES: To quantify the costs and work of diagnostic radiology (DR) residents using the radiology key performance indicator turn-around time (TAT) as the outcome measure. MATERIALS AND METHODS: In an Institutional Review Board-approved study, the annual cost of a DR resident was determined using salary, benefits, and a cost allocation of faculty effort. The volume of cases reported in the 2015-16 academic year and median and interquartile range (IQR) TAT for a trainee preliminary (Complete to Prelim, C-P) or an attending final (Complete to Final, C-F) radiology report were measured and stratified by time of day and patient location. Wilcoxon rank-sum tests were used (significance, p values < 0.05). RESULTS: The annual cost of a DR resident was $99,109, 34% greater than direct salary/benefits and 27% of the direct salary/benefits cost of an attending. The total per minute cost of rendering care was $4.36 with both trainee ($0.70/minute) and faculty ($3.66/minute). Residents participated in 139,084/235,417 (59%) imaging studies. The C-P TAT was 74 (IQR, 27-180) minutes compared to 51 (IQR, 18-129) minutes C-F TAT of faculty working alone and C-F TAT of 213 (IQR, 71-469) minutes with a resident (p < 0.001). The C-P TAT vs C-F TAT between 4 pm-9 am and weekends with residents is 44 (IQR, 18-119) minutes vs 60 (IQR, 18-179) minutes without. CONCLUSION: The cost of training DR residents exceeds the salary and benefits allocated to their training. Residents increase the absolute professional labor cost of caring for a patient. Overall TAT is slower with residents but the care delivered by residents after-hours is faster.

Cost Implications of Oral Contrast Administration in the Emergency Department: A Time-Driven Activity-Based Costing Analysis.

PURPOSE: To quantify the monetary and time costs associated with oral contrast administration in the emergency department (ED) for patients with nontraumatic abdominal pain and to evaluate the cost savings associated with an institutional policy change in the criteria for oral contrast administration. METHODS: A HIPAA-complaint, institutional review board-approved time-driven activity-based costing analysis was performed using both prospective time studies and retrospective data obtained from a quaternary care center. Retrospective data spanned a 1-year period (January 1, 2016, to December 31, 2016). A process map was generated. Examination volume-related data, labor costs, and material costs were determined and applied to a base-case model. Univariate and multivariate sensitivity analyses were conducted. Multivariate analysis was used to estimate the cost savings associated with a policy change eliminating oral contrast for patients with body mass index ≥ 25 kg/m2, no prior abdominal surgery within 30 days preceding CT, and no inflammatory bowel disease. RESULTS: The baseline oral contrast utilization rate was 86% (4,541 of 5,263). The annual base-case cost estimate for oral contrast administration was $82,552. In multivariate analyses, this ranged from $13,685 to $315,393. The model was most sensitive to the volume of CTs requiring oral contrast. Applying parameters from the new policy change reduced the annual cost by 52% (cost saving: $35,836.57). Impact of oral contrast on time to discharge was highly variable and dependent on the contrast agent utilized. CONCLUSION: Costs associated with oral contrast in the ED are modest and should be balanced with its potential diagnostic benefits. Our criteria reduced oral contrast utilization by 52%.

Characteristics of Physicians and Other Providers Frequently Ordering Intravenous Pyelograms.

PURPOSE: To assess characteristics of physicians and other providers frequently ordering intravenous pyelography (IVP). METHODS: The 2014 Medicare Referring Provider Utilization for Procedures data set was used to identify providers who ordered more than 10 IVP examinations ("high-ordering providers") in Medicare beneficiaries. The Medicare Provider and Other Supplier Public Use File and Physician Supplier Procedure Summary Master Files were used to obtain physician characteristics and total service counts, respectively. RESULTS: Of 18,344 IVPs performed in 2014 in Medicare fee-for-service beneficiaries, 6,321 (34.5%) were ordered by just 233 high-ordering providers. Of these, 220 (94.4%) were urologists. These urologists represented just 2.4% of all 8,981 Medicare-participating urologists and ordered an average of 27.1 IVPs (maximum 239). Urologists ordering IVPs (versus those not ordering IVPs) were more likely (P < .05) to practice in rural areas (6.4% versus 2.7%), be in practice more than 15 years (87.4% versus 71.2%), and be in practices with 100 members or fewer (71.3% versus 55.5%). They were also less likely (P < .05) to be female (3.2% versus 7.4%) and in academic practices (5.1% versus 10.7%). High-IVP-ordering urologists were more likely to practice in the South (54.1% versus 36.9%) or Midwest (30.0% versus 21.3%) and less likely to practice in the Northeast (5.0% versus 23.1%) or West (10.9% versus 18.6%). CONCLUSION: Although uncommonly performed, IVPs continue to be used in the Medicare population. Providers most likely to frequently order IVPs were later-career urologists in smaller and rural practices in the South. Targeting education and appropriate use criteria initiatives to high-ordering providers may help optimize utilization.

Quantifying the costs of interruption during diagnostic radiology interpretation using mobile eye-tracking glasses.

What are the costs and consequences of interruptions during diagnostic radiology? The cognitive psychology literature suggests that interruptions lead to an array of negative consequences that could hurt patient outcomes and lead to lower patient throughput. Meanwhile, observational studies have both noted a strikingly high rate of interruptions and rising number of interruptions faced by radiologists. There is some observational evidence that more interruptions could lead to worse patient outcomes: Balint et al. (2014) found that the shifts with more telephone calls received in the reading room were associated with more discrepant calls. The purpose of the current study was to use an experimental manipulation to precisely quantify the costs of two different types of interruption: telephone interruption and an interpersonal interruption. We found that the first telephone interruption led to a significant increase in time spent on the case, but there was no effect on diagnostic accuracy. Eye-tracking revealed that interruptions strongly influenced where the radiologists looked: they tended to spend more time looking at dictation screens and less on medical images immediately after interruption. Our results demonstrate that while radiologists' eye movements are reliably influenced by interruptions, the behavioral consequences were relatively mild, suggesting effective compensatory mechanisms.

Dissecting Costs of CT Study: Application of TDABC (Time-driven Activity-based Costing) in a Tertiary Academic Center.

RATIONALE AND OBJECTIVES: The lack of understanding of the real costs (not charge) of delivering healthcare services poses tremendous challenges in the containment of healthcare costs. In this study, we applied an established cost accounting method, the time-driven activity-based costing (TDABC), to assess the costs of performing an abdomen and pelvis computed tomography (AP CT) in an academic radiology department and identified opportunities for improved efficiency in the delivery of this service. MATERIALS AND METHODS: The study was exempt from an institutional review board approval. TDABC utilizes process mapping tools from industrial engineering and activity-based costing. The process map outlines every step of discrete activity and duration of use of clinical resources, personnel, and equipment. By multiplying the cost per unit of capacity by the required task time for each step, and summing each component cost, the overall costs of AP CT is determined for patients in three settings, inpatient (IP), outpatient (OP), and emergency departments (ED). RESULTS: The component costs to deliver an AP CT study were as follows: radiologist interpretation: 40.1%; other personnel (scheduler, technologist, nurse, pharmacist, and transporter): 39.6%; materials: 13.9%; and space and equipment: 6.4%. The cost of performing CT was 13% higher for ED patients and 31% higher for inpatients (IP), as compared to that for OP. The difference in cost was mostly due to non-radiologist personnel costs. CONCLUSIONS: Approximately 80% of the direct costs of AP CT to the academic medical center are related to labor. Potential opportunities to reduce the costs include increasing the efficiency of utilization of CT, substituting lower cost resources when appropriate, and streamlining the ordering system to clarify medical necessity and clinical indications.

Big Data and the Future of Radiology Informatics.

Rapid growth in the amount of data that is electronically recorded as part of routine clinical operations has generated great interest in the use of Big Data methodologies to address clinical and research questions. These methods can efficiently analyze and deliver insights from high-volume, high-variety, and high-growth rate datasets generated across the continuum of care, thereby forgoing the time, cost, and effort of more focused and controlled hypothesis-driven research. By virtue of an existing robust information technology infrastructure and years of archived digital data, radiology departments are particularly well positioned to take advantage of emerging Big Data techniques. In this review, we describe four areas in which Big Data is poised to have an immediate impact on radiology practice, research, and operations. In addition, we provide an overview of the Big Data adoption cycle and describe how academic radiology departments can promote Big Data development.

Exact confidence intervals for channelized Hotelling observer performance in image quality studies.

Task-based assessments of image quality constitute a rigorous, principled approach to the evaluation of imaging system performance. To conduct such assessments, it has been recognized that mathematical model observers are very useful, particularly for purposes of imaging system development and optimization. One type of model observer that has been widely applied in the medical imaging community is the channelized Hotelling observer (CHO), which is well-suited to known-location discrimination tasks. In the present work, we address the need for reliable confidence interval estimators of CHO performance. Specifically, we show that the bias associated with point estimates of CHO performance can be overcome by using confidence intervals proposed by Reiser for the Mahalanobis distance. In addition, we find that these intervals are well-defined with theoretically-exact coverage probabilities, which is a new result not proved by Reiser. The confidence intervals are tested with Monte Carlo simulation and demonstrated with two examples comparing X-ray CT reconstruction strategies. Moreover, commonly-used training/testing approaches are discussed and compared to the exact confidence intervals. MATLAB software implementing the estimators described in this work is publicly available at http://code.google.com/p/iqmodelo/.

How to report a research study.

Incomplete reporting hampers the evaluation of results and bias in clinical research studies. Guidelines for reporting study design and methods have been developed to encourage authors and journals to include the required elements. Recent efforts have been made to standardize the reporting of clinical health research including clinical guidelines. In this article, the reporting of diagnostic test accuracy studies, screening studies, therapeutic studies, systematic reviews and meta-analyses, cost-effectiveness assessments (CEA), recommendations and/or guidelines, and medical education studies is discussed. The available guidelines, many of which can be found at the Enhancing the QUAlity and Transparency Of health Research network, on how to report these different types of health research are also discussed. We also hope that this article can be used in academic programs to educate the faculty and trainees of the available resources to improve our health research.

How to critically appraise the clinical literature.

Recent efforts have been made to standardize the critical appraisal of clinical health care research. In this article, critical appraisal of diagnostic test accuracy studies, screening studies, therapeutic studies, systematic reviews and meta-analyses, cost-effectiveness studies, recommendations and/or guidelines, and medical education studies is discussed as are the available instruments to appraise the literature. By having standard appraisal instruments, these studies can be appraised more easily for completeness, bias, and applicability for implementation. Appraisal requires a different set of instruments, each designed for the individual type of research. We also hope that this article can be used in academic programs to educate the faculty and trainees of the available resources to improve critical appraisal of health research.

Health issues and the practicing radiologist: defining concepts and developing recommendations for leave options and policies.

Radiologists today are faced with the challenges of maintaining and balancing individual and family health needs and the demands of the workplace. To provide the highest quality and safest care of our patients, a corresponding ethos of support for a healthy workforce is required. There is a paucity of targeted information describing protections for and maintenance of the health of the practicing radiologist, in both private and academic settings. However, a review of existing family and medical leave policies may be helpful to practice leaders and practicing radiologists as a platform for the development of strategic workforce plans. This writing, by members of the ACR Commission on Human Resources, addresses the following areas: (1) medical leave, (2) maternity and/or paternity leave, and (3) disability.

The cost-effectiveness of immediate treatment, percutaneous biopsy and active surveillance for the diagnosis of the small solid renal mass: evidence from a Markov model.

PURPOSE: The most effective diagnostic strategy for the very small, incidentally detected solid renal mass is uncertain. We assessed the cost-effectiveness of adding percutaneous biopsy or active surveillance to the diagnosis of a 2 cm or less solid renal mass. MATERIALS AND METHODS: A Markov state transition model was developed to observe a hypothetical cohort of healthy 60-year-old men with an incidentally detected, 2 or less cm solid renal mass, comparing percutaneous biopsy, immediate treatment and active surveillance. The primary outcomes assessed were the incremental cost-effectiveness ratio measured by cost per life-year gained at a willingness to pay threshold of $50,000. Model results were assessed by sensitivity analysis. RESULTS: Immediate treatment was the highest cost, most effective diagnostic strategy, providing the longest overall survival of 18.53 life-years. Active surveillance was the lowest cost, least effective diagnostic strategy. On cost-effectiveness analysis using a societal willingness to pay threshold of $50,000 active surveillance was the preferred choice at a $75,000 willingness to pay threshold while biopsy and treatment were acceptable ($56,644 and $70,149 per life-year, respectively). When analysis was adjusted for quality of life, biopsy dominated immediate treatment as the most cost-effective diagnostic strategy at $33,840 per quality adjusted life-year gained. CONCLUSIONS: Percutaneous biopsy may have a greater role in optimizing the diagnosis of an incidentally detected, 2 cm or less solid renal mass.

Should radiology residents be taught evidence-based radiology? An experiment with "the EBR Journal Club".

RATIONALE AND OBJECTIVES: Introduce radiology residents to evidence-based radiology (EBR) using a journal club format based on the Radiology Alliance for Health Services Research/American Alliance of Academic Chief Residents in Radiology (RAHSR/A3CR2) Critical Thinking Skills sessions and EBR series of articles published in Radiology in 2007. MATERIALS AND METHODS: The club began with a presentation outlining the process that would occur in an alternating format, with topics and articles chosen by residents. In session A, questions were rephrased in a Patient/Population, Intervention, Comparison, Outcome format, and a literature search was performed. Articles were discussed in session B, with residents assigned by year to the tasks of article summary, technology assessment, and comparison to checklists (Standards for Reporting of Diagnostic Accuracy, Consolidated Standards of Reporting Trials, or Quality of Reporting of Meta-analysis). The residents collectively assigned a level of evidence to each article, and a scribe provided a summary. RESULTS: Twenty-two residents participated, with 12/22 (55%) of residents submitting any question, 6/22 (27.3%) submitting more than one question, and 4 residents submitting questions in more than one session. Topics included radiation risk, emergency radiology, screening examinations, modality comparisons, and technology assessment. Of the 31 articles submitted for review, 15 were in radiology journals and 5 were published before 2000. For 2/9 topics searched, no single article that the residents selected was available through our library's subscription service. The maximum level of evidence assigned by residents was level III, "limited evidence." In each session, the residents concluded that they became less confident in the "right answer." They proposed that future reading recommendations come from attendings rather than literature searches. CONCLUSION: A journal club format is an effective tool to teach radiology residents EBR principles. Resistance comes from the difficulty in accessing good literature for review and in constructing good review questions.