Analysis of socioeconomic and demographic factors and imaging exam characteristics associated with missed appointments in pediatric radiology.

BACKGROUND: Missed appointments can have an adverse impact on health outcomes by delaying appropriate imaging, which can be critical in influencing treatment decisions. OBJECTIVE: To assess for socioeconomic and imaging exam factors associated with missed appointments among children scheduled for diagnostic imaging. MATERIALS AND METHODS: We retrospectively analyzed children (<18 years) scheduled for outpatient diagnostic imaging during a 12-month period. In doing so, we obtained socioeconomic and radiology exam characteristics (modality, intravenous contrast administration, radiation and use of sedation) data from the electronic medical record. We employed multivariate logistic regression to assess the association of socioeconomic, demographic and imaging exam characteristics with imaging missed appointments. RESULTS: In total, 7,275 children met inclusion criteria. The mean age was 8.8 years (standard deviation [SD] = 6.2 years) and the study population consisted of 52% female gender, 69% White race, 38% adolescent age group and 32% with a median household income by ZIP-code category of <$50,000. Logistic regression showed increased likelihood of missed appointments among children of Black/African-American race (odds ratio [OR] = 1.9; 95% confidence interval [CI] = 1.4-2.5); with insurance categories including Medicaid (OR=2.0; 95% CI=1.6-2.4), self-pay (OR=2.1; 95% CI=1.3-3.6) and other (OR=2.7; 95% CI=1.3-5.4); with <$50,000 median household income by ZIP-code category (OR=1.7; 95% CI=1.4-2.0); and with examination wait time of 7-21 days (OR=2.7; 95% CI=2.1-3.5) and >21 days (OR=3.7; 95% CI=2.9-4.8). The use of radiation, intravenous contrast agent or sedation was not associated with increased likelihood of missed appointments. CONCLUSION: Expanding our knowledge of how different socioeconomic and imaging-related factors influence missed appointments among children can serve as a foundational step to better understand existing and emerging disparities and inform strategies to advance health equity efforts in radiology.

Turning around cancer: Oncology imaging and implications for emergency department radiology workflow.

PURPOSE: Oncologic imaging in the emergency department (ED) is frequently encountered, including non-acute scans known as "metastatic workups" or "staging" (referred to as "cancer staging computed tomography (CT) exams"). This study examines the impact of oncologic staging CT exams on ED imaging turnaround time (TAT), defined as the time from the end of the CT exam to a final signed radiologist report, as well as order to scan completion time. METHODS: A retrospective review was conducted of all adult patients presenting to an urban, quaternary academic medical center ED from February 2016 to September 2017, who had CT imaging ordered, performed, and interpreted in the ED imaging department. CT exams containing institution-specific cancer descriptors were included. After excluding all acute exams, cancer staging CT exams were compared to a matched cohort of non-oncologic ED CT exams to evaluate median TAT and order to scan completion time using a log transformed multivariable linear regression. RESULTS: Adjusting for age and CT body part, cancer staging CT exams were associated with an independently statistically significant increased median log TAT compared to non-oncologic ED CT exams (114.5 min [IQR 112] versus 69 min [IQR 67], respectively, p < .0001) and an independently statistically significant increased median log initial order to scan completion time (166 min [IQR: 89] vs 119 min [IQR: 93], p < .0001). CONCLUSION: Oncology patients receiving non-acute metastatic workup scans in the ED have a significantly longer TAT compared to non-oncologic ED CT exams as well as longer order to scan completion times.

Allergic-like contrast reactions in the ED: Incidence, management, and impact on patient disposition.

PURPOSE: Determine the incidence, management, and impact on patient disposition of allergic-like contrast reactions (ALCR) to intravenous iodinated contrast in the emergency department (ED). METHODS: All ED patients who developed an ALCR following contrast-enhanced CT (CECT) from June 2011-December 2016 were retrospectively identified. Medical records were reviewed and reaction severity, management, and disposition were quantified using descriptive statistics. The total number of consecutive CECTs performed in the ED were available from June 2011-March 2016 and were used to derive ALCR incidence over that time period. RESULTS: A total of 90 patients developed an ALCR during the study period. An ALCR incidence of 0.2% was derived based on 74 ALCRs occurring out of 47,059 consecutive contrast injections in ED patients from June 2011-April 2016. Reaction severity was mild in 63/90 (70%) and moderate in 27/90 (30%) cases; no patient developed a severe reaction by American College of Radiology criteria. The most commonly administered treatments were diphenhydramine in 67/90 (74%), corticosteroid in 24/90 (27%), and epinephrine in 13/90 (14%); symptoms subsequently resolved in all cases. No patient required inpatient admission for contrast reaction alone, and 5 patients were sent to the ED observation unit for post-epinephrine monitoring and subsequently discharged. CONCLUSION: ALCR among ED patients undergoing CECT are rare, generally of mild severity, respond well to pharmacologic management, and do not alter patient disposition in most cases. Familiarity with symptoms, management, and prevention strategies is increasingly relevant to the emergency physician given the ubiquity of CECT.

Implications of iodinated contrast media extravasation in the emergency department.

PURPOSE: To characterize the management, outcomes, and emergency department (ED) length of stay (LOS) following iodinated contrast media extravasation events in the ED. METHODS: All ED patients who developed iodinated contrast media extravasation following contrast-enhanced CT (CECT) from October 2007-December 2016 were retrospectively identified. Medical records were reviewed and management, complications, frequency of surgical consultation, and ED LOS were quantified using descriptive statistics. The Wilcoxon rank sum test was used to compare ED LOS in patients who did and did not receive surgical consultation. RESULTS: A total of 199 contrast extravasation episodes occurred in ED patients during the 9-year study period. Of these, 42 patients underwent surgical consultation to evaluate the contrast extravasation event. No patient developed progressive symptoms, compartment syndrome, or tissue necrosis, and none received treatment beyond supportive care (warm/cold packs, elevation, compression). Median ED LOS for patients who did and did not receive surgical consultation was 11.3h versus 9.0h, respectively (p<0.01). CONCLUSION: Close observation and supportive care are sufficient for contrast extravasation events in the ED without concerning symptoms (progressive pain/swelling, altered tissue perfusion, sensory changes, or blistering/ulceration). Routine surgical consultation is likely unnecessary in the absence of these symptoms - concordant with the current American College of Radiology guidelines - and may be associated with longer ED LOS without impacting management.

Opportunity to reduce transfer of patients with mild traumatic brain injury and intracranial hemorrhage to a Level 1 trauma center.

OBJECTIVE: Current guidelines do not address the disposition of patients with mild traumatic brain injury (TBI) and resultant intracranial hemorrhage (ICH). Emergency medicine clinicians working in hospitals without neurosurgery coverage typically transfer patients with both to a trauma center with neurosurgery capability. Evidence is accruing which demonstrates that the risk of neurologic decompensation depends on the type of ICH and as a result, not every patient may need to be transferred. The purpose of this study was to identify risk factors for admission among patients with mild TBI and ICH who were transferred from a community hospital to the emergency department (ED) of a Level 1 trauma center. METHODS: Study subjects were patients ≥18years of age who were transferred from a community hospital to the ED of an urban, academic Level 1 trauma center between April 1, 2015 and March 31, 2016, and with an isolated traumatic ICH. Patients who had an epidural hematoma, were deemed to require a trauma center's level of service, were found to have non-traumatic ICHs, or had a Glasgow Coma Scale of <13 were excluded. Using a multivariable logistic regression model, we sought to determine patient factors and Computed Tomography (CT) findings which were associated with admission (to the floor, intensive care unit, or operating room with neurosurgery) of the Level 1 trauma center. RESULTS: 644 transferred patients were identified; 205 remained eligible after exclusion criteria. Presence of warfarin (odds ratio [OR] 4.09, 95% Confidence Interval [CI] 1.64, 10.25, p=0.0026) and a subdural hematoma (SDH) ≥1 cm (OR 6.28, 95% CI 1.24, 31.71, p=0.0263) were independently statistically significant factors predicting admission. Age, sex, GCS, presence of neurologic deficit, aspirin use, clopidogrel use, SDH <1 cm, IPH, and SAH were each independently not significant predictive factors of an admission. CONCLUSIONS: After controlling for factors, transferred patients with mild TBI with a SDH ≥1 cm or on warfarin have a higher odds ratio of requiring inpatient admission to a Level 1 trauma center. While these patients may require admission, there may be opportunities to develop and study a low risk traumatic intracranial hemorrhage protocol, which keeps a subgroup of patients with a mild TBI and resultant ICH at community hospitals with access to a nearby Level 1 trauma center.

Hospital Evaluations by Social Media: A Comparative Analysis of Facebook Ratings among Performance Outliers.

BACKGROUND: An increasing number of hospitals and health systems utilize social media to allow users to provide feedback and ratings. The correlation between ratings on social media and more conventional hospital quality metrics remains largely unclear, raising concern that healthcare consumers may make decisions on inaccurate or inappropriate information regarding quality. OBJECTIVES: The purpose of this study was to examine the extent to which hospitals utilize social media and whether user-generated metrics on Facebook(®) correlate with a Hospital Compare(®) metric, specifically 30-day all cause unplanned hospital readmission rates. DESIGN AND PARTICIPANTS: This was a retrospective cross-sectional study conducted among all U.S. hospitals performing outside the confidence interval for the national average on 30-day hospital readmission rates as reported on Hospital Compare. Participants were 315 hospitals performing better than U.S. national rate on 30-day readmissions and 364 hospitals performing worse than the U.S. national rate. MAIN MEASURES: The study analyzed ratings of hospitals on Facebook's five-star rating scale, 30-day readmission rates, and hospital characteristics including beds, teaching status, urban vs. rural location, and ownership type. KEY RESULTS: Hospitals performing better than the national average on 30-day readmissions were more likely to use Facebook than lower-performing hospitals (93.3 % vs. 83.5 %; p < 0.01). The average rating for hospitals with low readmission rates (4.15 ± 0.31) was higher than that for hospitals with higher readmission rates (4.05 ± 0.41, p < 0.01). Major teaching hospitals were 14.3 times more likely to be in the high readmission rate group. A one-star increase in Facebook rating was associated with increased odds of the hospital belonging to the low readmission rate group by a factor of 5.0 (CI: 2.6-10.3, p < 0.01), when controlling for hospital characteristics and Facebook-related variables. CONCLUSIONS: Hospitals with lower rates of 30-day hospital-wide unplanned readmissions have higher ratings on Facebook than hospitals with higher readmission rates. These findings add strength to the concept that aggregate measures of patient satisfaction on social media correlate with more traditionally accepted measures of hospital quality.

Intra-articular fibroma of tendon sheath arising in the acromioclavicular joint.

Fibroma of the tendon sheath, a rare benign soft tissue tumor that most often occurs in the distal upper extremities (hands and wrist), is exceedingly rare to present as an intraarticular mass. Presented here is the first case in the English literature, to our knowledge, of a fibroma of the tendon sheath arising in the acromioclavicular joint. The patient presented with recurrent shoulder pain with activity without antecedent trauma. Radiographs were essentially normal. MR images demonstrated a lobulated, heterogeneous mass with contrast enhancement arising from the acromioclavicular joint. Following surgical resection, histopathology revealed hypocellular collagen matrix with spindle-shaped fibroblasts, confirming the diagnosis of fibroma of tendon sheath. The imaging features of the fibroma of the tendon sheath and a brief review of the literature are presented.

Imaging Information Overload: Quantifying the Burden of Interpretive and Non-Interpretive Tasks for Computed Tomography Angiography for Aortic Pathologies in Emergency Radiology.

RATIONALE: Over the past decade, technological advances have provided new tools for radiologists. However, the effect of these technological advances on radiologist workload and detecting pathologies needs to be assessed. OBJECTIVE: The purpose of this study is to assess the workload, including non-interpretative tasks, associated with Computed Tomography Angiogram (CTA) of Aorta exams performed in the Emergency Department (ED) over a 10-year period and their relationship to detection of aortic pathology. MATERIALS AND METHODS: This is a retrospective analysis of CTAs of Aorta performed on adults with suspected acute aortic pathology within the ED at an academic level I quaternary care hospital from January 1, 2005, through December 31, 2015. Data assessed included (1) Interpretive tasks: total number of images, number of reformat series, number of radiology reports with positive aortic pathologies; and (2) Non-interpretative tasks: recommendations and documentation of verbal communication with requesting providers. Statistical analyses were performed to assess temporal trends of variables. P values less than 0.05 are considered significant. RESULTS: A total of 4368 examinations (mean age: 69.8, M/F: 56.8%/43.2%) were performed. Studies per year increased significantly from 2005 (n = 278) to 2007 (n = 445), but not significantly after. The number of images and reformat series per scan increased from 487 to 2819 and 6.4 to 13.7, respectively (both P-value < 0.01). The proportion of exams with aortic findings did not significantly change (28.1% in 2005 and 24.9% in 2015). However, The proportions of exams with verbal communication increased from 9.3% to 24.6% and with recommendations from 1.8% to 28.9% (both P-value < 0.01). CONCLUSION: During a 10-year period, CTAs performed in the ED for suspected aortic pathology were associated with a significant increase in images created, reformat series generated, recommendations, and verbal communications with ordering providers without a concomitant increase in the rate of aortic pathologies. To completely capture the complexities of CTA workloads, non-interpretive tasks such as radiologist recommendations and verbal communications should also be included.

Imaging Assessment of Thoracic Outlet Syndrome.

Imaging studies play a significant role in assessment of thoracic outlet syndrome. In this article, we discuss the etiology and definition of thoracic outlet syndrome and review the spectrum of imaging findings seen in patients with thoracic outlet syndrome. We then discuss an optimized technique for computed tomography and MRI of patients with thoracic outlet syndrome, based on the experience at our institution and present some representative examples. Based on our experience, a combination of computed tomography angiography and MRI (with postural maneuvers) effectively demonstrate thoracic outlet syndrome abnormalities.

Analysis of the Effects of a Patient-Centered Rideshare Program on Missed Appointments and Timeliness for MRI Appointments at an Academic Medical Center.

PURPOSE: The aim of this study was to assess the differences in timeliness to MRI appointments and missed MRI appointment rates before and after the implementation of a rideshare program. METHODS: Retrospective analysis of a rideshare program was performed 9 months after implementation to compare the effects before and after implementation. Variables obtained included demographics, MRI appointment variables, and data related to rideshare use. Descriptive statistics and linear and logistic regression analyses were used to compare demographic characteristics among patients using the rideshare program with (1) those who did not use the rideshare program after implementation and (2) patients before rideshare implementation. Rates of missed appointments derived from patient-related, same-day appointment cancellations were analyzed using logistic regression analyses. Timeliness was analyzed using linear regression analyses. All analyses were adjusted for potential confounders. RESULTS: Of 7,707 patients scheduled for MRI appointments during the postintervention period, 151 patients used the rideshare service (1.95%). There were no statistically significant differences in missed appointment rates after rideshare implementation (adjusted odds ratio, 1.09; 95% confidence interval, 0.93-1.27; P = .275). Patients using the rideshare service were more likely to be on time (adjusted coefficient = 13.0; 95% confidence interval, 5.4-20.5; P = .001). Older patients (P = .001), unemployed patients (P < .001), and patients without commercial insurance (P < .001) were more likely to use the rideshare service. CONCLUSIONS: Implementation of a rideshare program did not significantly decrease missed appointment rates, but it significantly improved timeliness to MRI appointments while assisting at-risk patient populations reporting transportation barriers.

A Radiology-focused Analysis of Transparency and Usability of Top U.S. Hospitals' Chargemasters.

RATIONALE AND OBJECTIVES: In 2019, Centers for Medicare and Medicaid Services enforced regulation from the Affordable Care Act, requiring all U.S. hospitals to publish standard hospital charges annually. This study assesses top U.S academic hospitals' chargemasters for selected advanced diagnostic imaging services and the usability of publicly available information to allow consumers to determine out-of-pocket costs. MATERIALS AND METHODS: Publicly available chargemasters and associated websites for the top 20 ranked hospitals in U.S. News and World Report were assessed for several features including: file format, inclusion of CPT codes, disclaimers on charges versus costs and professional fees, and tools allowing determination of actual out-of-pocket costs for selected advanced diagnostic imaging examinations. RESULTS: All hospitals had publicly available chargemasters, 90% of which were in Microsoft Excel format. Ten percent of chargemasters included CPT codes. All chargemaster websites had disclaimers regarding differences between charges versus patient costs; 20% had disclaimers regarding professional fees. 20% of hospitals provided out-of-pocket costs for uninsured patients or tools allowing out-of-pocket cost determination. Median (range) MR exam charges were: brain with and without contrast: $5375 ($834-$13,857), noncontrast knee: $3402 (4530-$6924); noncontrast lumbar spine: $ 3449 ($473-$7367). Median (range) CT exam charges were: noncontrast head: $1923 ($165-$4974), noncontrast chest: $1947 ($282-$2991); contrast abdomen/pelvis: $4307 ($486-$11,726). CONCLUSION: While all top-ranked hospitals had publicly available chargemasters, they rarely provided transparent information to allow patients to determine out-of-pocket costs for advanced diagnostic imaging services.

Analysis of Out-of-Pocket Cost of Lung Cancer Screening for Uninsured Patients Among ACR-Accredited Imaging Centers.

PURPOSE: To determine the variability in out-of-pocket costs of lung cancer screening (LCS) for uninsured patients and assess accessibility of this information by telephone or Internet. METHODS: LCS centers from the ACR's LCS database were randomly selected. Centers were called between July and August 2019 to determine out-of-pocket cost. Telephone call variables, accessibility of cost information on screening centers' websites, screening centers' chargemasters, and publicly available facility and state insurance coverage variables were obtained. Cost information was summarized using descriptive analyses. Multiple variable linear regression analyses were conducted to evaluate effects of facility and state-level characteristics on out-of-pocket costs. RESULTS: Fifty-five ACR-accredited LCS centers were included with 78% (43 of 55) willing to provide out-of-pocket cost. Average out-of-pocket cost was $583 ± $607 (mean ± standard deviation), range $49 to $2,409. Average telephone call length 6 ± 3.8 min. Two of fifty-five screening centers' websites provided out-of-pocket cost information, and one matched cost given over the telephone. A chargemaster was found for 30 of 55 screening centers. No statistically significant differences in out-of-pocket costs were found by geographic region, state percentages of uninsured residents, state percentages of residents with public insurance, or facility safety net hospital affiliation. DISCUSSION: Out-of-pocket LCS costs for uninsured patients and availability of this information is highly variable. Radiology practices should be aware of this variability that may influence participation rates among uninsured patients.

Predictors of MRI Leakage Among Patients Attributed to an Academic Medical Center Commercial Risk-Shared Insurance Contract.

PURPOSE: For health care organizations engaged in risk-shared insurance contracts, leakage of advanced diagnostic imaging to imaging sites not affiliated with the risk-sharing organization may undermine performance on financial and quality metrics. The goal of this study was to identify factors that are predictive of leakage of MRI examinations among patients attributed to an academic health care organization's risk-shared commercial insurance contract. METHODS: Administrative claims data from 2015 through 2016 for patients attributed to a single risk-shared commercial insurance contract at a large academic medical center (AMC) were analyzed. Primary outcome was MRI leakage: an outpatient MRI study performed at a site not affiliated with the AMC's integrated health care system. Ordering provider alignment with the AMC's risk-shared insurance contract was categorized as strong, weak, or none. Multivariate regression analyses were conducted to evaluate the relationship between provider alignment and MRI leakage, while adjusting for selected covariates. RESULTS: Among 8,215 patients meeting inclusion criteria, there were 13,272 MRI encounters. The overall proportion of leaked MRI studies was 12.7%. MRI studies ordered by providers with weak AMC alignment (odds ratio, 3.16; 95% confidence interval, 2.49-4.02) or no AMC alignment (odds ratio, 3.68; 95% confidence interval, 3.12-4.33) were more likely to leak than MRI studies ordered by providers with strong AMC alignment. CONCLUSIONS: An ordering provider with no alignment with an AMC's commercial risk-shared insurance contract was the strongest predictor of MRI leakage. Population health management initiatives aimed at reducing leakage should consider the impact of provider networks and clinical referral patterns that drive imaging utilization.

Characteristics of Paid Malpractice Claims Among Resident Physicians From 2001 to 2015 in the United States.

PURPOSE: Limited information exists about medical malpractice claims against physicians-in-training. Data on residents' involvement in malpractice actions may inform perceptions about medicolegal liability and influence clinical decision-making at a formative stage. This study aimed to characterize rates and payment amounts of paid malpractice claims on behalf of resident physicians in the United States. METHOD: Using data from the National Practitioner Data Bank, 1,248 paid malpractice claims against resident physicians (interns, residents, and fellows) from 2001 to 2015, representing 1,632,471 residents-years, were analyzed. Temporal trends in overall and specialty-specific paid claim rates, payment amounts, catastrophic (> $1 million) and small (< $100,000) payments, and other claim characteristics were assessed. Payment amounts were compared with attending physicians during the same time period. RESULTS: The overall paid malpractice claim rate was 0.76 per 1,000 resident-years from 2001 to 2015. Among 1,194 unique residents with paid claims, 95.7% had exactly 1 claim, while 4.3% had 2-4 claims during training. Specialty-specific paid claim rates ranged from 0.12 per 1,000 resident-years (pathology) to 2.96 (obstetrics and gynecology). Overall paid claim rates decreased by 52% from 2001-2005 to 2011-2015 (95% confidence interval [CI]: 0.45, 0.59). Median inflation-adjusted payment amount was $199,024 (2015 dollars), not significantly different from payments made on behalf of attending physicians during the same period. Proportions of catastrophic (11.2%) and small (33.1%) claims did not significantly change over the study period. CONCLUSIONS: From 2001 to 2015, paid malpractice claim rates on behalf of resident physicians decreased by 52%, while median payment amounts were stable. Resident paid claim rates were lower than attending physicians, while payment amounts were similar.