Interventional Imaging Systems in Radiology, Cardiology, and Urology: Energy Consumption, Carbon Emissions, and Electricity Costs.

BACKGROUND. The energy demand of interventional imaging systems has historically been estimated using manufacturer-provided specifications rather than directly measured. OBJECTIVE. The purpose of this study was to investigate the energy consumption of interventional imaging systems and estimate potential savings in the carbon emissions and electricity costs of such systems through hypothetical operational adjustments. METHODS. An interventional radiology suite, neurointerventional suite, radiology fluoroscopy unit, two cardiology laboratories, and two urology fluoroscopy units were equipped with power sensors. Power measurement logs were extracted for a single 4-week period for each radiology and cardiology system (all between June 1, 2022, and November 28, 2022) and for the 2-week period from July 31, 2023, to August 13, 2023, for each urology system. Power statuses, procedure time stamps, and fluoroscopy times were extracted from various sources. System activity was divided into off, idle (no patient in room), active (patient in room for procedure), and net-imaging (active fluoroscopic image acquisition) states. Projected annual energy consumption was calculated. Potential annual savings in carbon emissions and electricity costs through hypothetical operational adjustments were estimated using published values for Switzerland. RESULTS. Across the seven systems, the mean power draw was 0.3-1.1, 0.7-7.4, 0.9-7.6, and 1.9-12.5 kW in the off, idle, active, and net-imaging states, respectively. Across systems, the off state, in comparison with the idle state, showed a decrease in the mean power draw of 0.2-6.9 kW (relative decrease, 22.2-93.2%). The systems had a combined projected annual energy consumption of 115,684 kWh (range, 3646-26,576 kWh per system). The systems' combined projected energy consumption occurring outside the net-imaging state accounted for 93.3% (107,978/115,684 kWh) of projected total energy consumption (range, 89.2-99.4% per system). A hypothetical operational adjustment whereby all systems would be switched from the idle state to the off state overnight and on weekends (versus being operated in idle mode 24 hours a day, 7 days a week) would yield the following potential annual savings: for energy consumption, 144,640 kWh; for carbon emissions, 18.6 metric tons of CO2 equivalent; and for electricity costs, US$37,896. CONCLUSION. Interventional imaging systems are energy intensive, having high consumption outside of image acquisition periods. CLINICAL IMPACT. Strategic operational adjustments (e.g., powering down idle systems) can substantially decrease the carbon emissions and electricity costs of interventional imaging systems.

True Costs of Uterine Artery Embolization: Time-Driven Activity-Based Costing in Interventional Radiology Over a 3-Year Period.

PURPOSE: The aim of this study is to uncover potential areas for cost savings in uterine artery embolization (UAE) using time-driven activity-based costing, the most accurate costing methodology for direct health care system costs. METHODS: One hundred twenty-three patients who underwent outpatient UAE for fibroids or adenomyosis between January 2020 and December 2022 were retrospectively reviewed. Utilization times were captured from electronic health record time stamps and staff interviews using validated techniques. Capacity cost rates were estimated using institutional data and manufacturer proxy prices. Costs were calculated using time-driven activity-based costing for personnel, equipment, and consumables. Differences in time utilization and costs between procedures by an interventional radiology attending physician only versus an interventional radiology attending physician and trainee were additionally performed. RESULTS: The mean total cost of UAE was $4,267 ± $1,770, the greatest contributor being consumables (51%; $2,162 ± $811), followed by personnel (33%; $1,388 ± $340) and equipment (7%; $309 ± $96). Embolic agents accounted for the greatest proportion of consumable costs, accounting for 51% ($1,273 ± $789), followed by vascular devices (15%; $630 ± $143). The cost of embolic agents was highly variable, driven mainly by the number of vials (range 1-19) of tris-acryl gelatin particles used. Interventional radiology attending physician only cases had significantly lower personnel costs ($1,091 versus $1,425, P = .007) and equipment costs ($268 versus $317, P = .007) compared with interventional radiology attending physician and trainee cases, although there was no significant difference in mean overall costs ($3,640 versus $4,386; P = .061). CONCLUSIONS: Consumables accounted for the majority of total cost of UAE, driven by the cost of embolic agents and vascular devices.

Current Interventional Radiology-Related Benchmarked Clinical Quality Measures Are Less Likely to be "Capped" Than Diagnostic Radiology Clinical Quality Measures.

In the merit-based incentive payment system (MIPS), quality measures are considered topped out if national median performance rates are ≥95%. Quality measures worth 10 points can be capped at 7 points if topped out for ≥2 years. This report compares the availability of diagnostic radiology (DR)-related and interventional radiology (IR)-related measures worth 10 points. A total of 196 MIPS clinical quality measures were reviewed on the Center for Medicare and Medicaid Services MIPS website. There are significantly more IR-related measures worth 10 points than DR measures (2/9 DR measures vs 9/12 IR measures; P = .03), demonstrating that clinical IR services can help mixed IR/DR groups maximize their Center for Medicare and Medicaid Services payment adjustment.

The Role of Physician-Driven Device Preference in the Cost Variation of Common Interventional Radiology Procedures.

PURPOSE: To analyze the impact of physician-specific equipment preference on cost variation for procedures typically performed by interventional radiologists at a tertiary care academic hospital. MATERIALS AND METHODS: From October 2017 to October 2019, data on all expendable items used by 9 interventional radiologists for 11 common interventional radiology procedure categories were compiled from the hospital analytics system. This search yielded a final dataset of 44,654 items used in 2,121 procedures of 11 different categories. The mean cost per case for each physician as well as the mean, standard deviation, and coefficient of variation (CV) of the mean cost per case across physicians were calculated. The proportion of spending by item type was compared across physicians for 2 high-variation, high-volume procedures. The relationship between the mean cost per case and case volume was examined using linear regression. RESULTS: There was a high variability within each procedure, with the highest and the lowest CV for radioembolization administration (56.6%) and transjugular liver biopsy (4.9%), respectively. Variation in transarterial chemoembolization cost was mainly driven by microcatheters/microwires, while for nephrostomy, the main drivers were catheters/wires and access sets. Mean spending by physician was not significantly correlated with case volume (P =.584). CONCLUSIONS: Physicians vary in their item selection even for standard procedures. While the financial impact of these differences vary across procedures, these findings suggest that standardization may offer an opportunity for cost savings.

Financial implications of CT-guided lung biopsy in a tertiary centre: a radiologists' perspective.

AIM: To evaluate the financial costs of performing computed tomography (CT)-guided lung biopsies in a large tertiary centre to help guide service development. MATERIALS AND METHODS: Local financial data were collected to create a balance sheet, considering all expenses as well as revenue sources associated with the procedure. Data were based on accurate pricing and income data and evaluated on a per-procedure basis, with consideration of additional costs arising from post-procedural complications. Revenue data were estimated based on reimbursement information. A small coding quality audit was also performed to check if reimbursement claims were filed correctly. RESULTS: This study demonstrated a healthy income generated from CT-guided lung biopsy procedures with a profit margin of 50%. Notably different financial impact was observed when comparing the same procedure undertaken on an outpatient as opposed to inpatient basis with inpatient procedures generating a net loss of - £2,146.79 a year. Overall, the activity generated a profit of £157,015.25, after accounting for loss generated by inpatient activity. CONCLUSION: This analysis furthered understanding of the financial impact from performing CT-guided lung biopsy and will enable better planning and expansion of the service in the future, with emphasis around day-case and ambulatory service development, the positive intended consequence being an improved patient pathway.

Medicare Reimbursement Trends for Interventional Radiology Procedures: 2012 to 2020.

PURPOSE: To investigate the reimbursement trends for interventional radiology (IR) procedures from 2012 to 2020. MATERIALS AND METHODS: Reimbursement data from the Physician Fee Schedule look-up tool from the Centers for Medicare and Medicaid Services was compiled for 20 common IR procedures. The authors then investigated compensation trends after adjusting for inflation and from the unadjusted data between 2012 and 2020. RESULTS: From 2012 to 2020, the mean unadjusted reimbursement for procedures decreased by -6.9% (95% confidence interval [CI], -13.5% to -0.34%). This trend was even more profound after inflation was taken into account, with a mean decline in adjusted reimbursement of -18.7% (95% CI, -24.4% to -12.9%) during the study period, with a mean yearly decline of -2.8%. The difference between the mean unadjusted and adjusted payment amounts was significant (P = .012). Similarly, linear regression analysis of the adjusted average reimbursement across all procedures revealed an overall decline from 2012 to 2020 (R2 = 0.97), indicating a steady decline in reimbursement over time. CONCLUSIONS: In just under a decade, IR has experienced significant reimbursement cuts by Medicare, as demonstrated by both the unadjusted and inflation-adjusted payment trends. Knowledge of these trends is critically important for practicing interventional radiologists, leaders within the field, and legislators, who may play a role in formulating future reimbursement schedules for IR. These data may be used to help support more amenable reimbursement plans to sustain and facilitate the growth of the specialty.

Value Improvement by Assessing IR Care via Time-Driven Activity-Based Costing.

PURPOSE: To evaluate time-driven activity-based costing (TDABC) in interventional radiology for image-guided vascular malformation treatment as an example. MATERIALS AND METHODS: Retrospective analysis was performed on consecutive vascular malformation treatment cycles [67 venous malformations (VMs) and 11 arteriovenous malformations (AVMs)] in a university hospital in 2018. All activities were integrated with a process map, and spent resources were assigned accordingly. TDABC uses 2 parameters: (i) practical capacity cost rate, calculated as 80% of theoretical capacity, and (ii) time consumption of each resource determined by interviews (23 items). Thereby, the total costs were calculated. Treatment cycles were modified according to identified resource waste and TDABC-guided negotiations with health insurance. RESULTS: Total personnel time required was higher for AVM (1,191 min) than for VM (637 min) treatment. The interventional procedure comprised the major part (46%) of personnel time required in AVM, whereas it comprised 19% in VM treatment. Materials represented the major cost type in AVM (75%) and VM (45%) treatments. TDABC-based treatment process modification led to a decrease in personnel time need of 16% and 30% and a cost reduction of 5.5% and 15.7% for AVM and VM treatments, respectively. TDABC-guided cost reduction and TDABC-informed negotiations improved profit from -56% to +40% and from +41% to +69% for AVM and VM treatments, respectively. CONCLUSIONS: TDABC facilitated the precise costing of interventional radiologic treatment cycles and optimized internal processes, cost reduction, and revenues. Hence, TDABC is a promising tool to determine the denominator of interventional radiology's value.

Toxicity reduction required for MRI-guided radiotherapy to be cost-effective in the treatment of localized prostate cancer.

OBJECTIVE: To determine the toxicity reduction required to justify the added costs of MRI-guided radiotherapy (MR-IGRT) over CT-based image guided radiotherapy (CT-IGRT) for the treatment of localized prostate cancer. METHODS: The costs of delivering prostate cancer radiotherapy with MR-IGRT and CT-IGRT in conventional 39 fractions and stereotactic body radiotherapy (SBRT) 5 fractions schedules were determined using literature values and cost accounting from two institutions. Gastrointestinal and genitourinary toxicity rates associated with CT-IGRT were summarized from 20 studies. Toxicity-related costs and utilities were obtained from literature values and cost databases. Markov modeling was used to determine the savings per patient for every 1% relative reduction in acute and chronic toxicities by MR-IGRT over 15 years. The costs and quality adjusted life years (QALYs) saved with toxicity reduction were juxtaposed with the cost increase of MR-IGRT to determine toxicity reduction thresholds for cost-effectiveness. One way sensitivity analyses were performed. Standard $100,000 and $50,000 per QALY ratios were used. RESULTS: The added cost of MR-IGRT was $1,459 per course of SBRT and $10,129 per course of conventionally fractionated radiotherapy. Relative toxicity reductions of 7 and 14% are required for SBRT to be cost-effective using $100,000 and $50,000 per QALY, respectively. Conventional radiotherapy requires relative toxicity reductions of 50 and 94% to be cost-effective. CONCLUSION: From a healthcare perspective, MR-IGRT can reasonably be expected to be cost-effective. Hypofractionated schedules, such a five fraction SBRT, are most likely to be cost-effective as they require only slight reductions in toxicity (7-14%). ADVANCES IN KNOWLEDGE: This is the first detailed economic assessment of MR-IGRT, and it suggests that MR-IGRT can be cost-effective for prostate cancer treatment through toxicity reduction alone.

Financial Effect of Unbundling Moderate Sedation from Procedural Codes in Radiology.

PURPOSE: To assess and quantify the financial effect of unbundling newly unbundled moderate sedation codes across major payors at an academic radiology practice. MATERIALS AND METHODS: Billing and reimbursement data for 23 months of unbundled moderate sedation codes were analyzed for reimbursement rates and trends. This included 10,481 and 28,189 units billed and $443,257 and $226,444 total receipts for codes 99152 (initial 15 minutes of moderate sedation) and 99153 (each subsequent 15 minute increment of moderate sedation), respectively. Five index procedures-(i) central venous port placement, (ii) endovascular tumor embolization, (iii) tunneled central venous catheter placement, (iv) percutaneous gastrostomy placement, and (v) percutaneous nephrostomy placement-were identified, and moderate sedation reimbursements for Medicare and the dominant private payor were calculated and compared to pre-bundled reimbursements. Revenue variation models across different patient insurance mixes were then created using averages from 4 common practice settings among radiologists (independent practices, all hospitals, safety-net hospitals, and non-safety-net hospitals). RESULTS: Departmental reimbursement for unbundled moderate sedation in FY2018 and FY2019 totaled $669,701.34, with high per-unit variability across payors, especially for code 99153. Across the 5 index procedures, moderate sedation reimbursement decreased 1.3% after unbundling and accounted for 3.9% of procedural revenue from Medicare and increased 11.9% and accounted for 5.5% of procedural revenue from the dominant private payor. Between different patient insurance mix models, estimated reimbursement from moderate sedation varied by as much as 29.9%. CONCLUSIONS: Departmental reimbursement from billing the new unbundled moderate sedation codes was sizable and heterogeneous, highlighting the need for consistent and accurate reporting of moderate sedation. Total collections vary by case mix, patient insurance mix, and negotiated reimbursement rates.

Initial single centre experiences of a radiographer advanced practitioner led nephrostomy exchange programme.

INTRODUCTION: To evaluate the technical success, radiation dose, complications and costs from the introduction of a radiographer-led nephrostomy exchange service. METHODS: Post-graduate qualified interventional radiographers with several years' experience in performing other interventional procedures began performing nephrostomy exchanges. Training was provided by an interventional radiologist. Each radiographer performed ten procedures under direct supervision followed by independent practice with remote supervision. Each radiographer was then responsible for the radiological report, discharge, re-referral for further exchange and, where indicated, sending urine samples for culture and sensitivity. Data extraction included the time interval between exchanges, radiation dose/screening time and complications. RESULTS: Thirty-eight long-term nephrostomy patients had their histories interrogated back to the time of the initial insertion. The mean (range) age at nephrostomy insertion was 67 (35-93) years and 65% were male. Indications for nephrostomy were prostatic or gynaecological malignancy, ureteric injury, bulky lymphoma and post-transplant ureteric stricture. A total of 170 nephrostomy exchanges were performed with no statistically significant differences in the radiation dose, fluoroscopy time nor complication rates between consultants and radiographers. There was, however, a statistically significant reduction in the time interval between nephrostomy exchanges for the radiographer group (P = 0.022). CONCLUSION: Interventional radiographers can provide a safe, technically successful nephrostomy exchange program with radiation doses equivalent to radiologists. This is a cost-effective solution to the capacity issues faced in many departments, whilst providing career progression, job satisfaction and possibly improved care. IMPLICATIONS FOR PRACTICE: Radiographer-led interventional services should be considered by other institutions as a means of providing effective nephrostomy exchanges.

Single-Step Method for Pull-Type Gastrostomy Tube Placement.

Single-step pull-type gastrostomy tube (PGT) placement is a method involving gastric puncture with a curved 18-gauge trocar needle allowing retrograde cannulation of the gastroesophageal junction without use of a sheath or snare. This retrospective review of 102 patients who underwent single-step PGT placement demonstrated 91% success in advancing the wire up the esophagus using only the curved trocar. Successful placement of a gastrostomy tube was 100%. Two major and 2 minor complications occurred within 30 days, all unrelated to the single-step technique. Mean fluoroscopy time for all patients was 5.1 min (range, 1.5-19.2 min). Single-step PGT placement is an effective, safe, fast, and equipment-sparing method for gastrostomy placement.

Collaboration is Key - Bridging the Gap and Building an IR Endoscopy Practice.

While the tools and techniques employed by interventional radiologists on a day-to-day basis translate well to learning the skills required to perform basic endoscopic interventions, collaboration with other specialties is crucial to the success of an interventional radiology endoscopy program. As in any field in medicine, the paramount goal is to improve patient care. Adding the ability to directly visualize structures through an endoscope to certain interventional radiologic procedures may greatly augment the efficacy, safety, and success of interventional radiology procedures. Colleagues in urology, gastroenterology, and surgery should be involved in decision-making and treatment planning to ensure that a shared vision for optimal patient care is achieved.

Billing, Coding, and Credentialing for Interventional Radiology-Operated Endoscopy.

A sound understanding of billing and coding is essential to start a successful interventional radiology endoscopy practice. While the codes utilized are similar to gastrointestinal and genitourinary endoscopy codes, physicians and institutional coders need to be familiar with the codes used for these types of procedures in the interventional radiology setting. The following manuscript gives a brief overview of aspects relating to credentialing, billing, and coding in interventional radiology endoscopy.

A Descriptive Revenue Analysis of a Wound-Center IR Collaboration to Treat Lower Extremity Venous Ulcers.

PURPOSE: To describe the revenue from a collaboration between a dedicated wound care center and an interventional radiology (IR) practice for venous leg ulcer (VLU) management at a tertiary care center. MATERIALS AND METHODS: This retrospective study included 36 patients with VLU referred from a wound care center to an IR division during the 10-month active study period (April 2017 to January 2018) with a 6-month surveillance period (January 2018 to June 2018). A total of 15 patients underwent endovascular therapy (intervention group), whereas 21 patients did not (nonintervention group). Work relative value units (wRVUs) and dollar revenue were calculated using the Centers for Medicare and Medicaid Services Physician Fee Schedule. RESULTS: Three sources of revenue were identified: evaluation and management (E&M), diagnostic imaging, and procedures. The pathway generated 518.15 wRVUs, translating to $37,522. Procedures contributed the most revenue (342.27 wRVUs, $18,042), followed by E&M (124.23 wRVUs, $8,881), and diagnostic imaging (51.65 wRVUs, $10,599). Intervention patients accounted for 86.7% of wRVUs (449.48) and 80.0% of the revenue ($30,010). An average of 33 minutes (38.3 hours total) and 2.06 hours (36.8 hours total) were spent on E&M visits and procedures, respectively. CONCLUSIONS: In this collaboration between the wound center and IR undertaken to treat VLU, IR and E&M visits generated revenue and enabled procedural and downstream imaging revenue.

Tools for Simulation; Low Budget and No Budget.

Interventional Radiology (IR) incorporates a unique set of technical skills such as ultrasound-guided needle placement, inferior vena cava filter placement, and wire/catheter exchange, which are not easily attained in other aspects of medical training. Simple, low cost models can allow medical students and residents to attain these skills in a low risk setting. These simulated tasks will ultimately combine to improve preparedness of trainees during patient procedures allowing them to advance more quickly through the training paradigm without patient risk. Many commercially available devices may be cost prohibitive, so low cost solutions are presented.

Comparison of the value of superficial mark guided localization and hook-wire guided localization techniques for non-palpable breast microcalcifications: A retrospective clinical research.

AIM: The present study compares the effect and accuracy of the superficial mark guided localization (SGL) and hook-wire guided localization (WGL) techniques for non-palpable breast microcalcifications. METHODS: This retrospective study was conducted to compare SGL and WGL techniques. These techniques were performed on 51 patients with non-palpable breast microcalcifications from January 2015 to May 2016. RESULTS: Among these 51 patients, 25 (49.01%) patients were subjected to WGL and 26 patients (50.99%) were subjected to SGL. The SGL technique had a higher rate of malignant cancer detection (WGL = 12.0% and SGL = 23.0%). Furthermore, no significant differences were found with regard to average age, the rate of a second excision and the diameter of the excised tissue. Moreover, no complications were observed in the SGL group, while four (16.0%) patients in the WGL group experienced problems. CONCLUSION: The SGL technique is as accurate as the WGL technique. Furthermore, the procedure has advantages of being less expensive and causing less complications.