Cost Analysis of Dialysis Access Maintenance Interventions across Physician Specialties in U.S. Medicare Beneficiaries.

Background Dialysis maintenance interventions account for billions of dollars in U.S. Medicare spending and are performed by multiple medical specialties. Whether Medicare costs differ by physician specialty is, to the knowledge of the authors, not known. Purpose To assess patency-adjusted costs of endovascular dialysis access maintenance by physician specialty. Materials and Methods In this retrospective longitudinal cohort study, patients who were beneficiaries of Medicare undergoing their first arteriovenous access placement in 2009 were identified by using billing codes in the 5% Limited Data Set. By tracking their utilization data through 2014, postintervention primary patency and aggregate payments associated with maintenance interventions were calculated. Unadjusted payments per year of access patency gain were compared across physician specialty. A general linear mixed-effects model adjusted for covariates was used, as follows: patient characteristics, access type (fistula vs graft), clinical severity, type of intervention (angioplasty, stent, thrombolysis), clinical location (hospital outpatient vs office-based laboratory), and resource utilization (operating room use, anesthesia use). Results First arteriovenous access was performed in 1479 beneficiaries (mean age, 63 years ± 15 [standard deviation]; 820 men) in 2009. Through 2014, 8166 maintenance interventions were performed in this cohort. Unadjusted mean Medicare payments for each incremental year of patency were as follows: $71 000 for radiologists, $89 000 for nephrologists, and $174 000 for surgeons. Billing for operating room (41.8% [792 of 1895], surgery; 10.2% [277 of 2709], nephrology; and 31.1% [1108 of 3562], radiology) and anesthesia (19.9% [377 of 1895], surgery; 2.6% [70 of 2709], nephrology; 4.7% [170 of 3562], radiology) varied by specialty and accounted for 407% and 132% higher payments, respectively. After adjusting for clinical severity and location, type of intervention, and resource utilization, nephrologists and surgeons had 59% (95% confidence interval: 44%, 73%; P < .001) and 57% (95% confidence interval: 43%, 72%; P < .001) higher payments, respectively, for the same patency gain compared with radiologists. Operating room use and anesthesia services were major drivers of higher cost, with 407% (95% confidence interval: 374%, 443%; P < .001) and 132% (95% confidence interval: 116%, 150%; P < .001) higher costs, respectively. Conclusion Patency-adjusted payments for hemodialysis access maintenance differed by physician specialty, driven partly by discrepant rates of billing for operating room and anesthesia use. © RSNA, 2020 Online supplemental material is available for this article. See also the editorial by White in this issue.

CT and MR Protocol Standardization Across a Large Health System: Providing a Consistent Radiologist, Patient, and Referring Provider Experience.

Building and maintaining a comprehensive yet simple set of standardized protocols for a cross-sectional image can be a daunting task. A single department may have difficulty preventing "protocol creep," which almost inevitably occurs when an organized "playbook" of protocols does not exist and individual radiologists and technologists alter protocols at will and on a case-by-case basis. When multiple departments or groups function in a large health system, the lack of uniformity of protocols can increase exponentially. In 2012, the University of Colorado Hospital formed a large health system (UCHealth) and became a 5-hospital provider network. CT and MR imaging studies are conducted at multiple locations by different radiology groups. To facilitate consistency in ordering, acquisition, and appearance of a given study, regardless of location, we minimized the number of protocols across all scanners and sites of practice with a clinical indication-driven protocol selection and standardization process. Here we review the steps utilized to perform this process improvement task and insure its stability over time. Actions included creation of a standardized protocol template, which allowed for changes in electronic storage and management of protocols, designing a change request form, and formation of a governance structure. We utilized rapid improvement events (1 day for CT, 2 days for MR) and reduced 248 CT protocols into 97 standardized protocols and 168 MR protocols to 66. Additional steps are underway to further standardize output and reporting of imaging interpretation. This will result in an improved, consistent radiologist, patient, and provider experience across the system.

Breast Cancers Found with Digital Breast Tomosynthesis: A Comparison of Pathology and Histologic Grade.

To compare the pathology and histologic grading of breast cancers detected with digital breast tomosynthesis to those found with conventional digital mammography. The institutional review board approved this study. A database search for all breast cancers diagnosed from June 2012 through December 2013 was performed. Imaging records for these cancers were reviewed and patients who had screening mammography with tomosynthesis as their initial examination were selected. Five dedicated breast imaging radiologists reviewed each of these screening mammograms to determine whether the cancer was visible on conventional digital mammography or whether tomosynthesis was needed to identify the cancer. A cancer was considered mammographically occult if all five radiologists agreed that the cancer could not be seen on conventional digital mammography. The size, pathology and histologic grading for all diagnosed breast cancers were then reviewed. The Mann-Whitney U and Fisher exact tests were utilized to determine any association between imaging findings and cancer size, pathologic type and histologic grade. Sixty-five cancers in 63 patients were identified. Ten of these cancers were considered occult on conventional digital mammography and detected with the addition of tomosynthesis. These mammographically occult cancers were significantly associated with Nottingham grade 1 histologic pathology (p = 0.02), were smaller (median size: 6 mm versus 10 mm, p = 0.07) and none demonstrated axillary nodal metastases. Breast cancers identified through the addition of tomosynthesis are associated with Nottingham grade 1 histologic pathology and prognostically more favorable than cancers identified with conventional digital mammography alone.

Standardized MR terminology and reporting of implants and devices as recommended by the American College of Radiology Subcommittee on MR Safety.

Considerable confusion exists among the magnetic resonance (MR) imaging user community as to how to determine whether a patient with a metal implanted device can be safely imaged in an MR imaging unit. Although there has been progress by the device manufacturers in specifying device behavior in a magnetic field, and some MR imaging manufacturers provide maps of the "spatial gradients," there remains significant confusion because of the lack of standardized terminology and reporting guidelines. The American College of Radiology, through its Subcommittee on MR Safety, has proposed standardized terminology that will contribute to greater safety and understanding for screening metal implants and/or devices prior to MR imaging.

ABR examinations: the why, what, and how.

The American Board of Radiology (ABR) has provided certification for diagnostic radiologists and other specialists and subspecialists for more than 75 years. The Board certification process is a tangible expression of the social contract between the profession and the public by which the profession enjoys the privilege of self-regulation and the public is assured that it can expect medical professionals to put patients' interests first, guarantees the competence of practitioners, and guards the public health. A primary tool used by the ABR in fulfilling this responsibility is the secure proctored examination. This article sets forth seven standards based on authoritative sources in the field of psychometrics (the science of mental measurements), and explains in each case how the ABR implements that standard. Readers are encouraged to understand that, despite the multiple opinions that may be held, these standards developed over decades by experts using the scientific method should be the central feature in any discussion or critique of examinations given for the privilege of professional practice and for safeguarding the public well-being.

ACR guidance document on MR safe practices: 2013.

Because there are many potential risks in the MR environment and reports of adverse incidents involving patients, equipment and personnel, the need for a guidance document on MR safe practices emerged. Initially published in 2002, the ACR MR Safe Practices Guidelines established de facto industry standards for safe and responsible practices in clinical and research MR environments. As the MR industry changes the document is reviewed, modified and updated. The most recent version will reflect these changes.

Addressing overutilization in medical imaging.

The growth in medical imaging over the past 2 decades has yielded unarguable benefits to patients in terms of longer lives of higher quality. This growth reflects new technologies and applications, including high-tech services such as multisection computed tomography (CT), magnetic resonance (MR) imaging, and positron emission tomography (PET). Some part of the growth, however, can be attributed to the overutilization of imaging services. This report examines the causes of the overutilization of imaging and identifies ways of addressing the causes so that overutilization can be reduced. In August 2009, the American Board of Radiology Foundation hosted a 2-day summit to discuss the causes and effects of the overutilization of imaging. More than 60 organizations were represented at the meeting, including health care accreditation and certification entities, foundations, government agencies, hospital and health systems, insurers, medical societies, health care quality consortia, and standards and regulatory agencies. Key forces influencing overutilization were identified. These include the payment mechanisms and financial incentives in the U.S. health care system; the practice behavior of referring physicians; self-referral, including referral for additional radiologic examinations; defensive medicine; missed educational opportunities when inappropriate procedures are requested; patient expectations; and duplicate imaging studies. Summit participants suggested several areas for improvement to reduce overutilization, including a national collaborative effort to develop evidence-based appropriateness criteria for imaging; greater use of practice guidelines in requesting and conducting imaging studies; decision support at point of care; education of referring physicians, patients, and the public; accreditation of imaging facilities; management of self-referral and defensive medicine; and payment reform.

A quantitative approach to sequence and image weighting.

Weighting is the term most frequently used to describe magnetic resonance pulse sequences and the concept most commonly used to relate image contrast to differences in magnetic resonance tissue properties. It is generally used in a qualitative sense with the single tissue property thought to be most responsible for the contrast used to describe the weighting of the image as a whole. This article describes a quantitative approach for understanding the weighting of sequences and images, using filters and partial derivatives of signal with respect to logarithms of tissue property values. Univariate and multivariate models are described for several pulse sequences including methods for maximizing weighting and calculating both sequence and image weighting ratios. The approach provides insights into difficulties associated with qualitative use of the concept of weighting and a quantitative basis for assessing the signal, contrast, and weighting of commonly used sequences and images.

Ultrasound and Dual-Energy X-Ray Absorptiometry Report Transcription Error Rates and Strategies for Reduction.

PURPOSE: Radiologists play an essential role in patient care by providing accurate and timely results. An error-free radiology report is an expectation of both patients and referring physicians. Software is currently available that can eliminate measurement and side types of errors while saving radiologists and sonographers time. The objectives of this study were to evaluate the potential reduction in report errors, estimate the potential time savings associated with implementation, and conduct a cost-benefit analysis of implementing two software programs. METHODS: Data on the number of measurement errors and side errors in ultrasound and dual-energy x-ray absorptiometry reports were collected, and the time required for data entry that the software would reduce was measured by report type. Generalized estimating equations regression was used to estimate error rates and data entry times and corresponding 95% confidence intervals by report type for radiologists and sonographers. Current wages and report volumes were then applied to the time savings to estimate the annual wage savings. Projected volume increases were applied to the annual estimates to generate a 5-year savings estimate. RESULTS: Overall, measurement errors occurred in 6% to 28% of ultrasound reports, depending on the report type. Side errors were rare. It was estimated that over 5 years, the software could save $693,777 in radiologist wages and $130,771 in sonographer wages, a total of $824,548 (range, $621,866-$1,039,714). CONCLUSIONS: The use of data integration software would both significantly reduce errors in ultrasound and dual-energy x-ray absorptiometry reports and save a considerable amount of time and money.

Physician Knowledge of Radiation Exposure and Risk in Medical Imaging.

PURPOSE: Medical imaging is an increasingly important source of radiation exposure for the general population, and there are risks associated with such exposure; however, recent studies have demonstrated poor understanding of medical radiation among various groups of health care providers. This study had two aims: (1) analyze physicians' knowledge of radiation exposure and risk in diagnostic imaging across multiple specialties and levels of training, and (2) assess the effectiveness of a brief educational presentation on improving physicians' knowledge. METHODS: From 2014 to 2016, 232 health care providers from multiple departments participated in an educational presentation and pre- and postpresentation tests evaluating knowledge of radiation exposure and risk at a large academic institution. RESULTS: Knowledge of radiation exposure and risk was relatively low on the prepresentation test, including particularly poor understanding of different imaging modalities, with 26% of participants unable to correctly identify which modalities expose patients to ionizing radiation. Test scores significantly increased after the educational presentation. Radiologists had higher prepresentation test scores than other specialties, and therefore less opportunity for improvement, but also demonstrated improvement in radiation safety knowledge after education. Aside from radiology, there was no significant difference in initial knowledge of radiation exposure and risk among the other specialties. CONCLUSIONS: Providers' knowledge of radiation exposure and risk was low at baseline but significantly increased after a brief educational presentation. Efforts to educate ordering providers about radiation exposure and risk are needed to ensure that providers are appropriately weighing the risks and benefits of medical imaging and to ensure high-quality, patient-centered care.

An evaluation of the impact of clinically embedded reading rooms on radiologist-referring clinician communication.

The aim of this study was to investigate whether locating reading rooms in clinical areas at a large tertiary care, academic hospital in the United States corresponds with increased rates of direct communication between radiologists and clinicians. Data recorded included the frequency, form, duration, and general purpose of communications. Two-tailed Fisher's exact tests were used to determine the statistical significance of differences between the frequencies of communication methods for the reading rooms included in the study. During the observation period, there were a total of 175 episodes of communication between radiologists and referring providers in the 4 study reading rooms. There was a highly significant difference (P < .0001) in the percentage of visits and critical test result management messages sent between embedded and nonembedded reading rooms, while the differences in the proportion of calls both to and from referring providers was not significant (P = .4468). Although the purpose of this study was to assess the impact of reading room location on radiologists' communications with referring providers, several alternative hypotheses could also explain the results. The value of this study emerges from the documentation of the high degree of variability among institutions in communication practices among different kinds of radiologists and referring physicians. The extent of these different practices among the 4 reading rooms has important implications for future studies of communication patterns between radiologists and referring providers as well as for designing effective interventions to enhance the role of radiologists as consultants.

ABR examinations: the why, what, and how.

The American Board of Radiology (ABR) has provided certification for diagnostic radiologists and other specialists and subspecialists for more than 75 years. The Board certification process is a tangible expression of the social contract between the profession and the public by which the profession enjoys the privilege of self-regulation and the public is assured that it can expect medical professionals to put patients' interests first, guarantees the competence of practitioners, and guards the public health. A primary tool used by the ABR in fulfilling this responsibility is the secure proctored examination. This article sets forth seven standards based on authoritative sources in the field of psychometrics (the science of mental measurements), and explains in each case how the ABR implements that standard. Readers are encouraged to understand that, despite the multiple opinions that may be held, these standards developed over decades by experts using the scientific method should be the central feature in any discussion or critique of examinations given for the privilege of professional practice and for safeguarding the public well-being.

Introduction to value-based payment modifiers.

Value-based payment modifiers were legislated by Congress in the 2010 Patient Protection and Affordable Care Act. It is clear in the legislation, and the corresponding proposals published by the secretary of the US Department of Health and Human Services in late 2011, that the intent is to move from paying physicians for reporting to paying physicians for performance. The proposals, developed jointly with CMS, specify that the calculation of payments for performance will be a composite of quality and cost measures. The base year for determining performance benchmarks for the performance measures will be 2013, and the measures will be applied to physician payments on a limited basis beginning in 2015 and to all physician payments by 2017. The role of medical specialty boards, such as the ABR, in the development and deployment of measures is highlighted in this context. CMS's recent conversations with board representatives have indicated their view that the boards' measure development activities are key to increasing physician (especially specialist) participation in the Physician Quality Reporting System to 50% by 2015, from 20% to 30% today. The ABR will continue its past activities in this arena, working with the American Board of Medical Specialties, CMS, and specialty societies, so that ABR diplomates will be able to simultaneously complete their Maintenance of Certification requirements, satisfy the requirements for CMS incentives, and avoid penalties.