Utilization trends for MR arthrography of the hip and shoulder: a retrospective cross-sectional analysis of 20-year data from a tertiary care academic medical center.

OBJECTIVE: The purpose of this study is to analyze changes in the utilization of MRA of the hip and shoulder at a large tertiary care academic medical center during a period of significant technological advancements over the last 20 years. MATERIALS AND METHODS: This retrospective cross-sectional analysis identified MRA of the hip and shoulder performed at our institution over a 20-year period (2/2003-2/2023) in relation to the total number of MR hip and shoulder examinations during the same period. Patient characteristics and referring provider demographic information were extracted. Descriptive statistics and trend analysis were performed. RESULTS: The total number of MRIs of the hip and shoulder increased overall, with small dips in 2020 and 2022. MRA of the hip increased significantly over the first 10 years of the study period (p = 0.0005), while MRA of the shoulder did not change significantly (p = 0.33). The proportion of both MRA of the hip and shoulder declined over the last 10 years (hip, p = 0.0056; shoulder, p = 0.0017). Over the same period, there was significant increase in the proportion of examinations performed at 3 Tesla versus 1.5 (p < 0.0001). CONCLUSION: Overall, there was a downward trend in MR shoulder and hip arthrogram utilization in the second half of this 20-year study period. However, utilization varied somewhat by referring specialties and credentials. These changes are likely reflective of both improvements in image quality and evolving practice recommendations. Awareness of such trends may be valuable in ensuring appropriate patient care, as well as for anticipating the needs of a musculoskeletal radiology practice.

Intensive Care Physician-Led Clearance of the Cervical Spine: A Retrospective Review of the Utility of a Normal Cervical CT Scan for Safe Removal of Hard Collars by Critical Care Physicians.

Background: Cervical spine clearance in intubated patients due to blunt trauma remains contentious. Accumulating evidence suggests that a normal computed tomography (CT) cervical spine can be used to clear the cervical spine and remove the collar in unconscious patients presenting to the emergency department. However, whether this strategy can safely be employed by critical care physicians with intubated patients admitted to the trauma intensive care unit (TICU) with cervical collars in situ, has not been definitively studied. Methods: A retrospective review of 730 intubated victims of trauma who presented to the Level 1 Trauma center of a tertiary hospital was conducted. The rates of missed cervical injuries in patients who had their cervical collars removed by intensive care physicians based on a normal CT scan of the cervical spine, were reviewed. Secondary outcomes included rates of collar-related complications. Results: Three hundred and fifty patients had their cervical collars removed by Trauma ICU doctors based on a high-quality, radiologist-interpreted normal CT cervical spine. Seventy percent of patients were sedated and/or comatose at the time of collar removal. Fifty-one percent of patients had concomitant traumatic brain injury. The average GCS at time of collar removal was 9. The incidence of missed neurological injury discerned clinically at time of both ICU and hospital discharge was nil (negative predictive value 100%). The rate of collar-related complications was 2%. Conclusion: Cervical collar removal by intensive care physicians on TICU following normal CT cervical spine, is safe, provided certain quality conditions related to the CT scan are met. Not removing the collar early may be associated with increased complications. An algorithm is suggested to assist critical care decision-making in this patient cohort.

Effect of the COVID-19 pandemic on emergency department utilization of computed tomography scans of appendicitis and diverticulitis.

PURPOSE: Investigating the effect of the COVID-19 lockdown on adult patient visits, computed tomography (CT) abdominal scans, and presentations of appendicitis and diverticulitis, to emergency departments (ED) in St. John's NL. METHODS: A retrospective quantitative analysis was applied, using ED visits and Canadian Triage and Acuity Scale (CTAS) scores. mPower (Nuance Communications, UK) identified CT abdominal scan reports, which were categorized into (1) normal/other, (2) appendicitis, or (3) diverticulitis. Time intervals included pre-lockdown (January-February), lockdown (March-June), and post-lockdown (July-August). Data from 2018 to 2019 (January-August) were used to generate expected patient volumes for 2020, and pre- and post-lockdown were included to control for other variables outside the lockdown. RESULTS: Chi-squared goodness of fit tested for deviations from predicted means for 2018-2019. Compared to expectations, daily ED visits from January to August 2020 showed a significant (p < 0.001) decrease in patient volumes independent of gender, age, and CTAS scores. During and post-lockdown, CT abdominal scans did not drop in proportion to patient volume. Appendicitis presentations remained indifferent to lockdown, while diverticulitis presentations appeared to wane, with no difference in combined complicated cases in comparison to what was expected. CONCLUSION: During lockdown, significantly fewer patients presented to the ED. The proportion of ordered CT abdominal scans increased significantly per person seen, without change in CTAS scores. Considering combined pathology cases increased during the lockdown, ED physicians were warranted in increasing abdominal imaging as patients did not avoid the ED. This may have resulted from a change in clinical practice where the uncertainty of COVID-19 increased CT scan usage.

Ankle MRI and preceding radiographs: an evaluation of physician ordering practices.

OBJECTIVE: Multiple guidelines have been published for appropriate imaging in patients with ankle-related symptoms which suggest radiographs as the initial imaging examination for both acute and chronic ankle abnormalities. Few studies have evaluated adherence to these imaging guidelines. This study retrospectively evaluated the utilization of ankle MRI and preceding radiographs based on ordering provider group and MRI indication. MATERIALS AND METHODS: A total of 4186 ankle MRIs performed over a 9-year period at a single institution were evaluated for the presence of preceding ankle and/or foot radiographs at two time points, within 3 months and within 6 months of the MRI examination. Ankle MRIs were then categorized based on 6 ordering provider groups and 13 MRI indications. RESULTS: Of the 4186 MRIs evaluated, 68% had preceding radiographs within 3 months and 77% had radiographs within 6 months. Primary care, sports medicine, and podiatry had the lowest rates of preceding radiographs (73%, 68%, and 64%, respectively, within 6 months). Eighty-six percent of ankle MRIs ordered by orthopedic surgery had preceding radiographs within 6 months and 89% of ankle MRIs ordered by emergency medicine and inpatient providers had preceding radiographs. MRIs intended for evaluation of Achilles tendon or plantar fascia abnormalities were among the least likely indications to have preceding radiographs. CONCLUSION: Based on established clinical guidelines, there was a lower-than-expected rate of obtaining preceding radiographs for ankle MRIs among most provider groups, particularly non-orthopedic outpatient providers. Additional research is needed to address the lack of adherence to clinical imaging guidelines and ensure appropriate imaging.

Impact of the COVID pandemic on emergency department CT utilization: where do we go from here?

PURPOSE: To analyze the impact of the coronavirus disease (COVID) pandemic on emergency department (ED) computed tomography (CT) utilization. METHODS: A retrospective observational study was conducted assessing seven hospitals' ED imaging volumes between Jan. 6, 2019, and Feb. 27, 2021. Weekly CT utilization is reported as CTs ordered per 100 ED visits. Utilization was ascertained in aggregate and by body area. Interrupted time series analysis was performed to assess significance of utilization change. Prespecified sensitivity analysis was performed for influenza-like or COVID-like illness (ILI/CLI). RESULTS: Weekly ED CT utilization increased from 35.9 CTs per 100 visits (95% confidence interval [95% CI] 35.8-36.1) to 41.8 per 100 visits (95% CI 41.7-42.0) in pre- and post-pandemic periods. Weekly ED CT chest utilization increased immediately following the pandemic declaration (+ 0.52 chest CTs per 100 ED visits, 95% CI 0.01-1.03, p < 0.05) and compared to pre-pandemic period (+ 0.02 per 100 ED visits, 95% CI 0.02-0.05, p < 0.02). For both CT abdomen/pelvis and CT head, there was neither an immediate effect (+ 0.34 CT-AP per 100 ED visits, 95% CI - 0.74 to 1.44, p = 0.89; - 0.42 CT-H per 100 ED visits, 95% CI - 1.53 to 0.70, p = 0.46) nor a change in weekly CT utilization (+ 0.03 CT-AP per 100 ED visits, 95% CI - 0.01 to 0.05, p = 0.09; + 0.03 CT-H per 100 ED visits, 95% CI - 0.01 to 0.06, p = 0.10).  CONCLUSION: These data may help formulate future strategies for resource utilization and imaging operations as we envision a future with COVID and other federal mandates affecting imaging utilization and appropriateness.

Neck CT imaging and correlation with thyroid cancer incidence across age, gender and race.

OBJECTIVE: Incidental detection of thyroid cancers has been proposed as a cause of thyroid cancer increases over past decades, but few studies assess the impact of imaging utilization on thyroid cancer incidence. This study quantifies neck CT prevalence and its relationship with thyroid cancer incidence as a function of age, sex and race. DESIGN AND PATIENTS: Medical records of over 1 million patients at our institution were retrospectively analysed to quantify neck CT prevalence from 2004 to 2011 (study period). A national cancer database was used to compute thyroid cancer incidences over the study period and a reference period (1974-81) and to calculate change in thyroid incidence between the two periods. Both populations were partitioned into demographic subgroups of varying age, sex and race. Linear correlation between neck imaging and thyroid cancer incidence changes among subgroups was assessed using Pearson's correlation. RESULTS: Neck CT imaging and change in thyroid cancer incidence varied across all examined demographic variables, particularly age. When stratifying by age, CT use correlated strongly with recent national thyroid cancer incidence (R = .97) and with 30-year change in thyroid cancer incidence (R = .87). Across all demographic subgroups, CT prevalence correlated strongly and positively with change in thyroid cancer incidence (R = .60), greater for whites (R = .60) and blacks (R = .70) than other races (R = .28). CONCLUSION: Differences in neck CT usage strongly and positively correlates with the variation in thyroid cancer trends based on age, gender and race.

Use of Ultrasound to Determine Changes in Diaphragm Mechanics During A Spontaneous Breathing Trial.

OBJECTIVE: Assess change in ultrasound measures of diaphragm mechanics over the course of a 30-minute spontaneous breathing trial (SBT). DESIGN: Prospective observational study. SETTING: Single intensive care unit (Logan Hospital, Queensland, Australia), patients recruited from August 2016 to April 2018. PARTICIPANTS: Eligible patients were over the age of 18 years, ventilated for >24 hours, and planned to undergo an SBT. In total, 129 patients were screened. MAIN OUTCOME MEASURES: Ultrasound measures taken at 5 and 30 minutes during SBT: diaphragmatic excursion (DE), diaphragmatic thickening fraction (DTF), and diaphragmatic contraction speed (DCS). Diaphragmatic rapid shallow breathing index (DRSBI) was calculated using DE/respiratory rate. The presence of diaphragmatic dysfunction (DD) was also determined using DTF < 30%, DE < 11 mm, or DRSBI > 1.6. RESULTS: Eighteen patients had ultrasound measures during an SBT. Four were unable to have DTF visualized. There was no significant change in DTF (n = 14, 32.41 ± 32.21 vs 23.19 ± 17.42, P = .33) or DE (n = 18, 1.72 ± 0.63 vs 1.66 ± 0.59, P = .63) over time. Diaphragmatic contraction speed increased over time (n = 18, 2.21 ± 1.25 vs 2.67 ± 1.61, P = .007). Diaphragmatic rapid shallow breathing index worsened over time (n = 18, 1.65 ± 1.02 vs 2.08 ± 1.51, P = .03). There was no significant change in the presence of DD. Diaphragmatic dysfunction by DTF 8/14 versus 10/14, by DE 4/18 versus 3/18, and by DRSBI 7/18 versus 9/18. No patients failed SBT and one patient failed extubation. CONCLUSIONS: Diaphragmatic mechanics may change over the course of an SBT. Further research is required to determine the clinical implications of these changes and the optimal timing of diaphragmatic ultrasound to predict weaning outcome. Diaphragmatic ultrasound may be less feasible than the published data suggest.

Impact of the COVID-19 pandemic on radiology department emergency ultrasound utilization.

PURPOSE: To analyze the change in utilization of healthcare resources through a review of ultrasound examinations performed in the emergency department of an urban healthcare system in NYC during the time of peak COVID-19 outbreak. METHODS: This is a retrospective review analyzing ED ultrasound exams performed by the radiology department of an urban healthcare system during the 8-week time period of the peak COVID-19 outbreak in NYC, compared to a time-matched period one year prior. Data regarding the examination type and indication were obtained in addition to patient demographics and indicators of outcomes including admission, length of stay, and mortality. RESULTS: There was a 58% decrease in ED ultrasounds performed by the radiology department during the COVID-19 time period. Exams performed during the pandemic compared to the pre-pandemic period were more likely to be performed on men (28.3 vs 18.0%, p < 0.01), older patients (36 vs. 35 years, p = 0.02), and patients subsequently admitted (17.8 vs. 13.4%, p = 0.03). There was also a difference in the distribution of exam type (p = 0.01). There was no difference in death, rate of surgery/intervention performed, or distribution of clinical indication. When correcting for gender, there was only an increase in studies leading to hospital admission in the female-only group (14.9 vs. 10.7%, p = 0.05). CONCLUSION: COVID-19 had a drastic impact on the utilization of emergency department ultrasounds performed by the radiology department, with a decrease in total exams performed and changes in patient demographics, including a higher proportion of male patients and increases in some markers of disease severity, including rate of hospital admission.

COVID-19 infection in the cancer population: a study of emergency department imaging utilization and findings.

PURPOSE: To analyze emergency department (ED) computerized tomography (CT) utilization in cancer patients with coronavirus disease 2019 (COVID-19). METHODS: A retrospective chart review was performed to identify cancer patients who received COVID-19 diagnosis within the single healthcare system and presented to the ED within 30 days of COVID-19 positive date between May 1 and December 31, 2020. RESULTS: In our 61 patients, the mean age was 72.5 years old, with 34% of patients (n = 21) on active cancer therapy and 66% (n = 40) on surveillance only. Most patients (n = 53) received their COVID-19 diagnosis within the ED, with 8 patients diagnosed prior to initial ED visit. The most common CT studies ordered within the ED were CT chest (n = 25), CT abdomen/pelvis (A/P) (n = 20), CT head (n = 8), and CT chest/abdomen/pelvis (C/A/P) (n = 7). COVID-19 findings were present on 33 scans, findings of worsening malignancy on 12 scans, and non-COVID non-cancer findings on 9 scans. Significant differences in CT severity score (p = 0.0001), indication for hospitalization (p = 0.026), length of hospitalization (p = 0.004), interventions (remdesivir, mechanical ventilation, and vasopressor support) while hospitalized (p < 0.05), and mortality (p = 0.042) were found between the prior diagnosis and ED diagnosis groups. No such differences were found between the active treatment and surveillance groups. CONCLUSION: ED CT imaging findings in patients with cancer and COVID-19 are predominantly related to COVID-19 infection, rather than cancer history or anti-cancer therapy status.

Utilization Trends in Abdominal Imaging, 2004-2016.

OBJECTIVE. The purpose of this study was to analyze recent trends in abdominal imaging utilization in the Medicare population. MATERIALS AND METHODS. Medicare Part B databases for 2004-2016 were reviewed, and all Current Procedural Terminology codes pertaining to noninvasive imaging of the abdomen and pelvis were identified. Codes were grouped into six categories: CT and CT angiography (CTA), MRI and MR angiography (MRA), ultrasound, radionuclide imaging, radiography, and gastrointestinal fluoroscopy. Annual utilization rates per 1000 Medicare beneficiaries were calculated. Medicare physician specialty codes were used to identify studies performed by radiologists versus nonradiologist physicians. Reimbursements were determined. RESULTS. Total abdominal imaging utilization decreased from 558.0 examinations per 1000 Medicare beneficiaries in 2004 to 441.9 in 2016 (-20.8%). CT and CTA examinations increased by 22.5% from 2004 to 2010, followed by a sharp drop in 2011 caused by code bundling. From 2011 to 2016, CT and CTA use increased by only 7.2%. Radiography utilization decreased from 129.6 examinations per 1000 Medicare beneficiaries in 2004 to 91.5 in 2016 (-29.4%). Radionuclide studies decreased from 14.0 to 9.5 (-32.1%), and gastrointestinal fluoroscopy decreased from 37.8 examinations to 22.5 (-40.5%). Utilization of ultrasound increased slightly (1.5%), whereas MRI and MRA utilization sharply increased on a percentage basis (81.2%). Reimbursements peaked in 2009 at $1.704 billion, dropped substantially in 2011 because of code bundling, and remained relatively stable thereafter. The radiologists' market share of abdominal imaging was approximately 87% in both 2004 and 2016. CONCLUSION. Abdominal imaging utilization rates have declined in recent years, in part due to code bundling, but also largely because of a decrease in the use of abdominal radiography, gastrointestinal fluoroscopy, and nuclear imaging. Reimbursements have also declined. This study also showed that most of the abdominal imaging was performed by radiologists.

Identifying tests related to breast cancer care in claims data.

To develop a method for calculating rates of testing for breast cancer recurrence in patients who have already undergone initial treatment for breast cancer, we calculated rates in a cohort of Medicare breast cancer patients and an age-matched noncancer cohort. We first used only tests with claims including diagnosis codes indicating invasive breast cancer and then used all tests regardless of diagnosis code. For each method, we calculated testing rates in the breast cancer cohort above the background rate in the noncancer population. The two methods provided similar estimates of testing prevalence and frequency, with exception of prevalence of CT.

Quantifying the decrease in emergency department imaging utilization during the COVID-19 pandemic at a multicenter healthcare system in Ohio.

PURPOSE: To illustrate the change in emergency department (ED) imaging utilization at a multicenter health system in the state of Ohio during the COVID-19 pandemic. METHODS: A retrospective observational study was conducted assessing ED imaging volumes between March 1, 2020, and May 11, 2020, during the COVID-19 crisis. A rolling 7-day total value was used for volume tracking and comparison. Total imaging utilization in the ED was compared with new COVID-19 cases in our region. Utilization was first categorized by modality and then by plain films and computed tomography (CT) scans grouped by body part. CT imaging of the chest was specifically investigated by assessing both CT chest only exams and CT chest, abdomen, and pelvis (C/A/P) exams. Ultimately, matching pair-wise statistical analysis of exam volumes was performed to assess significance of volume change. RESULTS: Our multicenter health system experienced a 46% drop in imaging utilization (p < 0.0001) during the pandemic. Matching pair-wise analysis showed a statistically significant volume decrease by each modality and body part. The exceptions were non-contrast chest CT, which increased (p = 0.0053), and non-trauma C/A/P CT, which did not show a statistically significant volume change (p = 0.0633). CONCLUSION: ED imaging utilization trends revealed through actual health system data will help inform evidence-based decisions for more accurate volume predictions and therefore institutional preparedness for current and future pandemics.

Diagnostic Imaging Examinations Interpreted by Nurse Practitioners and Physician Assistants: A National and State-Level Medicare Claims Analysis.

OBJECTIVE. Nonphysician providers (NPPs) increasingly perform imaging-guided procedures, but their roles interpreting imaging have received little attention. We characterize diagnostic imaging services rendered by NPPs (i.e., nurse practitioners and physician assistants) in the Medicare population. MATERIALS AND METHODS. Using 1994-2015 Medicare Physician/Supplier Procedure Summary Master Files, we identified all diagnostic imaging services, including those billed by NPPs, and categorized these by modality and body region. Using 2004-2015 Medicare Part B 5% Research Identifiable File Carrier Files, we separately assessed state-level variation in imaging services rendered by NPPs. Total and relative utilization rates were calculated annually. RESULTS. Between 1994 and 2015 nationally, diagnostic imaging services increased from 339,168 to 420,172 per 100,000 Medicare beneficiaries (an increase of 24%). During this same period, diagnostic imaging services rendered by NPPs increased 14,711% (from 36 to 5332 per 100,000 beneficiaries) but still represented only 0.01% and 1.27% of all imaging in 1994 and 2015, respectively. Across all years, radiography and fluoroscopy constituted most of the NPP-billed imaging services and remained constant over time (e.g., 94% of all services billed in 1994 and 2015), representing only 0.01% and 2.1% of all Medicare radiography and fluoroscopy services. However, absolute annual service counts for NPP-billed radiography and fluoroscopy services increased from 10,899 to 1,665,929 services between 1994 and 2015. NPP-billed imaging was most common in South Dakota (7987 services per 100,000 beneficiaries) and Alaska (6842 services per 100,000 beneficiaries) and was least common in Hawaii (231 services per 100,000 beneficiaries) and Pennsylvania (478 services per 100,000 beneficiaries). CONCLUSION. Despite increasing roles of NPPs in health care across the United States, NPPs still rarely interpret diagnostic imaging studies. When they do, it is overwhelmingly radiography and fluoroscopy. Considerable state-to-state variation exists and may relate to local care patterns and scope-of-practice laws.

Life-Threatening Pancreatitis in Jehovah's Witness Patients With Severe Anemia Treated Without Transfusions and by Interventional Radiology Techniques.

Blood transfusions in anemic patients frequently are used for critically ill patients as a life-saving therapeutic maneuver. Jehovah's Witness (JW) patients typically refuse blood transfusions due to religious beliefs. Numerous clinical reports, in a wide spectrum of medical specialties, have shown no greater morbidity or mortality in JW patients or others who refused transfusions compared to those patients who accept transfusions. We report our experience with two JW patients who presented with severe anemia and life-threatening pancreatitis. Despite undergoing percutaneous drainages by interventional radiology (IR) for complex pancreatic collections (and other IR drainages), neither patient suffered any adverse effect from the IR procedures, even though they refused blood transfusions. Our experience suggests that IR procedures also may be successful with this more limited blood product protocol.

Is repeat head CT necessary in patients with mild traumatic intracranial hemorrhage.

BACKGROUND: Patients with traumatic intracranial hemorrhage (TIH) frequently receive repeat head CT scans (RHCT) to assess for progression of TIH. The utility of this practice has been brought into question, with some studies suggesting that in the absence of progressive neurologic symptoms, the RHCT does not lead to clinical interventions. METHODS: This was a retrospective review of consecutive patients with CT-documented TIH and GCS ≥ 13 presenting to an academic emergency department from 2009 to 2013. Demographic, historical, and physical exam variables, number of CT scans during admission were collected with primary outcomes of: neurological decline, worsening findings on repeat CT scan, and the need for neurosurgical intervention. RESULTS: Of these 1126 patients with mild traumatic intracranial hemorrhage, 975 had RHCT. Of these, 54 (5.5% (4.2-7.2 95 CI) had neurological decline, 73 (7.5% 5.9-9.3 95 CI) had hemorrhage progression on repeat CT scan, and 58 (5.9% 4.5-7.6 95 CI) required neurosurgical intervention. Only 3 patients (0.3% 0.1-0.9% 95 CI) underwent neurosurgical intervention due to hemorrhage progression on repeat CT scan without neurological decline. In this scenario, the number of RHCT scans needed to be performed to identify this one patient is 305. CONCLUSIONS: RHCT after initial findings of TIH and GCS ≥ 13 leading to a change to operative management in the absence of neurologic progression is a rare event. A protocol that includes selective RHCT including larger subdural hematomas or patients with coagulopathy (vitamin K inhibitors and anti-platelet agents) may be a topic for further study.

Use of natural language processing to improve predictive models for imaging utilization in children presenting to the emergency department.

OBJECTIVE: To examine the association between the medical imaging utilization and information related to patients' socioeconomic, demographic and clinical factors during the patients' ED visits; and to develop predictive models using these associated factors including natural language elements to predict the medical imaging utilization at pediatric ED. METHODS: Pediatric patients' data from the 2012-2016 United States National Hospital Ambulatory Medical Care Survey was included to build the models to predict the use of imaging in children presenting to the ED. Multivariable logistic regression models were built with structured variables such as temperature, heart rate, age, and unstructured variables such as reason for visit, free text nursing notes and combined data available at triage. NLP techniques were used to extract information from the unstructured data. RESULTS: Of the 27,665 pediatric ED visits included in the study, 8394 (30.3%) received medical imaging in the ED, including 6922 (25.0%) who had an X-ray and 1367 (4.9%) who had a computed tomography (CT) scan. In the predictive model including only structured variables, the c-statistic was 0.71 (95% CI: 0.70-0.71) for any imaging use, 0.69 (95% CI: 0.68-0.70) for X-ray, and 0.77 (95% CI: 0.76-0.78) for CT. Models including only unstructured information had c-statistics of 0.81 (95% CI: 0.81-0.82) for any imaging use, 0.82 (95% CI: 0.82-0.83) for X-ray, and 0.85 (95% CI: 0.83-0.86) for CT scans. When both structured variables and free text variables were included, the c-statistics reached 0.82 (95% CI: 0.82-0.83) for any imaging use, 0.83 (95% CI: 0.83-0.84) for X-ray, and 0.87 (95% CI: 0.86-0.88) for CT. CONCLUSIONS: Both CT and X-rays are commonly used in the pediatric ED with one third of the visits receiving at least one. Patients' socioeconomic, demographic and clinical factors presented at ED triage period were associated with the medical imaging utilization. Predictive models combining structured and unstructured variables available at triage performed better than models using structured or unstructured variables alone, suggesting the potential for use of NLP in determining resource utilization.

Coronary CT Angiography: Use in Patients With Chest Pain Presenting to Emergency Departments.

OBJECTIVE: Previously published reports have shown that coronary CT angiography (CCTA) is a more efficient method of diagnosis than myocardial perfusion imaging (MPI) and stress echocardiography for patients presenting to emergency departments (EDs) with acute chest pain. In light of this evidence, the objective of this study was to examine recent trends in the use of these techniques in EDs. MATERIALS AND METHODS: The nationwide Medicare Part B databases for 2006-2015 were the data source. The Current Procedural Terminology, version 4, codes for CCTA, MPI, and stress echocardiography were selected. Medicare place-of-service codes were used to determine procedure volumes in EDs. Medicare specialty codes were used to ascertain how many of these examinations were interpreted by radiologists, cardiologists, and other physicians as a group. RESULTS: From 2006 to 2015, there was essentially no change in the number of MPI examinations performed in EDs for patients using Medicare (22,342 in 2006, 22,338 in 2015) or in the number of stress echocardiograms (3544 in 2006, 3520 in 2015). By contrast, the number of CCTA examinations increased rapidly, from 126 in 2006 to 1919 in 2015 (compound annual growth rate, 35%). Despite this rapid growth, patients in EDs underwent 11.6 times as many MPI as CCTA examinations in 2015. In that last year of the study, radiologists interpreted 78% of ED MPI and 83% of ED CCTA examinations. CONCLUSION: Use of CCTA in EDs has increased rapidly, but far more MPI examinations are still being performed. This finding suggests that recently acquired evidence is not yet being fully acted upon.

Changing Musculoskeletal Extremity Imaging Utilization From 1994 Through 2013: A Medicare Beneficiary Perspective.

OBJECTIVE: The objective of our study was to assess temporal changes in the utilization of musculoskeletal extremity imaging in Medicare beneficiaries over a recent 20-year period (1994-2013). MATERIALS AND METHODS: Medicare Physician Supplier Procedure Summary Master Files from 1994 through 2013 were used to study changing utilization and utilization rates of the four most common musculoskeletal imaging modalities: radiography, MRI, CT, and ultrasound. RESULTS: Utilization rates (per 1000 beneficiaries) for all four musculoskeletal extremity imaging modalities increased over time: 43% (from 441.7 to 633.6) for radiography, 615% (5.4-38.6) for MRI, 758% (1.2-10.3) for CT, and 500% (1.8-10.8) for ultrasound. Radiologists were the most common billing specialty group for all modalities throughout the 20-year period, maintaining dominant market shares for MRI and CT (84% and 96% in 2013). In recent years, the second most common billing group was orthopedic surgery for radiography, MRI, and CT and podiatry for ultrasound. The physician office was the most common site of service for radiography, MRI, and ultrasound, whereas the hospital outpatient and inpatient settings were the most common sites for CT. CONCLUSION: In the Medicare population, the most common musculoskeletal extremity imaging modalities increased substantially in utilization over the 2-decade period from 1994 through 2013. Throughout that time, radiology remained the most common billing specialty, and the physician office and hospital outpatient settings remained the most common sites of service. These insights may have implications for radiology practice leaders in making decisions regarding capital infrastructure, workforce, and training investments to ensure the provision of optimal imaging services for extremity musculoskeletal care.

Use and Yield of Baseline Imaging and Laboratory Testing in Stage II Breast Cancer.

BACKGROUND: Despite guideline recommendations, baseline laboratory testing and advanced imaging are widely ordered in clinical practice to stage asymptomatic patients with clinical stage II breast cancer (BC). MATERIALS AND METHODS: A retrospective study at two academic centers in Boston, Massachusetts, between 2006 and 2007 explored the use, results, and implications of laboratory tests, tumor markers, and imaging in patients with clinical stage II BC. RESULTS: Among 411 patients, 233 (57%) had liver function testing, 134 (33%) had tumor marker tests, and 237 (58%) had computed tomography (CT) as part of their initial diagnostic workup. Median age was 52 (range, 23-90 years). On multivariable analysis, young age, more advanced stage, and tumor subtype (human epidermal growth receptor-positive [HER2+] and triple-negative breast cancer [TNBC]) were significantly associated with baseline CT. The rate of detection of true metastatic disease with use of baseline staging imaging was 2.1% (95% confidence interval, 0.7%-5%). It was 2.2% (3 of 135) for estrogen receptor/progesterone receptor-positive disease, 1.9% (1 of 54) for HER2+ disease, and 2.1% (1 of 48) for TNBC. At 5 years of follow-up, 46 of 406 patients were diagnosed with metastatic breast cancer. Thirty-four of 46 (73.9%) who developed recurrent disease had imaging at their initial diagnosis, and of these, five had abnormalities on their initial imaging that was correlated with where they developed metastatic disease. CONCLUSION: In this cohort of women with stage II BC, staging imaging at diagnosis had a low yield in detecting distant metastases (2.1%). The detection rate was not higher with HER2+ disease or TNBC, despite the trend that patients with these subtypes were more likely to undergo imaging. IMPLICATIONS FOR PRACTICE: Despite guideline recommendations, asymptomatic patients with stage II breast cancer (BC) often undergo staging imaging with computed tomography, bone scanning, or positron emission tomography. Physicians have often reported that they order imaging despite recommendations because they believe that younger patients or patients with more aggressive BC phenotypes, such as human epidermal receptor 2-positive BC or triple-negative BC, benefit from staging imaging. In this cohort of women younger than those in prior studies, the yield of detecting distant metastatic disease in patients with clinical stage II BC was very low and the detection rate was not higher in the presence of HER2-positive or triple-negative BC.

Multicenter Survey of Current Practice Patterns in Perfusion MRI in Neuroradiology: Why, When, and How Is It Performed?

OBJECTIVE: Perfusion MRI is an advanced imaging technique with a number of potential neuroradiologic applications. However, there are few guidelines about the application of perfusion MRI in clinical practice. The purpose of this study was to assess when and how perfusion MRI is performed across national and international practices. MATERIALS AND METHODS: An international survey was conducted through the American Society of Neuroradiology e-mail list. The survey included questions relating to demographics, whether perfusion MRI was offered, technical details, reporting, and reimbursement. RESULTS: Most (81.0%) of the practices responding offered perfusion MRI; this proportion increases to 94.3% among academic and 95.3% among large practices. Intraaxial tumor, stroke, and arterial stenosis are the most frequent reasons for offering perfusion imaging. Most practices offer perfusion imaging on the basis of the judgment of the referring physician or person writing the protocol for the study, or they offer it for all intraaxial tumors. The most frequent method is dynamic susceptibility contrast-enhanced MRI (86.8%) followed by dynamic contrast-enhanced MRI (40.7%) and arterial spin-labeling MRI (34.8%). A minority (22.7%) of practices seek reimbursement for perfusion MRI. Most of the practices provide quantitative findings in radiology reports, most frequently cerebral blood volume (92.7%), cerebral blood (62.9%), and mean transit time (51.0%). CONCLUSION: Despite the paucity of high-quality trials and guidelines for specific clinical applications, perfusion MRI is widely used by both academic and private practices. A minority of practices attempt to obtain reimbursement. This widespread adoption of perfusion imaging beyond its apparent financial footprint suggests that practicing radiologists and referring clinicians find value in the technique and underscores the need for more high-quality trials to solidify understanding of the role of perfusion MRI.