Program for Supporting Frontline Improvement Projects in an Academic Radiology Department.

OBJECTIVE. The purpose of this study was to describe the results of an ongoing program implemented in an academic radiology department to support the execution of small- to medium-size improvement projects led by frontline staff and leaders. MATERIALS AND METHODS. Staff members were assigned a coach, were instructed in improvement methods, were given time to work on the project, and presented progress to department leaders in weekly 30-minute reports. Estimated costs and outcomes were calculated for each project and aggregated. An anonymous survey was administered to participants at the end of the first year. RESULTS. A total of 73 participants completed 102 projects in the first 2 years of the program. The project type mix included 25 quality improvement projects, 22 patient satisfaction projects, 14 staff engagement projects, 27 efficiency improvement projects, and 14 regulatory compliance and readiness projects. Estimated annualized outcomes included approximately 4500 labor hours saved, $315K in supply cost savings, $42.2M in potential increased revenues, 8- and 2-point increase in top-box patient experience scores at two clinics, and a 60-incident reduction in near-miss safety events. Participant time equated to approximately 0.35 full-time equivalent positions per year. Approximately 0.4 full-time equivalent was required to support the program. Survey results indicated that the participants generally viewed the program favorably. CONCLUSION. The program was successful in providing a platform for simultaneously solving a large number of organizational problems while also providing a positive experience to frontline personnel.

A Multicenter Survey on the Trend of Chest CT Scan Utilization: Tracing the First Footsteps of COVID-19 in Iran.

BACKGROUND: Chest computed tomography (CT) scan has been used widely to diagnose COVID-19 in Iran. OBJECTIVES: To trace the footsteps of COVID-19 in Iran by exploring the trend in using chest CT scans and its economic impact on radiology departments. Methods: In this cross-sectional study, the number of imaging examinations from 33 tertiary radiology departments in 9 large cities of Iran was collected from September 23, 2019 to March 20, 2020 (Months 1 to 6) and the corresponding months in 2018-2019. RESULTS: A 50.2% increase was noted in the chest CT scan utilization in 2019-2020 compared to 2018-2019. This increase was +15%, +15%, +27%, +2%, +1% in Months 1-5 of 2019-2020, respectively. In Month 6 of 2019-2020, a 251% increase in the acquisition of chest CT scans was observed compared to the Month 6 of 2018-2019. Following negative balance of revenue from Month 1 to 5 with respect to the inflation rate, the total income in Month 6 was further 1.5% less than the same Month in 2018-19. CONCLUSION: The observed peak in chest CT utilization in Month 3 prior to the surge in Month 6 could be explained by the seasonal influenza. However, unawareness about an emerging viral disease, i.e. COVID-19, might have underutilized chest CT in Months 4 and 5 before the official announcement in Month 6. The unbalanced increase in the workload of radiology departments in the shortage of cardiothoracic radiologists with the simultaneous decrease in income initiated a vicious cycle that worsened the economic repercussions of the pandemic.

Policies and Guidelines for COVID-19 Preparedness: Experiences from the University of Washington.

The coronavirus disease 2019 (COVID-19) pandemic initially manifested in the United States in the greater Seattle area and has rapidly progressed across the nation in the past 2 months, with the United States having the highest number of cases in the world. Radiology departments play a critical role in policy and guideline development both for the department and for the institutions, specifically in planning diagnostic screening, triage, and management of patients. In addition, radiology workflows, volumes, and access must be optimized in preparation for the expected surges in the number of patients with COVID-19. In this article, the authors discuss the processes that have been implemented at the University of Washington in managing the COVID-19 pandemic as well in preparing for patient surges, which may provide important guidance for other radiology departments who are in the early stages of preparation and management.

Recommendations for additional imaging of abdominal imaging examinations: frequency, benefit, and cost.

OBJECTIVES: To investigate the frequency, determinants, clinical implications, and costs of recommendations for additional imaging (RAIs) in secondary interpretations of abdominal imaging examinations. METHODS: This retrospective study included 2225 abdominal imaging examinations from outside institutions that were reinterpreted as part of standard clinical care at a tertiary care center in a one-year time frame. RESULTS: Two hundred forty-six RAIs were present in 231 of 2225 reports (10.4%) of secondary abdominal imaging interpretations. Patient age and experience of the radiologist who performed the secondary interpretation were independently significantly associated with the presence of an RAI (both p = 0.002), with odds ratios of 0.99 per year increase in patient age (95% confidence interval [CI], 0.98-1.00) and 1.06 per year increase in experience of the radiologist (95% CI, 1.02-1.10). If followed, RAIs changed clinical management in 31.2%. Total costs of all 246 RAIs, whether performed or not by the referring physicians, amounted to €71,032.21, thus resulting in €31.92 per secondary abdominal imaging interpretation. Total costs of the 140 RAIs that were actually performed by the referring physicians amounted to €42,683.08, resulting in €19.18 per secondary abdominal imaging interpretation. CONCLUSIONS: The frequency of RAIs in reports of secondary interpretations of abdominal imaging examinations (which appear to be affected by patients' age and radiologists' experience) and associated costs are non-negligible. However, RAIs not infrequently change clinical management. The presented data may be helpful to radiology departments and healthcare policy makers to make well-informed decisions on the value and facilitation of the practice of secondary interpretations. KEY POINTS: • Frequency of recommendations for additional imaging (RAIs) in secondary interpretations of abdominal imaging examinations at a tertiary care center is approximately 10.4%. • RAIs appear to be more frequently issued in younger patients and by more experienced radiologists, and if followed by referring clinicians, change clinical management in about one third of cases. • RAI costs per secondary interpretation in the Dutch Healthcare system are €31.92 (considering all RAIs) or €19.18 (considering only those RAIs that are actually performed).

Ordering of Diagnostic Imaging by Physical Therapists: A 5-Year Retrospective Practice Analysis.

BACKGROUND: Significant progress has been made in implementing direct access. As more therapists transition into direct access roles, it seems prudent to consider how additional resources common to other first-contact providers might impact patient care. OBJECTIVES: Direct referral for diagnostic imaging by physical therapists is relatively rare in the civilian setting and little has been published on the subject. The primary objective of this study was to examine the appropriateness of diagnostic imaging studies referred by civilian physical therapists at an academic medical center. Secondary objectives were to track reimbursement data and overall use rates. DESIGN: This was a single-center, retrospective practice analysis of 10 physical therapists over a period of nearly 5 years. METHODS: The electronic medical record was reviewed for each patient who had an imaging referral placed by a physical therapist. Relevant clinical exam findings and patient history were provided to a radiologist who then applied the American College of Radiology Appropriateness Criteria to determine appropriateness. Reimbursement data and therapist use rates were also evaluated. RESULTS: Of the 108 total imaging studies, 91% were considered appropriate. Overall, use rates per direct access evaluation were 9% for plain film x-rays and 4% for advanced imaging. Reimbursement was 100%. LIMITATIONS: This study was limited to 10 physical therapists at 1 practice location. Appropriateness was evaluated by 1 radiologist. The educational background of referring therapists was not evaluated. CONCLUSIONS: Physical therapists demonstrated appropriate use of diagnostic imaging in the vast majority of cases (91%). They were judicious in their use of imaging, and there were no issues with reimbursement. These findings could be useful for physical therapists interested in acquiring diagnostic imaging referral privileges.

Prospective Comparison of Diagnostic Accuracy Between Point-of-Care and Conventional Ultrasound in a General Diagnostic Department: Implications for Resource-Limited Settings.

OBJECTIVES: To compare the diagnostic accuracy of hand-held point-of-care (POC) versus conventional sonography in a general diagnostic setting with the intention to inform medical providers or clinicians on the rational use of POC ultrasound in resource limited settings. METHODS: Over 3 months in 2010, 47 patients were prospectively enrolled at a single academic center to obtain 54 clinical conventional ultrasound examinations and 54 study-only POC ultrasound examinations. Indications were 48% abdominal, 26% retroperitoneal, and 24% obstetrical. Nine blinded readers (sonographers, residents, and attending radiologists) sequentially assigned diagnoses to POC and then conventional studies, yielding 476 interpreted study pairs. Diagnostic accuracy was obtained by comparing POC and conventional diagnoses to a reference diagnosis established by the unblinded, senior author. Analysis was stratified by study type, body mass index (BMI), diagnostic confidence, and image quality. RESULTS: The mean diagnostic accuracy of conventional sonography was 84% compared with 74% for POC (P < .001). This difference was constant regardless of reader, exam type, or BMI. The sensitivity and specificity to detect abnormalities with conventional was 85 and 83%, compared with 75 and 68% for POC. The POC sonography demonstrated greater variability in image quality and diagnostic confidence, and this accounted for lower diagnostic accuracy. When image quality and diagnostic confidence were similar between POC and conventional examinations, there was no difference in accuracy. CONCLUSIONS: Point-of-care was nearly as accurate as conventional sonography for basic, focused examinations. Observed differences in accuracy were attributed to greater variation in POC image quality.

Maximize Marketing with a Deeper Dive into Data and Metrics.

In the current business environment for contract radiology services, a more stra- tegic approach to marketing can strengthen the ability of an organization to retain existing contracts and win new ones. Although over 70% of surveyed AHRA members believe that marketing is valued within their organizations, only a quarter rated their current marketing programs as highly effective. Survey responses indicate recognition of an unmet need for-marketing programs that are data driven and designed to be evaluated based on meas6rable outcomes. Starting with an understanding of a few key essentials of marketing data and basic categories of marketing metrics can form the foundation of a demonstra- bly effective marketing program for a contract-based radiology organization.

Optimizing MRI Logistics: Focused Process Improvements Can Increase Throughput in an Academic Radiology Department.

OBJECTIVE: The purpose of this study was to describe and evaluate the effect of focused process improvements on protocol selection and scheduling in the MRI division of a busy academic medical center, as measured by examination and room times, magnet fill rate, and potential revenue increases and cost savings to the department. MATERIALS AND METHODS: Focused process improvements, led by a multidisciplinary team at a large academic medical center, were directed at streamlining MRI protocols and optimizing matching protocol ordering to scheduling while maintaining or improving image quality. Data were collected before (June 2013) and after (March 2015) implementation of focused process improvements and divided by subspecialty on type of examination, allotted examination time, actual examination time, and MRI parameters. Direct and indirect costs were compiled and analyzed in consultation with the business department. Data were compared with evaluated effects on selected outcome and efficiency measures, as well as revenue and cost considerations. Statistical analysis was performed using a t test. RESULTS: During the month of June 2013, 2145 MRI examinations were performed at our center; 2702 were performed in March 2015. Neuroradiology examinations were the most common (59% in June 2013, 56% in March 2015), followed by body examinations (25% and 27%). All protocols and parameters were analyzed and streamlined for each examination, with slice thickness, TR, and echo train length among the most adjusted parameters. Mean time per examination decreased from 43.4 minutes to 36.7 minutes, and mean room time per patient decreased from 46.3 to 43.6 minutes (p = 0.009). Potential revenue from increased throughput may yield up to $3 million yearly (at $800 net revenue per scan) or produce cost savings if the facility can reduce staffed scanner hours or the number of scanners in its fleet. Actual revenue and expense impacts depend on the facility's fixed and variable cost structure, payer contracts, MRI fleet composition, and unmet MRI demand. CONCLUSION: Focused process improvements in selecting MRI protocols and scheduling examinations significantly increased throughput in the MRI division, thereby increasing capacity and revenue. Shorter scan and department times may also improve patient experience.

Assessment of Using 99Mo and 99mTc Isotopes in Kuwait Medical Sector.

The Ministry of Health (MOH) in the state of Kuwait currently depends on importing the radioisotope molybdenum (Mo) in its isotopic form (Mo) to fulfill its demands. The present study was conducted on all nuclear medicine departments in the state of Kuwait. Daily, weekly, and monthly data were analyzed to statistically determine the current and future demands for the isotope Tc. This analysis was performed by collecting and analyzing data on MOH consumption of Tc for different diagnostic applications. The overall results indicate a partial decrease of 1.012% in the overall total demand for Tc up to the year 2018 for the state of Kuwait.

Rural ED transfers due to lack of radiology services.

PURPOSE: Our objectives were to determine the frequency of patient transfers to a tertiary care emergency department (Tertiary ED) due to a lack of radiology services in rural hospital EDs (Rural EDs), and examine the community and patient attributes that are associated with these transfers. METHODS: This was a retrospective chart review of patients transferred to a Tertiary ED from Rural EDs. Transfers excluded from the study included pediatric patients (age <18 years old) and patients transferred for trauma surgeon evaluation. Only those patients who were transferred for radiology services were included in the final analysis. RESULTS: Over a 12-month period, 1445 patients were transferred to the Tertiary ED with 73.8% (n = 1066) of this population being transferred from a Rural ED. Excluding 381 trauma and pediatric patients, 64.3% (n = 685) of patients were transferred from a Rural ED and were included in the study. Of these 685 transfers, 24.5% (n = 168) were determined to be due primarily to a lack of a radiology service. DISCUSSION: Lack of radiology services in Rural EDs leads to numerous patient transfers to the Tertiary ED each year. A disproportionate number of these transfer patients are African American. These transfers place additional financial and social burdens on patients and their families. This study discusses these findings and alternative diagnostic options (ie, telemedicine and ultrasound video transfer) to address the lack of radiology services available in Rural EDs. The use of these alternate diagnostic options will likely reduce the number of patient transfers to Tertiary EDs.

The Shift in Outpatient Advanced Imaging From Private Offices to Hospital Facilities.

PURPOSE: To study recent outpatient imaging trends in private offices and hospital outpatient departments (HOPDs), to determine if shifting between the two has occurred. Concern is currently focused on whether reduced reimbursements and other factors might lead to a shift to higher-cost HOPDs. METHODS: The nationwide Medicare Physician/Supplier Procedure Summary Master Files for 2001 to 2013 were studied. All Current Procedural Terminology codes for MRI, echocardiography, nuclear medicine, ultrasound, and CT were selected, and procedure utilization rates per 1,000 Medicare beneficiaries were determined for each year. Medicare location codes identified the settings where the scans were performed. RESULTS: Total utilization rates, per 1,000 beneficiaries, of all these examination types in private offices, grew from 478 in 2001, to 874 in 2008 (+83%), and then declined to 503 in 2011 (-42%), primarily as a result of code bundling. No further bundling occurred in 2012 or 2013, but the decline continued in those years, to 462. In HOPDs, the total rate rose from 416 in 2001, to 523 in 2008 (+26%), followed by similar bundling-related declines, to 418 (-20%) in 2011. But in 2012 and 2013, in contrast to private office trends, the HOPD rate increased to 447. The ratio of private office to HOPD advanced imaging was 1.67 in 2008, declining to 1.03 in 2013. In addition, individual modality shifts away from offices and into HOPDs were quite apparent. CONCLUSIONS: In recent years, a shift has occurred in utilization of all advanced imaging modalities, from private offices to HOPDs. This change could portend a loss of access for patients and an increase in costs.

Outpatient falls prevention program outcome: an increase, a plateau, and a decrease in incident reports.

OBJECTIVE: We implemented an outpatient falls guideline in 2008 in the department of radiology. Here, we describe our multiyear experience. MATERIALS AND METHODS: This was a retrospective study conducted between April 2006 and September 2013 to investigate outpatient falls. The span of the study was divided into eight periods. The incident reporting system was searched for the falls and the fall-related variables. RESULTS: A total of 327 falls occurred during 5,080,512 radiology examinations (rate, 0.64/10,000 total examinations). The highest rate was in period 6 (0.83/10,000 examinations). The average for periods 1 and 2 is 0.39/10,000 examinations (37 falls/945,427 examinations), and the average for periods 3-6 is 0.77/10,000 examinations (204 falls/2,656,805 examinations). The average rate for periods 7 and 8 is 0.58/10,000 examinations (86 falls/1,478,280 examinations). There was a statistically significant increase in the total number of falls reported between period 2 and period 3 (p = 0.02). There was a statistically significant decrease in outpatient falls between period 6 and period 7 (p = 0.01). The number of falls among patients 60 years old or older was 177 falls/2,180,093 examinations (rate, 0.81/10,000 examinations), and that among patients younger than 60 years was 150 falls/2,900,419 examinations (rate, 0.52/10,000 examinations), with a statistically significant difference (p = 0.007). Although the rate of falls was higher among female patients, there was no statistically significant difference between the sexes (p = 0.18). CONCLUSION: The outcome of the outpatient falls guideline was characterized by an increase, a plateau, and a decrease in incident reports. The initial increase may be due to the Hawthorne effect. The plateau may represent the value closest to the true incidence. The decrease may represent the effect of the program.

Radiology utilization in the emergency department: trends of the past 2 decades.

OBJECTIVE: The objective of our study was to assess radiology utilization trends for emergency department (ED) patients from 1993 through 2012. MATERIALS AND METHODS: For this retrospective study, we reviewed radiology utilization at a 793-bed quaternary care academic medical center from January 1, 1993, through December 31, 2012, during which time the number of ED patient visits increased from approximately 48,000 to 61,000, and determined the number of imaging studies by modality (radiography, sonography, CT, MRI, other) and associated relative value units (RVUs). We used linear regression to assess for trends in the number of imaging RVUs and imaging accession numbers, our primary and secondary outcomes, respectively. RESULTS: The total RVUs attributable to ED imaging per 1000 ED visits increased 208% from 1993 to 2007 (p < 0.0001) and then decreased 24.7% by 2012 (p = 0.0019). The total number of imaging accession numbers per 1000 ED visits increased 47.8% from 1993 until 2005 (p = 0.0003) and then decreased 26.9% by 2012 (p < 0.0001). CT RVUs per 1000 ED visits increased 493% until 2007 (p < 0.0001) and then decreased 33.4% (p < 0.0001), and MRI RVUs increased 2475% until 2008 (p < 0.0001) and then decreased 20.6% (p < 0.0032). Sonography RVUs increased 75.7% over the study period (p < 0.0001), whereas radiography RVUs decreased 28.1% (p = 0.0009). CONCLUSION: After a period of substantial increase from 1993 to 2007, volume-adjusted ED imaging RVUs declined from 2007 through 2012, largely because of the decreasing use of CT and MRI. Additional studies are needed to determine the causes of this decline, which may include quality improvement activities, advocacy for appropriateness by leadership, concerns regarding radiation exposure and cost, and health information technology interventions.

Analysis of the last decade of weekend out-of-hours CT imaging: how have things changed?

CT has become an invaluable diagnostic tool. The clinical applications and technological capacity of CT has continued to increase. There is an increasing demand for radiology services including during weekend on-call hours. The objective of this study was to assess the trend in weekend CT imaging requests over a ten-year period form 2001-2010. Electronic data was retrieved from the hospital Radiology Inpatient System. In total 8530 CT scans were performed during weekend on-call hours. Over the decade weekend imaging grew from 466 to 1448 (210.7%) CT examinations. CT brain imaging accounted for 3944 of the total 8530(46%) and this was a 126% increase. A ten-fold, eight-fold and three-fold increase occurred in adult CT thorax, CT pelvis and CT abdominal imaging respectively. These results demonstrate rising demand on radiology services and need to plan for continued future growth. Radiology and emergency departments need to prepare and develop pathways to deal with this projected growth.

Launching a permanent out-of-hour interventional radiology service: single-center experience from a German University Hospital.

PURPOSE: To evaluate the feasibility, frequency of use, types of intervention and labor costs of a formal round-the-clock interventional radiology on-call service. MATERIALS AND METHODS: In 11/2011 a formal and permanent out-of-hour interventional radiology rota in addition to the general radiology out-of-hour rota (OOHR) was established. We retrospectively screened the interventional radiology database for procedures completed outside regular working hours, reviewed all interventions and manually selected cases in which the on-call interventionist was called in from home. We determined the type, frequency of use and costs (€/year and procedure) of this service between 1/2012 and 12/2012. The referring physicians' (sub-) specialties were evaluated. RESULTS: During the 12-month period, the on-call interventionists (n = 3) performed 92 procedures OOH. The procedures included angiography and hemorrhage control (n = 36, 39.1 %), angiography and intervention for acute limb ischemia (n = 25, 27.2 %), percutaneous biliary drainage (PTCD) (n = 10, 10.9 %), angiography for non-occlusive ischemia (n = 7, 7.6 %), and other (n = 14, 15.3 %). The total labor costs for the OOHR were €â€Š42,312.21 (€â€Š32,982.60 lump sum for stand-by, €â€Šâ€Š9,329.61 for hours spent on procedures). The labor costs per procedure totaled €â€Š459.92. The referring physicians' specialties were general/visceral (n = 25), vascular surgery (n = 24), internal medicine (n = 21), cardiac/thoracic vascular (n = 9), trauma surgery (n = 5), urology (n = 5), and anesthesiology (n = 3). CONCLUSION: A formal interventional OOHR is practicable in a university hospital setting. Most procedures were requested by general, vascular, and thoracic surgery as well as internal medicine with a focus on hemorrhage control, treatment of acute limb ischemia, and PTCD. The overall labor costs for the OOHR appear moderate. KEY POINTS: • In a university setting an OOHR for IR is feasible.• Labor costs per procedure appear moderate.• Hemorrhage control and treatment of limb ischemia were the most frequent procedures. Citation Format: • Goltz JP, Janssen H, Petritsch B et al. Launching a Permanent Out-of-Hour Interventional Radiology Service: Single-Center Experience from a German University Hospital. Fortschr Röntgenstr 2014; 186: 136 - 141.

Measuring and managing radiologist workload: application of lean and constraint theories and production planning principles to planning radiology services in a major tertiary hospital.

INTRODUCTION: We describe how techniques traditionally used in the manufacturing industry (lean management, the theory of constraints and production planning) can be applied to planning radiology services to reduce the impact of constraints such as limited radiologist hours, and to subsequently reduce delays in accessing imaging and in report turnaround. METHODS: Targets for imaging and reporting were set aligned with clinical needs. Capacity was quantified for each modality and for radiologists and recorded in activity lists. Demand was quantified and forecasting commenced based on historical referral rates. To try and mitigate the impact of radiologists as a constraint, lean management processes were applied to radiologist workflows. A production planning process was implemented. RESULTS: Outpatient waiting times to access imaging steadily decreased. Report turnaround times improved with the percentage of overnight/on-call reports completed by a 1030 target time increased from approximately 30% to 80 to 90%. The percentage of emergency and inpatient reports completed within one hour increased from approximately 15% to approximately 50% with 80 to 90% available within 4 hours. The number of unreported cases on the radiologist work-list at the end of the working day reduced. The average weekly accuracy for demand forecasts for emergency and inpatient CT, MRI and plain film imaging was 91%, 83% and 92% respectively. For outpatient CT, MRI and plain film imaging the accuracy was 60%, 55% and 77% respectively. Reliable routine weekly and medium to longer term service planning is now possible. CONCLUSIONS: Tools from industry can be successfully applied to diagnostic imaging services to improve performance. They allow an accurate understanding of the demands on a service, capacity, and can reliably predict the impact of changes in demand or capacity on service delivery.

Measuring and managing radiologist workload: a method for quantifying radiologist activities and calculating the full-time equivalents required to operate a service.

INTRODUCTION: Accurate and transparent measurement and monitoring of radiologist workload is highly desirable for management of daily workflow in a radiology department, and for informing decisions on department staffing needs. It offers the potential for benchmarking between departments and assessing future national workforce and training requirements. We describe a technique for quantifying, with minimum subjectivity, all the work carried out by radiologists in a tertiary department. METHODS: Six broad categories of clinical activities contributing to radiologist workload were identified: reporting, procedures, trainee supervision, clinical conferences and teaching, informal case discussions, and administration related to referral forms. Time required for reporting was measured using data from the radiology information system. Other activities were measured by observation and timing by observers, and based on these results and extensive consultation, the time requirements and frequency of each activity was agreed on. An activity list was created to record this information and to calculate the total clinical hours required to meet the demand for radiologist services. RESULTS: Diagnostic reporting accounted for approximately 35% of radiologist clinical time; procedures, 23%; trainee supervision, 15%; conferences and tutorials, 14%; informal case discussions, 10%; and referral-related administration, 3%. The derived data have been proven reliable for workload planning over the past 3 years. CONCLUSIONS: A transparent and robust method of measuring radiologists' workload has been developed, with subjective assessments kept to a minimum. The technique has value for daily workload and longer term planning. It could be adapted for widespread use.