A Claims-Based Method for Identification and Characterization of Practicing Interventional Radiologists.

PURPOSE: To propose a research method for identifying "practicing interventional radiologists" using 2 national claims data sets. MATERIALS AND METHODS: The 2015-2019 100% Medicare Part B data and 2015-2019 private insurance claims from Optum's Clinformatics Data Mart (CDM) database were used to rank-order radiologists' interventional radiology (IR)-related work as a percentage of total billed work relative value units (RVUs). Characteristics were analyzed at various threshold percentages. External validation used Medicare self-designated specialty with Society of Interventional Radiology (SIR) membership records; Youden index evaluated sensitivity and specificity. Multivariate logistic regression assessed practicing IR characteristics. RESULTS: In the Medicare data, above a 10% IR-related work threshold, only 23.8% of selected practicing interventional radiologists were designated as interventional radiologists; above 50% and 90% thresholds, this percentage increased to 42.0% and 47.5%, respectively. The mean percentage of IR-related work among practicing interventional radiologists was 45%, 84%, and 96% of total work RVUs for the 10%, 50%, and 90% thresholds, respectively. At these thresholds, the CDM practicing interventional radiologists included 21.2%, 35.2%, and 38.4% designated interventional radiologists, and evaluation and management services comprised relatively more total work RVUs. Practicing interventional radiologists were more likely to be males, metropolitan, and earlier in their careers than other radiologists at all thresholds. CONCLUSIONS: Most radiologists performing IR-related work are designated in claims data as diagnostic radiologists, indicating insufficiency of specialty designation for IR identification. The proposed method to identify practicing interventional radiologists by percent IR-related work effort could improve generalizability and comparability across claims-based IR studies.

Medicare Payment Policy: The Basics.

The mechanisms of payment for medical services are complicated and create predictable incentives. Physicians can benefit from understanding how hospitals, practices, employers, and payers understand payment, since this has a role in determining how certain patient care services are valued and prioritized. Type of hospital, location of service delivery, and a physician's relationship with the payer or provider entity can greatly impact the value of a physician's work. The landscape of payers is large, but Medicare payment has come to drive the behavior of many private payers. This article will outline the key components of Medicare and how they apply to physicians, hospitals, and ambulatory surgical centers to provide a basic structure for thinking about payment for medical services. This review of the fundamentals of Medicare payment will provide a framework for physicians to understand the financial incentives that underlie clinical and operational decisions in the healthcare system.

Results of an American College of Radiology-Society of Interventional Radiology Membership Survey on Exclusive Contracts and the Attitudes of Interventional Radiologists.

PURPOSE: To assess the attitudes of interventional radiologists (IRs) and diagnostic radiologists (DRs) toward exclusive contracts and independently practicing IRs who may request privileges at a hospital where an exclusive contract exists with a different group of radiologists. MATERIALS AND METHODS: A total of 22,400 survey instruments were distributed to 4,490 IRs and 17,910 DRs in the United States. Statistical evaluation included multivariate ordinal logistic regression analysis with calculation of the odds ratios and forest plots. RESULTS: Completed surveys were received from 525 (11.69%) IRs and 401 (2.23%) DRs. Given the low response rate of DRs, data analysis was focused on IRs. Early-career IRs and those in outpatient practices had a more positive attitude toward independent IRs who requested admitting and/or procedural privileges. A supermajority of both IRs and DRs who responded to the survey agreed that the importance of IR to hospital and health system contracts will increase. CONCLUSIONS: This survey identified many interrelated and complex variables that significantly affected the attitudes of IRs in various practice settings toward independent IRs requesting hospital admitting and/or procedural privileges. It will benefit independent IRs seeking admitting privileges to better understand some of the factors that impact the potential willingness of the radiology groups and other IRs with exclusive hospital contracts to work toward mutually beneficial practice paradigms, especially as more clinically oriented IRs complete their training in the new, integrated residency programs.

Surgery or Endovascular Therapy for Chronic Limb-Threatening Ischemia.

BACKGROUND: Patients with chronic limb-threatening ischemia (CLTI) require revascularization to improve limb perfusion and thereby limit the risk of amputation. It is uncertain whether an initial strategy of endovascular therapy or surgical revascularization for CLTI is superior for improving limb outcomes. METHODS: In this international, randomized trial, we enrolled 1830 patients with CLTI and infrainguinal peripheral artery disease in two parallel-cohort trials. Patients who had a single segment of great saphenous vein that could be used for surgery were assigned to cohort 1. Patients who needed an alternative bypass conduit were assigned to cohort 2. The primary outcome was a composite of a major adverse limb event - which was defined as amputation above the ankle or a major limb reintervention (a new bypass graft or graft revision, thrombectomy, or thrombolysis) - or death from any cause. RESULTS: In cohort 1, after a median follow-up of 2.7 years, a primary-outcome event occurred in 302 of 709 patients (42.6%) in the surgical group and in 408 of 711 patients (57.4%) in the endovascular group (hazard ratio, 0.68; 95% confidence interval [CI], 0.59 to 0.79; P<0.001). In cohort 2, a primary-outcome event occurred in 83 of 194 patients (42.8%) in the surgical group and in 95 of 199 patients (47.7%) in the endovascular group (hazard ratio, 0.79; 95% CI, 0.58 to 1.06; P = 0.12) after a median follow-up of 1.6 years. The incidence of adverse events was similar in the two groups in the two cohorts. CONCLUSIONS: Among patients with CLTI who had an adequate great saphenous vein for surgical revascularization (cohort 1), the incidence of a major adverse limb event or death was significantly lower in the surgical group than in the endovascular group. Among the patients who lacked an adequate saphenous vein conduit (cohort 2), the outcomes in the two groups were similar. (Funded by the National Heart, Lung, and Blood Institute; BEST-CLI ClinicalTrials.gov number, NCT02060630.).

Interventional Radiology Workforce Shortages Affecting Small and Rural Practices: A Report of the SIR/ACR Joint Task Force on Recruitment and Retention of Interventional Radiologists to Small and Rural Practices.

Radiology practices characterized as small and rural are challenged to recruit and retain interventional radiologists. Lack of access to interventional radiologic services results in a failure to meet the needs of patients, hospitals, and other community stakeholders. Acknowledging this challenge, the ACR's Commission on General, Small, Emergency and/or Rural Practice and Commission on Interventional and Cardiovascular Imaging and the Society of Interventional Radiology partnered to establish a joint task force to study this issue and identify strategies the ACR and the Society of Interventional Radiology should take to improve small and rural practice recruitment and retention of interventional radiologists. This report describes the deliberations and recommendations of the task force.

Comparative effectiveness of pelvic arterial embolization versus laparotomy in adults with pelvic injuries: A National Trauma Data Bank analysis.

PURPOSE: To compare the clinical outcomes and trends of arterial embolization (AE) versus laparotomy which are used in the management of pelvic trauma. MATERIALS AND METHODS: Adult patients with pelvic injuries were identified using the National Trauma Data Bank (NTDB) from 2007 to 2015. Patients with non-pelvic life-threatening injuries were excluded. Patients were grouped in operatively managed pelvic ring injuries, laparotomy ± fixation, AE ± fixation, and laparotomy and AE ± fixation. Using a linear mixed regression and logistic regression models, hospital length of stay (LOS), ICU days, ventilator days, and mortality for different therapies were compared. A propensity score weighting method was used to further eliminate treatment selection bias in the study sample and compare the outcomes between AE and laparotomy. RESULTS: Of 7473 pelvic trauma patients, 1226 (16.4%) patients were only operatively managed. 3730 patients (49.9%) underwent laparotomy, 2136 underwent AE (28.6%), and 381 (5.1%) patients underwent both laparotomy and AE. The year of injury, patient age, gender, race, severity of injury and presence of shock were found to be predictors of receipt of different therapies (P < 0.001 for all). When correcting for these confounding factors, the mortality rate was lower in the AE group compared to the laparotomy group 6.6% vs. 20.6% (P < 0.001). Additionally, LOS and ICU days were shorter for the AE group than the laparotomy group (P < 0.001). CONCLUSION: AE in patients with pelvic injuries is associated with lower mortality, as well as shorter LOS and ICU stays compared to laparotomy.

Academic Radiology in the United States: Defining Gender Disparities in Faculty Leadership and Academic Rank.

RATIONALE AND OBJECTIVES: Female physicians in academic medicine have faced barriers that potentially affect representation in different fields and delay promotion. Little is known about gender representation differences in United States academic radiology departments, particularly within the most pursued subspecialties. PURPOSE: To determine whether gender differences exist in United States academic radiology departments across seven subspecialties with respect to academic ranks, departmental leadership positions, experience, and scholarly metrics. MATERIALS AND METHODS: In this cross-sectional study from November 2018 to June 2020, a database of United States academic radiologists at 129 academic departments in seven subspecialties was created. Each radiologist's academic rank, departmental leadership position (executive-level - Chair, Director, Chief, and Department or Division Head vs vice-level - vice, assistant, or associate positions of executive level), self-identified gender, years in practice, and measures of scholarly productivity (number of publications, citations, and h-index) were compiled from institutional websites, Doximity, LinkedIn, Scopus, and official NPI profiles. The primary outcome, gender composition differences in these cohorts, was analyzed using Chi2 while continuous data were analyzed using Kruskal-Wallis rank sum test. The adjusted gender difference for all factors was determined using a multivariate logistic regression model. RESULTS: Overall, 5086 academic radiologists (34.7% women) with a median 14 years of practice (YOP) were identified and indexed. There were 919 full professors (26.1% women, p < 0.01) and 1055 executive-level leadership faculty (30.6% women, p < 0.01). Within all subspecialties except breast imaging, women were in the minority (35.4% abdominal, 79.1% breast, 12.1% interventional, 27.5% musculoskeletal, 22.8% neuroradiology, 45.1% pediatric, and 19.5% nuclear; p < 0.01). Relative to subspecialty gender composition, women full professors were underrepresented in abdominal, pediatric, and nuclear radiology (p < 0.05) and women in any executive-level leadership were underrepresented in abdominal and nuclear radiology (p < 0.05). However, after adjusting for h-index and YOP, gender did not influence rates of professorship or executive leadership. The strongest single predictors for professorship or executive leadership were h-index and YOP. CONCLUSION: Women academic radiologists in the United States are underrepresented among senior faculty members despite having similar levels of experience as men. Gender disparities regarding the expected number of women senior faculty members relative to individual subspecialty gender composition were more pronounced in abdominal and nuclear radiology, and less pronounced in breast and neuroradiology. Overall, h-index and YOP were the strongest predictors for full-professorship and executive leadership among faculty. KEY RESULTS: ● Though women comprise 34.7% of all academic radiologists, women are underrepresented among senior faculty members (26.1% of full professors and 30.6% of executive leadership) ● Women in junior faculty positions had higher median years of practice than their male counterparts (10 vs 8 for assistant professors, 21 vs 13 for vice leadership) ● Years of practice and h-index were the strongest predictors for full professorship and executive leadership.

Clinical presentation and outcomes after endovascular management in a mixed pediatric and adult Klippel-Trenaunay syndrome population.

OBJECTIVE: We retrospectively studied the clinical presentations and outcomes of endovascular management in a mixed pediatric and adult Klippel-Trenaunay syndrome (KTS) population at a single academic medical center. METHODS: We performed a retrospective study of patients with KTS who had been referred for endovascular intervention after evaluation and diagnosis by a multidisciplinary team at a single academic medical center during a 10-year period. The patient demographics, areas affected, presenting symptoms, previous treatments, imaging modalities, endovascular treatment types, number of treatments, and complications were assessed. The technical and clinical success rates were calculated. RESULTS: Twenty-six patients with suspected KTS were evaluated. Of these 26 patients, 20, aged 2 to 75 years, had been diagnosed with KTS using the International Society for the Study of Vascular Anomalies criteria and referred for endovascular management. The left lower extremity was affected most often. The presenting symptoms were pain (80%), edema (70%), bleeding (10%), numbness (25%), and claudication (25%). Of the 20 patients, 16 (80%) had undergone treatment of KTS before presenting to our institution. Magnetic resonance imaging and ultrasound (US) were the most common imaging modalities. Fifteen patients underwent 46 endovascular treatments during the study period. The treatments included 5 endovenous ablations only, 4 US-guided sclerotherapies with endovenous ablation, 5 US-guided sclerotherapies only, and 32 catheter-directed venograms with additional interventions. Localized intravascular coagulopathy was the only procedure-related complication and occurred in one patient after three treatments. The technical success rate was 97.8%, and the clinical success rate was 100%. CONCLUSIONS: Endovascular intervention is safe and effective for KTS patients for whom conservative management has failed. Pain and edema were the most common presenting symptoms. Presenting symptoms may be related to pathology of anomalous veins, orthotopic superficial veins or deep veins. Venous claudication can be present in those with KTS despite patency of the deep venous system. Magnetic resonance imaging and duplex US are frequently used modalities for venous assessment. The complications of endovascular treatment are rare but include localized intravascular coagulopathy.

Issues Most Pressing to Early-Career Interventional Radiologists: Results of a Descriptive Survey.

PURPOSE: To determine demographics, practice patterns, needs from Society of Interventional Radiology (SIR), and preferences of interventional radiologists (IRs) early in their careers. METHODS: A 28-question descriptive survey was used to identify demographic and practice composition, practice issues, and needs of early career IRs. The survey was distributed to SIR members in the United States (US) (n = 859) within the first 8 years of practice, with 213 respondents (25%). RESULTS: Respondents were primarily male (n = 181, 87%), less than 40 years old (n = 156, 73%), in practice for 6 years or less (n = 167, 79%), and satisfied with IR as a career (n = 183, 92.4%). The majority were in academic practice (n = 89, 43.2%) or large private practice group (n = 67, 32.5%). Most respondents read diagnostic imaging daily or weekly (n = 130, 61%). The majority of respondents perform complex procedures regularly including transarterial tumor therapy, percutaneous tumor ablation, peripheral arterial interventions, and biliary interventions monthly. Many respondents (n = 49, 23%) have changed jobs at least once citing career advancement, practice issues/disagreements, or compensation as reason. Most respondents would serve as mentors (n = 170, 80%) for trainees and were satisfied with their career mentorship (n = 166, 78%). Respondents felt that mentorship, identification of barriers facing early career IRs, and networking should be the most important functions of the Early Career Section (ECS)of the SIR. CONCLUSION: As nearly all survey respondents indicated that early career IRs have different needs and priorities than established physicians, they felt that mentorship, identification of barriers facing early career IRs, and networking should be the most important functions of the ECS. Additionally, this same group of IRs report low comfort with the business side of medicine and may benefit from directed content provided by the SIR ECS.

Meta-analysis of Intraprocedural Comparative Effectiveness of Vascular Plugs Vs Coils in Proximal Splenic Artery Embolization and Associated Patient Radiation Exposure.

PURPOSE: To compare vascular plugs to coil embolization of the proximal splenic artery and evaluate differences in radiation exposure to the patients. METHODS: An electronic literature search was performed for relevant studies from January 2000 to July 2018 that compared the efficacy of vascular plugs vs coils in splenic artery embolization. Only studies that investigated coil or vascular plug use, without combination with other embolic agents, were included. Meta-analysis was performed using a fixed effects model approach with the inverse variance-weighted average method to determine pooled differences in time to vessel occlusion, procedure time, fluoroscopy time, total number of devices used, and radiation exposure. Heterogeneity was assessed using the I square statistic. Pooled outcomes were compared, and quality assessments were evaluated using the Newcastle Ottawa Scale. RESULTS: Eight studies met inclusion criteria. 81 patients were embolized with vascular plugs and 52 patients with coils only. The most common indication for splenic artery embolization was trauma. Time to vessel occlusion was shorter in the vascular plug group by 7.11 minutes (P = 0.003). Fluoroscopy time was shorter by 13.82 minutes in the vascular plug cohort, and these patients received less radiation (-439 mGy) compared to the coil group (P = 0.006 and P = 0.02, respectively). The number of devices was significantly fewer in the vascular plug group (-3.54; P < 0.001). Procedure time was not statistically significant. CONCLUSION: Our data supports the vascular plug is superior to coils for embolization of the proximal splenic artery with respect to occlusion time, fluoroscopy time, patient radiation exposure, and number occlusive devices used.

Experience of Women in IR in the Arab World: Survey by the Pan Arab Interventional Radiology Society.

We report our assessment of the experience of female interventional radiologists in different Arab countries based on an online questionnaire that was sent to 57 female interventional radiologists in 5 Arab countries. These interventional radiologists were identified from the Pan Arab Interventional Radiology Society database and through personal communications. The survey included items related to demographics, social status, and the professional challenges of interventional radiologists, with a response rate of 93%. Forty-five percent of respondents were between 31 and 45 years of age. Interventional radiology practice represented 25%-50% of work time for 51% of respondents, and the main challenges reported were related to radiation exposure, balancing family/work life, and the male-dominated interventional radiology community.

Clinical Approach to and Work-up of Bleeding Patients.

A bleeding patient is a common consult for interventional radiologists. Prompt triage, preprocedural evaluation specific to the site of hemorrhage, and knowledge of resuscitative strategies allow for a potentially life-saving procedure to be appropriately and safely performed. Having a firm understanding of the clinical work-up and management of a bleeding patient has never been more important. In this article, a discussion of the clinical approach and work-up of a bleeding patient for whom interventional radiology is consulted is followed by a discussion of etiology-specific preprocedural work-up.

Contemporary Management of Hepatic Trauma: What IRs Need to Know.

Trauma remains one of the leading causes of death in the United States in patients younger than 45 years. Blunt trauma is most commonly a result of high-speed motor vehicular collisions or high-level fall. The liver and spleen are the most commonly injured organs, with the liver being the most commonly injured organ in adults and the spleen being the most affected in pediatric blunt trauma. Liver injuries incur a high level of morbidity and mortality mostly secondary to hemorrhage. Over the past 20 years, angiographic intervention has become a mainstay of treatment of hepatic trauma. As there is an increasing need for the interventional radiologists to embolize active hemorrhage in the setting of blunt and penetrating hepatic trauma, this article aims to review the current level of evidence and contemporary management of hepatic trauma from the perspective of interventional radiologists. Embolization techniques and associated outcome and complications are also reviewed.

Update: Splenic Artery Embolization in Blunt Abdominal Trauma.

The spleen is the most commonly injured organ after blunt abdominal trauma. Nonoperative management with splenic arterial embolization (SAE) is the current standard of care for hemodynamically stable patients. Current data favor the use of proximal and coil embolization techniques in adults, while observation is suggested in the pediatric population. In this review, the authors describe the most recent evidence informing the clinical indications, techniques, and complications for SAE.

A Meta-analysis of Comparative Outcome and Cost-Effectiveness of Internal Iliac Artery Embolization with Vascular Plug Versus Coil.

PURPOSE: To evaluate the comparative outcome and cost of vascular plugs versus coils for internal iliac artery embolization prior to endovascular aortic aneurysm repair. METHOD: A search was performed for internal iliac artery embolization studies in adult patients from January 2005 to July 2018. Inclusion criteria included embolization of unilateral or bilateral IIAs with either coils or plug(s) prior to endovascular aortic repair. Meta-analysis was performed using a fixed effects model with the inverse variance-weighted average method to determine pooled differences in surgical time, fluoroscopy time, radiation exposure, number of devices used, cost of devices, and post-embolization buttock claudication. Heterogeneity was assessed using the Chi-square statistic. Pooled outcomes were compared, and quality assessments were evaluated using the Newcastle-Ottawa scale. RESULT: Six studies met inclusion criteria. One hundred and eighty-one patients were included in the study, of which 87 were in the plug group and 94 in the coil group. Vascular plug use led to 35.32 min shorter surgery time (p < 0.001), 15.64 min less fluoroscopy time (p < 0.001), 157,599 mGy/cm2 less radiation (p < 0.001), and 5.88 fewer occlusive devices (p < 0.001) than the use of coils alone. The estimated total cost of occlusion devices was $575.45 USD lower in the plug cohort (p < 0.001). The development of buttock claudication 12 months after EVAR was 11% less likely in the plug cohort but was not statistically significant (p = 0.71). CONCLUSION: The vascular plug appears to be superior to coils in embolization of the internal iliac artery due to shorter surgical time, fluoroscopy time, radiation exposure, and total cost of occlusive devices.

Development of Research Agenda in Prostate Artery Embolization: Summary of Society of Interventional Radiology Consensus Panel.

PURPOSE: To summarize the Society of Interventional Radiology Foundation's Research Consensus Panel development of a research agenda on prostate artery embolization (PAE). MATERIALS AND METHODS: PAE for the treatment of lower urinary tract symptoms has been shown to be safe and effective in decreasing symptoms and prostate size. Lack of randomized controlled trials (RCTs) on PAE in the United States has prevented inclusion in American Urologic Association guideline recommendations for treatment of lower urinary tract symptoms resulting from benign prostatic hyperplasia. Recognizing the need for well-designed trials, the SIR Foundation funded a Research Consensus Panel to prioritize a research agenda. The panel included interventional radiologists, urologists, SIR Foundation leadership, and industry representatives. The goal of the meeting was to discuss weaknesses with current data and study design for development of US trials to report long-term outcomes data. RESULTS: Final consensus on a research design could not be made because the group was split on 3 research designs: (i) RCT of PAE versus sham with crossover of the sham group. (ii) RCT of PAE versus simple prostatectomy. (iii) RCT of PAE versus holmium laser enucleation of the prostate/thulium laser enucleation of the prostate. The panel recommended a nonindustry-funded registry to obtain real-world data. CONCLUSIONS: Level 1 data are required to be included in the American Urologic Association guidelines for treatment of benign prostatic hyperplasia. Because of concerns with all 3 study designs, the panel did not reach a consensus. Further meetings are planned with the panel to select among these research designs.

The resuscitative endovascular balloon occlusion of aorta (REBOA) device-what radiologists need to know.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a novel device approved by the Food and Drug administration (FDA) in 2017 as an alternative to resuscitative emergent thoracotomy (RET). Due to advancements in placement of REBOA, including newly validated placement using anatomic landmarks, REBOA is now widely used by interventional radiologists and emergency physicians in acute subdiaphragmatic hemorrhage. Increased use of REBOA necessitates that radiologists are familiar with verification of proper REBOA placement to minimize complications. This review describes the REBOA device, indications, placement, and complications, summarizing the current available literature.