Central venous access: evolving roles of radiology and other specialties nationally over two decades.

PURPOSE: The aim of this study was to evaluate national trends in central venous access (CVA) procedures over 2 decades with regard to changing specialty group roles and places of service. METHODS: Aggregated claims data for temporary central venous catheter and long-term CVA device (CVAD) procedures were extracted from Medicare Physician/Supplier Procedure Summary Master Files from 1992 through 2011. Central venous catheter and CVAD procedure volumes by specialty group and place of service were studied. RESULTS: Between 1992 and 2011, temporary and long-term CVA placement procedures increased from 638,703 to 808,071 (+27%) and from 76,444 to 316,042 (+313%), respectively. For temporary central venous catheters, radiology (from 0.4% in 1992 to 32.6% in 2011) now exceeds anesthesiology (from 37% to 22%) and surgery (from 30.4% to 11.7%) as the dominant provider group. Surgery continues to dominate in placement and explantation of long-term CVADs (from 80.7% to 50.4% and from 81.6% to 47.7%, respectively), but radiology's share has grown enormously (from 0.7% to 37.6% and from 0.2% to 28.6%). Although volumes remain small (<10% of all procedures), midlevel practitioners have experienced >100-fold growth for most services. The inpatient hospital remains the dominant site for temporary CVA procedures (90.0% in 1992 and 81.2% in 2011), but the placement of long-term CVADs has shifted from the inpatient (from 68.9% to 45.2%) to hospital outpatient (from 26.9% to 44.3%) setting. In all hospital settings combined, radiologists place approximately half of all tunneled catheters and three-quarters all peripherally inserted central catheters. CONCLUSIONS: Over the past 2 decades, CVA procedures on Medicare beneficiaries have increased considerably. Radiology is now the dominant overall provider.

Physician documentation deficiencies in abdominal ultrasound reports: frequency, characteristics, and financial impact.

PURPOSE: The aim of this study was to assess the frequency, characteristics, and financial impact of physician documentation deficiencies in abdominal ultrasound reports. METHODS: Using a multi-institutional coding and billing database and natural language processing software, 12,699,502 radiology reports from 37 practices were used to identify and analyze abdominal ultrasound reports. Using standard Current Procedural Terminology(®) (CPT(®)) criteria, examinations were categorized as complete (all 8 required elements documented) or limited (<8 elements). Assuming incomplete documentation, examinations were categorized as very likely, likely, or possibly complete depending on whether a minimum of 7, 6, or 5 elements were reported. Frequency and financial impact were assessed using all 3 models, and presumed documentation deficiencies were characterized. RESULTS: Of 336,062 abdominal ultrasound reports by 1,136 radiologists, 252,478 (75.1%) documented all 8 elements for CPT coding as complete examinations, 25,925 (7.7%) documented 7 elements, 20,559 (5.6%) documented 6 elements, 17,521 (4.8%) documented 5 elements, and 49,579 (13.5%) documented ≤4 elements. For very likely, likely, and possibly complete examination models, deficiencies were present in 9.3%, 15.5%, and 20.2% of cases, resulting in 2.5%, 4.2%, and 5.5% decreases in legitimate professional payments. The spleen (41.2%) was the most frequent element neglected. Of 106,168 examinations titled complete, only 92,824 (87.4%) fulfilled complete CPT criteria. In 221,887 (60.6%), examination titles were clearly erroneous or too ambiguous for code assignment. Documentation deficiencies were less frequent for high-volume radiologists (P < .0001). CONCLUSIONS: Incomplete physician documentation in abdominal ultrasound reports is common (9.3%-20.2% of cases) and results in 2.5% to 5.5% in lost professional income. Structured reporting may improve documentation and mitigate lost revenue.

Type II endoleak after endovascular abdominal aortic aneurysm repair: a conservative approach with selective intervention is safe and cost-effective.

OBJECTIVES: The conservative versus therapeutic approach to type II endoleak after endovascular repair of abdominal aortic aneurysm (EVAR) has been controversial. The purpose of this study was to evaluate the safety and cost-effectiveness of the conservative approach of embolizing type II endoleak only when persistent for more than 6 months and associated with aneurysm sac growth of 5 mm or more. METHODS: Data for 486 consecutive patients who underwent EVAR were analyzed for incidence and outcome of type II endoleaks. Spiral computed tomography (CT) scans were reviewed, and patient outcome was evaluated at either office visit or telephone contact. Patients with new or late-appearing type II endoleak were evaluated with spiral CT at 6-month intervals to evaluate both persistence of the endoleak and size of the aneurysm sac. Persistent (>or=6 months) type II endoleak and aneurysm sac growth of 5 mm or greater were treated with either translumbar glue or coil embolization of the lumbar source, or transarterial coil embolization of the inferior mesenteric artery. RESULTS: Type II endoleaks were detected in 90 (18.5%) patients. With a mean follow-up of 21.7 +/- 16 months, only 35 (7.2%) patients had type II endoleak that persisted for 6 months or longer. Aneurysm sac enlargement was noted in 5 patients, representing 1% of the total series. All 5 patients underwent successful translumbar sac embolization (n = 4) or transarterial inferior mesenteric artery embolization (n = 4) at a mean follow-up of 18.2 +/- 8.0 months, with no recurrence or aneurysm sac growth. No patient with treated or untreated type II endoleak has had rupture of the aneurysm. The mean global cost for treatment of persistent type II endoleak associated with aneurysm sac growth was US dollars 6695.50 (hospital cost plus physician reimbursement). Treatment in the 30 patients with persistent type II endoleak but no aneurysm sac growth would have represented an additional cost of US dollars 200000 or more. The presence or absence of a type II endoleak did not affect survival (78% vs 73%) at 48 months. CONCLUSIONS: Selective intervention to treat type II endoleak that persists for 6 months and is associated with aneurysm enlargement seems to be both safe and cost-effective. Longer follow-up will determine whether this conservative approach to management of type II endoleak is the standard of care.