Practice Management Strategies for Imaging Facilities Facing an Acute Iodinated Contrast Media Shortage.

An unanticipated but severe shortage in iodinated contrast media (ICM) is currently affecting imaging practices across the globe and is expected to persist through at least the end of June 2022. This supply shock may lead health care systems to experience an acute imaging crisis, given that many affected facilities have contrast agent supplies that are anticipated to last only a week or two under normal operating conditions. To maximize the opportunity to continue to provide optimal care for patients with emergent or life-threatening imaging indications and thereby minimize the overall impact on patient care, practice leaders will need to quickly assess their contrast material inventories, prioritize examination indications, and reduce their expected short-term usage of ICM. This Clinical Perspective reviews ICM conservation techniques that the Yale School of Medicine has deployed or is considering deploying, depending on the severity and length of the supply shortage.

The Economic Impact of the COVID-19 Pandemic on Radiology Practices.

The coronavirus 2019 (COVID-19) pandemic will have a profound impact on radiology practices across the country. Policy measures adopted to slow the transmission of disease are decreasing the demand for imaging independent of COVID-19. Hospital preparations to expand crisis capacity are further diminishing the amount of appropriate medical imaging that can be safely performed. Although economic recessions generally tend to result in decreased health care expenditures, radiology groups have never experienced an economic shock that is simultaneously exacerbated by the need to restrict the availability of imaging. Outpatient-heavy practices will feel the biggest impact of these changes, but all imaging volumes will decrease. Anecdotal experience suggests that radiology practices should anticipate 50%-70% decreases in imaging volume that will last a minimum of 3-4 months, depending on the location of practice and the severity of the COVID-19 pandemic in each region. The Coronavirus Aid, Relief, and Economic Security, or CARES, Act provides multiple means of direct and indirect aid to health care providers and small businesses. The final allocation of this funding is not yet clear, and it is likely that additional congressional action will be necessary to stabilize health care markets. Administrators and practice leaders must be proactive with practice modifications and financial maneuvers that can position them to emerge from this pandemic in the most viable economic position. It is possible that this crisis will have lasting effects on the structure of the radiology field.

Benefit of a Visual Aid in the Management of Moderate-Severity Contrast Media Reactions.

OBJECTIVE: The purpose of this study was to compare management of moderate-severity reactions with and without a visual aid or flowchart in contrast medium reaction simulations. SUBJECTS AND METHODS: All attending radiologists and trainees were requested to participate in a contrast medium reaction simulation program, including a moderate-severity reaction scenario, and were randomized to groups having or not having a visual aid. The time to administer intramuscular (IM) epinephrine via automated injector and errors in administration were recorded. After the simulation, all participants completed a survey assessing their comfort in treating reactions to contrast media with and without a visual aid. RESULTS: A total of 138 participants were divided into 21 sessions in the program, with 68 participants in the moderate-severity reaction scenario. Eleven groups were provided a visual aid; 10 groups were not. Errors in management occurred in 18.2% (2 of 11) of groups with visual aids versus 40% (4 of 10) in groups without (p = 0.35), with epinephrine self-administration reflecting the most common error. Excluding the groups with errors, the mean time to administration of IM epinephrine was 97 seconds with versus 152 seconds without the visual aid (p = 0.04). Of the 138 participants, 97.8% agreed that the poster would aid in medication administration, and 87% agreed that it would help decrease time to administer medications. CONCLUSION: A visual aid increased the subjective confidence of radiologists in the dose and route of medication administration in the contrast medium reaction simulation and led to faster administration of epinephrine. Self-administration IM epinephrine errors were common and seen in both groups.

Sonographic Evaluation of Complications of Extracranial Carotid Artery Interventions.

Carotid endarterectomy and carotid artery stenting are among the most common peripheral vascular procedures performed worldwide. Sonography is the initial and often only imaging modality used in the evaluation of iatrogenic carotid arterial injuries. This pictorial essay provides an overview of the clinical and sonographic findings of complications after interventions in the extracranial carotid arteries, including dissection, fluid collections, pseudoaneurysm, thrombosis, thromboembolism, restenosis, and stent deformation. Grayscale, color, and pulsed Doppler imaging findings are reviewed, and correlations with computed tomography, magnetic resonance imaging, and angiography are provided.

JOURNAL CLUB: Benefit of Epinephrine Autoinjector for Treatment of Contrast Reactions: Comparison of Errors, Administration Times, and Provider Preferences.

OBJECTIVE: Given the rarity of contrast reactions in practice, most radiologists have little to no experience in their management, and errors are common. The purpose of this study was to compare treatment of a moderate-severity reaction with intramuscular epinephrine by either the traditional manual method of drawing up and delivering epinephrine with a needle and syringe or the use of an epinephrine autoinjector. SUBJECTS AND METHODS: All diagnostic radiologists at the study institution were requested to participate in an annual contrast reaction simulation program, which consisted of three simulation scenarios in a high-fidelity simulation laboratory. During the moderate-severity simulation scenario, the time to administer intramuscular epinephrine and any errors in administration were recorded. Groups were randomized to use an autoinjector device or manual delivery. All participants completed a survey assessing the experience with epinephrine and their comfort in treating contrast reactions using a traditional manual approach versus an epinephrine autoinjector. RESULTS: Among 189 participants in the contrast reaction simulation program, 76 participated in a moderate-severity reaction simulation two to five at a time in 25 sessions. Mean total time to administration was significantly longer for manual (108.8 seconds) than for autoinjector (38.7 seconds) delivery (p < 0.001). There were 11 errors in the manual group and one error in the autoinjector group (p = 0.005). Ninety-four percent of participants reported feeling very comfortable or comfortable with the autoinjector as opposed to 60% for manual delivery (p < 0.001). Overall, 96% of participants thought the autoinjector was easier to use. CONCLUSION: Use of an epinephrine autoinjector for treatment of contrast reactions was associated with a significantly greater degree of provider comfort, shorter time to administration, and fewer errors.

Geographic distribution of general industry payments to advanced-practice clinicians.

Following the recent expansion of the Open Payments program to include advanced-practice clinicians (APCs) as covered recipients, we characterized the geographical distribution of general industry payments to nurse practitioners and physician assistants using the Open Payments database. The number and dollar value of payments, as well as the average and median payment amount earned per provider, varied by state. However, a significantly higher proportion of APCs received payments in states with more restrictive scope-of-practice laws. Understanding how and why payments to APCs vary by state can elucidate how industry-APC relationships are related to changing scope-of-practice and state-specific transparency/disclosure laws, informing future legislation.

Clinical Implementation of a Combined Artificial Intelligence and Natural Language Processing Quality Assurance Program for Pulmonary Nodule Detection in the Emergency Department Setting.

OBJECTIVE: This quality assurance study assessed the implementation of a combined artificial intelligence (AI) and natural language processing (NLP) program for pulmonary nodule detection in the emergency department setting. The program was designed to function outside of normal reading workflows to minimize radiologist interruption. MATERIALS AND METHODS: In all, 19,246 CT examinations including at least some portion of the lung anatomy performed in the emergent setting from October 1, 2021, to June 1, 2022, were processed by the combined AI-NLP program. The program used an AI algorithm trained on 6-mm to 30-mm pulmonary nodules to analyze CT images and an NLP to analyze radiological reports. Cases flagged as negative for pulmonary nodules by the NLP but positive by the AI algorithm were classified as suspected discrepancies. Discrepancies result in secondary review of examinations for possible addenda. RESULTS: Out of 19,246 CT examinations, 50 examinations (0.26%) resulted in secondary review, and 34 of 50 (68%) reviews resulted in addenda. Of the 34 addenda, 20 patients received instruction for new follow-up imaging. Median time to addendum was 11 hours. The majority of reviews and addenda resulted from missed pulmonary nodules on CT examinations of the abdomen and pelvis. CONCLUSION: A background quality assurance process using AI and NLP helped improve the detection of pulmonary nodules and resulted in increased numbers of patients receiving appropriate follow-up imaging recommendations. This was achieved without disrupting in-shift radiologist workflow or causing significant delays in patient follow for the diagnosed pulmonary nodule.

A Survey of Practicing Radiologists on the Use of Premedication Before Intravenous Iodinated Contrast Medium Administration.

OBJECTIVE: To determine whether updated guidance by the ACR in 2017 advocating use of intravenous (IV) premedication in emergency department (ED) patients and inpatients with reported iodinated contrast allergy was associated with a change in clinical practice. METHODS: An anonymous survey was distributed via e-mail in October 2020 to practicing radiologist members of the ACR interrogating use of corticosteroid premedication for two clinical vignettes: an indicated routine (perform within 24 hours) inpatient contrast-enhanced CT (CE-CT) and an indicated urgent (perform within 6 hours) ED CE-CT. In both scenarios, the patient had a prior moderate hypersensitivity reaction to iodinated contrast media. Clinical management was evaluated. Data were compared to historical controls from 2009. RESULTS: The response rate was 11% (724 of 6,616). For the inpatient scenario, 72% (518 of 724) would use corticosteroid premedication with CE-CT, and 28% (200 of 724) would perform noncontrast CT. For the ED scenario, 67% (487 of 724) would use corticosteroid premedication with CE-CT, and 30% (217 of 724) would perform noncontrast CT. Oral premedication (85%, 439 of 518) was preferred for routine inpatients, and rapid IV premedication (89%, 433 of 487) was preferred for urgent ED patients. Of those who provided rapid IV dosing data in the ED, two doses of corticosteroids were used by 53% (216 of 410) and one dose was used by 45% (185 of 410), with academic radiologists more likely than private or hybrid practice radiologists to administer two doses (74% [74 of 100] versus 48% [151 of 312], P < .001, odds ratio, 3.03; 95% confidence interval, 1.84-5.00). Rapid IV premedication was more commonly used in 2020 than in 2009 (60% [433 of 724] versus 29% [20 of 69], P < .001, odds ratio, 3.65; 95% confidence interval, 2.12-6.26). Antihistamine use was common in both inpatient (93%, 480 of 518) and ED settings (92%, 447 of 487). Only 32% (229 of 721) of radiologists practiced in accordance with ACR guidelines, suggesting no need for routine premedication before CE-CT in patients with prior severe hypersensitivity reaction to gadolinium-based contrast media. Nonetheless, most (93%, 670 of 724) said the ACR Manual on Contrast Media was a major determinant of their practice. CONCLUSIONS: Use of rapid IV premedication in urgent settings has increased since 2009, following updated ACR guidelines, but there is disagreement over whether one or two corticosteroid doses is required. Despite reported high reliance on ACR guidelines, deviations from those guidelines remain common. In general, when ACR guidelines were not followed, it was in a risk-averse direction.

Use of artificial intelligence in emergency radiology: An overview of current applications, challenges, and opportunities.

The value of artificial intelligence (AI) in healthcare has become evident, especially in the field of medical imaging. The accelerated pace and acuity of care in the Emergency Department (ED) has made it a popular target for artificial intelligence-driven solutions. Software that helps better detect, report, and appropriately guide management can ensure high quality patient care while enabling emergency radiologists to better meet the demands of quick turnaround times. Beyond diagnostic applications, AI-based algorithms also have the potential to optimize other important steps within the ED imaging workflow. This review will highlight the different types of AI-based applications currently available for use in the ED, as well as the challenges and opportunities associated with their implementation.

Impact of Radiologist-Driven Change-Order Requests on Outpatient CT and MRI Examinations.

PURPOSE: To assess impact of electronic medical record-embedded radiologist-driven change-order request on outpatient CT and MRI examinations. METHODS: Outpatient CT and MRI requests where an order change was requested by the protocoling radiologist in our tertiary care center, from April 11, 2017, to January 3, 2018, were analyzed. Percentage and categorization of requested order change, provider acceptance of requested change, patient and provider demographics, estimated radiation exposure reduction, and cost were analyzed. P < .05 was used for statistical significance. RESULTS: In 79,310 outpatient studies in which radiologists determined protocol, change-order requests were higher for MRI (5.2%, 1,283 of 24,553) compared with CT (2.9%, 1,585 of 54,757; P < .001). Provider approval of requested change was equivalent for CT (82%, 1,299 of 1,585) and MRI (82%, 1,052 of 1,283). Change requests driven by improper contrast media utilization were most common and different between CT (76%, 992 of 1,299) and MRI (65%, 688 of 1,052; P < .001). Changing without and with intravenous contrast orders to with contrast only was most common for CT (39%, 505 of 1,299) and with and without intravenous contrast to without contrast only was most common for MRI (26%, 274 of 1,052; P < .001). Of approved changes in CT, 51% (661 of 1,299) resulted in lower radiation exposure. Approved changes frequently resulted in less costly examinations (CT 67% [799 of 1,198], MRI 48% [411 of 863]). CONCLUSION: Outpatient CT and MRI orders are deemed incorrect in 2.9% to 5% of cases. Radiologist-driven change-order request for CT and MRI are well accepted by ordering providers and decrease radiation exposure associated with imaging.

Disparities in Care Among Patients With Cardiac Implantable Electronic Devices Undergoing MRI.

IMPORTANCE: Abundant data now demonstrate safe use of MRI for patients with non-MR conditional cardiac implantable electronic devices (CIEDs). However, CMS does not currently reimburse these examinations. OBJECTIVE: Determine whether differences in reimbursement between commercial insurance carriers and CMS are impacting the completion rates of MRI examinations ordered in patients with non-MR conditional CIEDs. METHODS: This study retrospectively examined patients with non-MR conditional CIEDs for whom an MRI was ordered between January 1, 2015, and August 31, 2016. Completion rates of MRI in patients with Medicare or Medicaid insurance were compared with those in patients with commercial insurance. Before November 7, 2015, all patients with non-MR conditional CIEDs underwent MRI examinations at no charge to the patient regardless of insurance. After that date, outpatients with only Medicare or Medicaid insurance coverage received an Advanced Beneficiary Notice that informed them that they would have to pay out of pocket for the entire cost of their MRI examinations. RESULTS: Of 143 MRI examinations ordered, 127 met inclusion criteria for analysis. In the post-Advanced Beneficiary Notice period, outpatients with commercial insurance were significantly more likely to complete their MRI examinations (19 of 22 patients, 86%) when compared with patients with Medicare or Medicaid insurance (1 of 36 patients, 3%; P <.0001). No significant difference was observed in the inpatient setting. CONCLUSIONS: Due to CMS coverage policies based on now outdated concepts about MRI safety, patients with non-MR conditional CIEDs and Medicare or Medicaid insurance are undergoing significantly fewer appropriate diagnostic MRI examinations than patients with commercial insurance.