Cost and radiation savings of partial substitution of ultrasound for CT in appendicitis evaluation: a national projection.

OBJECTIVE: The costs of an ultrasound-CT protocol and a CT-only protocol for an appendicitis evaluation are compared. For the ultrasound-CT protocol, patients with right lower quadrant abdominal pain undergo an ultrasound examination. If it is positive for appendicitis, they are sent directly to surgery, avoiding CT. MATERIALS AND METHODS: A comparative effectiveness research study was conducted. The costs of imaging tests, excess surgeries, and excess surgical deaths for the ultrasound-CT protocol and the costs of imaging tests and excess cancer deaths in the CT-only protocol were estimated. Data sources were Centers for Medicare & Medicaid Services (CMS) datasets, national hospital discharge surveys, radiology information system cases, and U.S. Census Bureau life tables. A meta-analysis and sensitivity analyses were also conducted. RESULTS: The meta-analysis showed a positive predictive value of 92.5% for CT and 91.0% for ultrasound. Analysis of CMS files showed that utilization of CT was almost exactly 2.0 examinations (one abdominal and one pelvic) per patient and for ultrasound was almost nil. The cost of this imaging protocol was $547 per patient, whereas the cost of a limited ultrasound study would be $88 per patient. For the total U.S. population, the cost savings in imaging minus the cost of extra surgeries and extra surgical deaths is $24.9 million per year. Following model VII proposed by the Committee on the Biological Effects of Ionizing Radiation (BEIR), which is known as "BEIR VII," the avoidance of a 12.4-mSv exposure for 262,500 persons would prevent 180 excess cancer deaths. The value of the years of life lost would be $339.5 million. The sensitivity analyses indicate that the cost savings are robust. CONCLUSION: An ultrasound-CT protocol for appendicitis evaluation offers potentially large savings over the standard CT-only protocol. There are moderate savings from using a less expensive imaging technique despite extra surgeries and large savings from radiation exposure avoided.

Single-center comparison of three chemoembolization regimens for hepatocellular carcinoma.

PURPOSE: Transarterial chemoembolization regimens for hepatocellular carcinoma (HCC) vary, without a gold-standard method. The present study was performed to evaluate outcomes in patients with HCC treated with doxorubicin/ethiodized oil (DE), cisplatin/doxorubicin/mitomycin-c/ethiodized oil (CDM), or doxorubicin drug-eluting beads (DEBs). MATERIALS AND METHODS: Patients received the same regimen at all visits, without crossover. Groups were compared based on Child-Pugh disease status, tumor/node/metastasis stage, and Barcelona Clinic Liver Cancer stage. Imaging outcomes were assessed based on modified Response Evaluation Criteria in Solid Tumors to calculate tumor response (ie, sum of complete and partial response), progressive disease (PD), and time to progression (TTP). RESULTS: A total of 228 infusions were performed in 122 patients: 59 with DE, 30 with CDM, and 33 with DEBs. The groups had similar Child-Pugh status (P = .45), tumor/node/metastasis stages (P = .5), and Barcelona Clinic Liver Cancer scores (P = .22). Follow-up duration was similar among groups (P = .24). Patients treated with DE underwent significantly more treatments (2.3 ± 1.4) than those treated with CDM (1.6 ± 0.7; P = .004) or DEBs (1.4 ± 0.6; P<.0001). Compared with DE (51%), tumor response was significantly more common with CDM (84%; P = .003) or DEBs (82%; P = .004). PD was significantly more likely with DE (37%) than with CDM (13%; P = .02) or DEBs (9%; P = .004). TTP was similar between groups (P = .07). CDM and DEBs were similar in regard to disease progression (P = .6) and response (P = .83). CONCLUSIONS: During a similar follow-up period, patients treated with CDM or DEB chemoembolization showed a significantly higher response rate and a lower incidence of tumor progression, with fewer required treatment sessions, than those treated with DE chemoembolization.

Bending the curve: the recent marked slowdown in growth of noninvasive diagnostic imaging.

OBJECTIVE: The purpose of this article is to determine whether there has been any change in the rapid growth pattern that has characterized noninvasive diagnostic imaging in recent years. MATERIALS AND METHODS: The annual nationwide Medicare Part B databases were used. All Current Procedural Terminology codes for discretionary noninvasive diagnostic imaging were identified. The overall utilization rates per 1,000 fee-for-service beneficiaries were calculated from 1998 through 2008, as were rates by modality. Determination was made as to whether studies were interpreted by radiologists or nonradiologist physicians. RESULTS: The total utilization rate of noninvasive diagnostic imaging grew at a compound annual growth rate of 4.1% from 1998 to 2005, but this decreased to 1.4% from 2005 to 2008. From 2005 through 2008, the overall growth trends flattened dramatically for MRI and nuclear medicine and abated somewhat for CT, ultrasound, and echocardiography. In ambulatory settings, flattening of the advanced imaging growth curves was seen in both private offices and hospital outpatient facilities. From 1998 to 2005, the compound annual growth rate was 3.4% among radiologists and 6.6% among nonradiologist physicians. From 2005 to 2008, the compound annual growth rate decreased to 0.8% among radiologists and 1.8% among nonradiologists. CONCLUSION: There has been a distinct slowing in the growth of discretionary noninvasive diagnostic imaging in the Medicare fee-for-service population since 2005. The slowdown has been most pronounced in MRI and nuclear medicine. This should allay some of the concerns of policymakers and payers. Both before and after 2005, growth was approximately twice as rapid among nonradiologist physicians as among radiologists.

Accuracy of MRI, MR arthrography, and ultrasound in the diagnosis of rotator cuff tears: a meta-analysis.

OBJECTIVE: The purpose of this study was to compare the diagnostic accuracy of MRI, MR arthrography, and ultrasound for the diagnosis of rotator cuff tears through a meta-analysis of the studies in the literature. MATERIALS AND METHODS: Articles reporting the sensitivities and specificities of MRI, MR arthrography, or ultrasound for the diagnosis of rotator cuff tears were identified. Surgical (open and arthroscopic) reference standard was an inclusion criterion. Summary statistics were generated using pooled data. Scatterplots of the data sets were plotted on a graph of sensitivity versus (1 - specificity). Receiver operating characteristic (ROC) curves were generated. RESULTS: Sixty-five articles met the inclusion criteria for this meta-analysis. In diagnosing a full-thickness tear or a partial-thickness rotator cuff tear, MR arthrography is more sensitive and specific than either MRI or ultrasound (p < 0.05). There are no significant differences in either sensitivity or specificity between MRI and ultrasound in the diagnosis of partial- or full-thickness rotator cuff tears (p > 0.05). Summary ROC curves for MR arthrography, MRI, and ultrasound for all tears show the area under the ROC curve is greatest for MR arthrography (0.935), followed by ultrasound (0.889) and then MRI (0.878); however, pairwise comparisons of these curves show no significant differences between MRI and ultrasound (p > 0.05). CONCLUSION: MR arthrography is the most sensitive and specific technique for diagnosing both full- and partial-thickness rotator cuff tears. Ultrasound and MRI are comparable in both sensitivity and specificity.

Continued growth in emergency department imaging is bucking the overall trends.

PURPOSE: The aim of this study was to examine recent trends in imaging utilization in emergency departments (EDs) in the Medicare population. METHODS: The 2002 to 2012 Medicare Part B databases were used. Imaging studies were categorized by modality. Medicare's place-of-service codes identified those studies performed in ED patients. Specialty codes identified the specialties of the interpreting physicians. Utilization rates per 1,000 Medicare beneficiaries were calculated. Trends were assessed in plain radiography (XR), CT, noncardiac ultrasound, MRI, and nuclear medicine. RESULTS: XR and CT were the most widely used modalities in ED patients. From 2002 to 2012, the XR utilization rate per 1,000 increased from 248.7 to 320.0 (+29%), and CT increased from 57.2 to 147.9 (+159%). Utilization rates of the other modalities were much lower. Ultrasound increased from 9.5 to 21.0 (+121%), while MRI increased from 1.4 to 5.1 (+264%). Growth in these 4 modalities was continuous and did not show the flattening that has characterized the utilization trends in other places of service. Nuclear medicine use was very low and remained essentially flat. During the study period, CT accrued 91 new examinations per 1,000, followed by XR at 71 and ultrasound at 11.5. The vast majority of examinations were interpreted by radiologists. CONCLUSIONS: Despite the cessation of overall utilization growth of the various modalities in recent years, ED utilization rates continued to increase. The greatest increases, in terms of accrued new examinations per 1,000, were seen in CT and XR. This suggests that radiologists and ED physicians need to work together to better manage imaging utilization.

Analysis of radiologists' imaging workload trends by place of service.

PURPOSE: The aim of this study was to determine what proportion of noninvasive diagnostic imaging (NDI) work done by radiologists occurred in each of the 4 primary places of service where imaging is conducted. METHODS: Medicare's Physician/Supplier Procedure Summary Master Files for 2000 to 2011 were the data source. Specialty codes were used to identify radiologists, and place-of-service codes identified studies done in hospital outpatient facilities, hospital inpatient facilities, private offices, and emergency departments (EDs). The applicable total professional component relative value units (RVUs) were assigned to each NDI Current Procedural Terminology code, and RVU rates per 1,000 Medicare beneficiaries were calculated. RVU rates reflect workload and costs and are therefore a better metric than utilization rates based on volume. RESULTS: From 2000 to 2006, radiologists' RVU rates per 1,000 Medicare beneficiaries increased in each of the 4 primary venues. However, from 2006 to 2011, rates remained essentially flat in hospital outpatient and inpatient facilities and offices but continued to increase in EDs. Absolute RVU rate increases from 2000 through 2011 were 289 in hospital outpatient facilities, 218 in EDs, 194 in private offices, and 99 in inpatient facilities. In 2011, 19% of radiologists' workload occurred in offices; the remainder was conducted in the 3 hospital settings. Twice as much elective outpatient NDI work by radiologists was done in hospital outpatient facilities as in radiologists' private offices. CONCLUSIONS: Radiologists' workload in hospital outpatient and inpatient facilities and offices grew from 2000 through 2006, but no further growth occurred thereafter. EDs were the only venue where growth continued. The vast proportion of radiology NDI RVUs (81% in 2011) are produced in hospital settings.

VPAC1 receptors for imaging breast cancer: a feasibility study.

UNLABELLED: VPAC1 encodes G-protein-coupled receptors expressed on all breast cancer (BC) cells at the onset of the disease, but not on benign lesions. Our extensive preclinical studies have shown that (64)Cu-TP3805 has a high affinity for VPAC1, is stable in vivo, and has the ability to distinguish spontaneously grown malignant BC masses from benign lesions. Our long-term goal is to develop (64)Cu-TP3805 as an agent to perform in vivo histology, to distinguish malignant lesions from benign masses noninvasively and thereby avoid patient morbidity and the excess economic costs of benign biopsies. METHODS: (18)F-FDG obtained commercially served as a control. (64)Cu-TP3805 was prepared using a sterile kit containing 20 µg of TP3805. Radiochemical purity and sterility were examined. Nineteen consenting women with histologically proven BC were given 370 MBq of (18)F-FDG. One hour later, 6 of these patients were imaged with PET/CT and 13 with positron emission mammography (PEM). Two to 7 d later, 6 PET/CT patients received 111 MBq (± 10%) (n = 2), 127 MBq (± 10%) (n = 2), or 148 MBq (± 10%) (n = 2) of (64)Cu-TP3805 and were imaged 2 and 4 h later. Thirteen PEM patients received 148 MBq (± 10%) of (64)Cu-TP3805 and were imaged 15 min, 1 h, 2 h, and 4 h later. Standardized uptake value (SUV) was calculated for PET/CT patients, and PUV/BGV (PEM uptake value/background value) was calculated for PEM patients. Tumor volume was also calculated. RESULTS: The radiochemical purity of (64)Cu-TP3805 was 97% ± 2%, and specific activity was 44.4 GBq (1.2 Ci)/µmol. In 19 patients, a total of 24 lesions were imaged (15 invasive ductal carcinoma, 1 high-grade mammary carcinoma, 3 lobular carcinoma, 1 invasive papilloma, and 4 sentinel lymph nodes). All lesions were unequivocally detected by (64)Cu-TP3805 and by (18)F-FDG. The average tumor volume as determined by PET/CT with (64)Cu-TP3805 was 90.6% ± 16.1% of that with (18)F-FDG PET/CT, and the average SUV was 92% ± 26.4% of that with (18)F-FDG. For PEM, the tumor volume with (64)Cu-TP3805 was 113% ± 37% of that with (18)F-FDG and the PUV/BGV ratio was 97.7% ± 24.5% of that with (18)F-FDG. CONCLUSION: (64)Cu-TP3805 is worthy of further investigation in patients requiring biopsy of suggestive imaging findings, to further evaluate its ability to distinguish malignant lesions from benign masses noninvasively.

The sharp reductions in medicare payments for noninvasive diagnostic imaging in recent years: will they satisfy the federal policymakers?

PURPOSE: The aim of this study was to examine recent trends in Medicare reimbursements for noninvasive diagnostic imaging (NDI). METHODS: The Medicare Part B databases for 2000 to 2010 were used. For each procedure code, these files provide payment and other data. All NDI codes were selected. Medicare physician specialty codes were used to identify radiologists, cardiologists, all other nonradiologist physicians as a group, and independent diagnostic testing facilities. Part B NDI payment trends were tracked. RESULTS: Overall Part B spending for NDI rose from $5.921 billion in 2000 to $11.910 billion in 2006 (+101%). There was then a sharp drop in 2007, resulting from the implementation of the Deficit Reduction Act. This was followed by a slight rise in 2008, then successive smaller drops the next 2 years, reaching $9.457 billion in 2010 (-21% vs 2006). Radiologists' payments were $2.936 billion in 2000, rose to a peak of $5.3 billion in 2006 (+81%), then dropped to $4.712 billion in 2010 (-11% vs 2006). Cardiologists' NDI payments were $1.327 billion in 2000, peaking at $2.998 billion in 2006 (+126%), then dropping to $1.996 billion in 2010 (-33% vs 2006). Other physicians' payments were $1.106 billion in 2000, peaking at $2.378 billion in 2006 (+115%), then dropping to $1.968 billion in 2010 (-17% vs 2006). Similar trends occurred in independent diagnostic testing facilities. CONCLUSIONS: After years of rapid growth in Medicare NDI payments, an abrupt reversal occurred starting in 2007. By 2010, overall NDI costs to Medicare Part B were down 21% compared with their 2006 peak. It is unclear whether this large payment reduction will satisfy federal policymakers.

Noncardiac point-of-care ultrasound by nonradiologist physicians: how widespread is it?

PURPOSE: The use of point-of-care (POC) ultrasound by nonradiologist physicians has recently been advocated. The aim of this study was to see how widespread this practice is. METHODS: The Medicare Part B databases for 2004 to 2009 were used. Global and professional component claims for noncardiac ultrasound were tabulated, and utilization rates per 1,000 beneficiaries were calculated. Provider specialty was determined. Utilization rates of ultrasound by radiologists and other specialists were compared, and changes over the years were studied. RESULTS: In 2009, 425.3 Medicare noncardiac ultrasound examinations per 1,000 beneficiaries were performed (+21% since 2004). Of these, radiologists performed 233.7 (55%), and another 15.6 (4%) were done at independent diagnostic testing facilities, for which provider specialty could not be determined. The remaining 175.7 (41%) constituted POC ultrasound by nonradiologists. Between 2004 and 2009, radiologists' utilization rate increased by 17%, compared with 28% for nonradiologists. Radiologists' market share of noncardiac ultrasound was 56.6% in 2004 and 54.9% in 2009. Other major specialties involved in POC ultrasound and their 2009 rates per 1,000 and percentage increases since 2004 were cardiology (39.7 [+60%]), vascular surgery (34.9 [+36%]), primary care (27.2 [+11%]), general surgery (24.2 [+8%]), and urology (22.3 [+12%]). CONCLUSIONS: Between 2004 and 2009, there was a 21% increase in the overall utilization rate of noncardiac ultrasound. Point-of-care ultrasound by nonradiologists amounted to 41% of all studies done in 2009. Multiple nonradiologic specialties are involved, but radiologists' involvement is far higher than any other single specialty. Radiologists' ultrasound market share remained relatively stable between 2004 and 2009.

Trends in utilization rates of the various imaging modalities in emergency departments: nationwide Medicare data from 2000 to 2008.

PURPOSE: To study utilization trends in the various imaging modalities in emergency departments (EDs) over a recent multiyear period. METHODS: The nationwide Medicare Part B databases for 2000 to 2008 were queried. Medicare's location codes were used to identify imaging examinations done on ED patients. All diagnostic imaging Current Procedural Terminology(®) codes were grouped by modality. For each code, the database provides procedure volume; utilization rates per 1,000 beneficiaries were then calculated. Medicare's physician specialty codes were used to determine provider specialty. Utilization trends were studied between 2000 and 2008. RESULTS: The overall utilization rate per 1,000 beneficiaries for all imaging in EDs increased from 281.0 in 2000 to 450.4 in 2008 (+60%). The radiography utilization rate rose from 227.3 in 2000 to 294.3 in 2008 (+29%, 67 accrued new studies per 1,000). The CT rate rose from 40.0 in 2000 to 130.7 in 2008 (+227%, 90.7 accrued new studies per 1,000). The ultrasound rate rose from 9.6 in 2000 to 18.7 in 2008 (+95%, 9.1 accrued new studies per 1,000). Other modalities had much lower utilization. In 2000, CT constituted 14% of all ED imaging, but by 2008, it constituted 29%. In 2008, radiologists performed 96% of all ED imaging examinations. CONCLUSIONS: The rate of utilization of imaging is increasing in EDs. Growth is by far the most pronounced in CT, in terms of both the growth rate itself and the actual number of accrued new studies per 1,000 beneficiaries. Radiologists strongly predominate as the physicians of record for all ED imaging.

Medicare payments for noninvasive diagnostic imaging are now higher to nonradiologist physicians than to radiologists.

PURPOSE: Radiologists have always been considered the physicians who "control" noninvasive diagnostic imaging (NDI) and are primarily responsible for its growth. Yet nonradiologists have become increasingly aggressive in their performance and interpretation of imaging. The purpose of this study was to track overall Medicare payments to radiologists and nonradiologist physicians in recent years. METHODS: The Medicare Part B files covering all fee-for-service physician payments for 1998 to 2008 were the data source. All codes for discretionary NDI were selected. Procedures mandated by the patient's clinical condition (eg, supervision and interpretation codes for interventional procedures, radiation therapy planning) were excluded, as were nonimaging radionuclide tests. Medicare physician specialty codes were used to identify radiologists and nonradiologists. Payments in all places of service were included. Overall Medicare NDI payments to radiologists and nonradiologist physicians from 1998 through 2008 were compared. A separate analysis of NDI payments to cardiologists was conducted, because next to radiologists, they are the highest users of imaging. RESULTS: In 1998, overall Part B payments to radiologists for discretionary NDI were $2.563 billion, compared with $2.020 billion to nonradiologists (ie, radiologists' payments were 27% higher). From 1998 to 2006, payments to nonradiologists increased by 166%, compared with 107% to radiologists. By 2006, payments to nonradiologists exceeded those to radiologists. By 2008, the second year after implementation of the Deficit Reduction Act, payments to radiologists had dropped by 13%, compared with 11% to nonradiologists. In 2008, nonradiologists received $4.807 billion for discretionary NDI, and radiologists received $4.638 billion. Payments to cardiologists for NDI increased by 195% from 1998 to 2006, then dropped by 8% by 2008. CONCLUSIONS: The growth in fee-for-service payments to nonradiologists for NDI was considerably more rapid than the growth for radiologists between 1998 and 2006. Then, by the end of 2008, 2 years after the implementation of the Deficit Reduction Act, steeper revenue losses had been experienced by radiologists. The result was that by 2008, overall Medicare fee-for-service payments for NDI were 4% higher to nonradiologists than they were to radiologists.

How widely is computer-aided detection used in screening and diagnostic mammography?

PURPOSE: The aim of this study was to determine how widely computer-aided detection (CAD) is used in screening and diagnostic mammography and to see if there are differences between hospital facilities and private offices. METHODS: The nationwide Medicare Part B fee-for-service databases for 2004 to 2008 were used. The Current Procedural Terminology(®) codes for screening and diagnostic mammography (both digital and screen film) and the CAD add-on codes were selected. Procedure volume was compared for screening vs diagnostic mammography and for hospital facilities vs private offices. RESULTS: From 2004 to 2008, Medicare screening mammography volume increased slightly from 5,728,419 to 5,827,326 (+2%), but the use of screening CAD increased from 2,257,434 to 4,305,595 (+91%). By 2008, CAD was used in 74% of all screening mammographic studies. During this same time period, the Medicare volume of diagnostic mammography declined slightly from 1,835,700 to 1,682,026 (-8%), but the use of diagnostic CAD increased from 360,483 to 845,461 (+135%). By 2008, CAD was used in 50% of all diagnostic mammographic studies. In hospital facilities in 2008, CAD was used in 70% of all screening mammographic studies, compared with 81% in private offices. For diagnostic mammography in 2008, CAD was used in 48% in hospitals, compared with 55% in private offices. CONCLUSION: Despite some operational drawbacks to using CAD, radiologists have embraced it in an effort to improve cancer detection. Its use has grown rapidly, and in 2008, it was used in three-quarters of all screening mammographic studies and half of all diagnostic mammographic studies. Women undergoing either screening or diagnostic mammography are more likely to receive CAD if they go to a private office than if they go to a hospital facility, although the differences are not great.

The disproportionate effects of the Deficit Reduction Act of 2005 on radiologists' private office MRI and CT practices compared with those of other physicians.

PURPOSE: The Deficit Reduction Act of 2005 (DRA) sharply reduced technical component payments for private office magnetic resonance imaging (MRI) and computed tomographic (CT) imaging. Although radiologists have no control over referrals, nonradiologist physicians (NRPs) can potentially make up for revenue shortfalls by self-referring more examinations. The purpose of this study was therefore to compare the effects of the DRA on the in-office MRI and CT practices of radiologists and NRPs. MATERIALS AND METHODS: The nationwide Medicare Part B databases for 2002 to 2007 were studied. All MRI and CT codes were selected. Using Medicare physician specialty and place-of-service codes, examinations performed in private offices by radiologists were identified and compared with those performed by NRPs. Trends in procedure volume and payments were studied. The pre-DRA compound annual growth rates for 2002 to 2006 and the post-DRA one-year rates for 2007 are reported. RESULTS: For MRI, radiologists' private office volume increased by 8.4% yearly from 2002 to 2006 but then dropped by 2.0% in 2007. Nonradiologist physicians' office volume increased by 24.8% yearly, then increased by another 7.6% in 2007. Office MRI payments to radiologists increased by 11.2% yearly from 2002 to 2006 but then dropped by 30.1% in 2007. Nonradiologist physicians' office MRI payments increased by 25.7% yearly, then dropped by 23.5% in 2007. For CT imaging, radiologists' private office volume increased by 11.2% yearly from 2002 to 2006 but then increased by only 2.9% in 2007. Nonradiologist physicians' office volume increased by 31.8% yearly, then increased by another 18.1% in 2007. Office CT payments to radiologists increased by 13.4% yearly from 2002 to 2006 but then dropped by 5.2% in 2007. Nonradiologist physicians' office CT payments increased by 34.9% yearly, then increased by another 8.3% in 2007. CONCLUSION: After the DRA took effect, office MRI volume dropped among radiologists but increased among NRPs. Payments for MRI to both dropped, but the percentage decrease to radiologists was greater. Office CT volume increased slightly among radiologists but increased much more among NRPs on a percentage basis. Payments for CT imaging to radiologists dropped, but they increased to NRPs. These results suggest that NRPs may be able to ameliorate the effects of the DRA by increasing self-referral. These trends are of concern and should be scrutinized in future years.

Recent shifts in place of service for noninvasive diagnostic imaging: have hospitals missed an opportunity?

PURPOSE: The aim of this study was to examine recent shifts in place of service for noninvasive diagnostic imaging (NDI) and determine whether hospitals have lost business to private outpatient imaging facilities. METHOD AND MATERIALS: The nationwide Medicare Part B databases for 1996 through 2006 were used, and all Current Procedural Terminology((R)), fourth edition, codes for NDI were studied. Utilization rates per 1,000 Medicare beneficiaries were calculated. Medicare uses place-of-service codes to differentiate examinations performed in hospital inpatients, hospital outpatients, and hospital emergency departments from those performed in private office settings. Changes in utilization rates in these locations were compared over the course of the decade, with particular emphasis on possible outpatient NDI shifts between hospital outpatient departments and private offices or imaging centers. Also, Medicare physician specialty codes were used to determine whether radiologists or other specialists were more responsible for growth. RESULTS: Between 1996 and 2006, Medicare NDI utilization rates per 1,000 -hospital inpatients increased from 1,056.5 to 1,211.8 (+15%). Emergency department rates increased from 222.1 to 392.2 (+77%). Hospital outpatient rates increased from 793.4 to 993.2 (+25%), while private office rates went from 883.3 to 1,442.2 (+63%). Total outpatient imaging rates (both hospital and office) went from 1,676.7 to 2,435.4 (+45%). As a result of the more rapid growth in private office imaging, hospitals' share of this market dropped from 47% in 1996 to 41% in 2006. Private office imaging utilization rates between 1996 and 2006 grew by 71% among nonradiologist physicians, compared with 44% among radiologists. CONCLUSION: Medicare NDI utilization rates increased in all places of service between 1996 and 2006. Growth in hospital outpatient imaging was slower than that in private imaging facilities. Because NDI can be a profitable business, it seems that hospitals have lost an important opportunity. Much of this loss of business was to nonradiologist physicians, whose private office imaging utilization rate grew considerably more rapidly than that of radiologists.

Recent payment and utilization trends in radionuclide myocardial perfusion imaging: comparison between self-referral and referral to radiologists.

PURPOSE: The aim of this study was to examine the effects of self-referral by comparing recent trends in payments and utilization rates for radionuclide myocardial perfusion imaging (MPI) among radiologists and cardiologists between 1998 and 2006. MATERIALS AND METHODS: Nationwide Medicare Part B claims databases for 1998 through 2006 were used. The 4 primary MPI codes were selected. Using Medicare's physician specialty codes, physician providers were identified as radiologists, cardiologists, or other physicians. Payments for MPI to the 3 groups were tracked over the study period. Trends in utilization rates in both hospital and private office settings were also compared among the 3 groups. In addition, utilization trends were studied for related procedures, such as stress echocardiography (SE) and invasive diagnostic coronary angiography (CA). RESULTS: Between 1998 and 2006, Medicare Part B payments to radiologists for MPI increased from $72.6 million to $84.0 million (+16%), while among cardiologists, payments increased from $242.6 million to $972.0 million (+301%). Private office utilization rates per 1,000 Medicare beneficiaries increased by 215% among cardiologists, compared with 32% among radiologists. In hospital settings, the rate changes were much more modest. Hospital utilization rates were consistently higher among radiologists than cardiologists; in hospital settings in 2006, the rate was 15.3 per 1,000 among radiologists, compared with 11.8 per 1,000 among cardiologists. Between 1998 and 2006, the utilization rate for SE among cardiologists increased by 20%, and the rate for diagnostic CA among cardiologists also increased by 20%. CONCLUSION: In recent years, there have been very sharp increases in the costs and utilization of MPI among cardiologists compared with radiologists. Most of the growth occurred in cardiologists' private offices. In hospital settings, radiologists still do more MPI examinations than cardiologists. Because MPI is a highly reimbursed procedure and there is no evidence that coronary disease is increasing in frequency in the Medicare population, this trend raises a concern about inappropriate self-referral. This is particularly true in view of the facts that the utilization of a competing procedure such as SE also continues to increase among cardiologists and that MPI is not substituting for an invasive procedure such as diagnostic CA.

Endovascular repair vs open surgical repair of abdominal aortic aneurysms: comparative utilization trends from 2001 to 2006.

PURPOSE: Within the past few years, endovascular aneurysm repair (EVAR) has come into use for the treatment of abdominal aortic aneurysms (AAAs). In many cases, EVAR has the potential to replace traditional open surgical repair (OSR), which is more invasive, risky, and expensive. The aim of this study was to determine to what extent EVAR is replacing OSR, whether the frequency of treatment is increasing with the advent of the less invasive approach, and which specialties are performing the procedures. MATERIALS AND METHODS: The Medicare Part B data sets for 2001 through 2006 were studied. Procedure volume and utilization rates per 100,000 Medicare beneficiaries were determined for the 7 Current Procedural Terminology, fourth edition, procedure codes that describe EVAR and the 4 codes that describe OSR for AAA. Medicare's physician specialty codes were used to ascertain the specialties of the physician providers. RESULTS: A total of 31,965 OSRs for AAA were performed in Medicare beneficiaries in 2001, dropping to 15,665 by 2006 (-51%). In contrast, EVAR was carried out in 11,028 instances in 2001, increasing to 28,937 by 2006 (+162%). The utilization rate per 100,000 for OSR dropped from 90 to 42 (a rate decrease of 48) during the study period, while the rate for EVAR increased from 31 to 77 (a rate increase of 46). The combined utilization rate per 100,000 of the two types of interventions for AAA (EVAR and OSR) decreased from 121 in 2001 to 119 in 2006. In performing EVAR, procedure volume and market share in 2006 by specialty were 1) 22,003 procedures by surgeons, a 76% share; 2) 3,287 procedures by radiologists, an 11% share; 3) 1,915 procedures by cardiologists, a 7% share; and 4) 1,732 procedures by all other physicians, a 6% share. CONCLUSIONS: Treatment for AAA seems to be an example of the responsible use of new technology by physicians. The newer, less invasive, and less risky procedure (EVAR) is replacing the older and more invasive procedure (OSR) to a considerable degree. However, the overall combined utilization rate of both types of AAA treatment has remained stable in the Medicare population. There is thus no evidence to suggest that the introduction of the newer approach has led to the overtreatment of patients. Although radiologists do have a role in EVAR, surgeons strongly predominate.

Recent trends in mammography utilization in the Medicare population: is there a cause for concern?

CONTEXT: Recent published reports have shown a decline in the mammography screening rate in women over age 40, but it is not known whether this trend is a reason for concern in the Medicare population. OBJECTIVE: To study recent trends in mammography utilization in the Medicare population and determine how the newer digital mammography may be affecting mammography utilization. DESIGN AND SETTING: The Centers for Medicare & Medicaid Services Physician/Supplier Procedure Summary Master Files for 1996 through 2005 were examined to determine overall trends in mammography utilization, as well as trends in screening vs diagnostic and conventional screen-film vs newer digital examinations. Medicare Limited Datasets for 2002 to 2004 were used to determine 2-year mammography and multiple imaging rates in individual patients. MAIN OUTCOME MEASURE: Mammography utilization. RESULTS: Overall, the mammography utilization rate increased from 26,646 per 100,000 in 1996 to 39,363 per 100,000 in 2005, a 48% increase. The diagnostic mammography rate decreased by 39% (from 15,314 to 9,301), whereas the rate for screening mammography increased by 166% (from 11,332 to 30,062). Digital mammography increased from 2.2% of all mammography in 2002 to 10.4% in 2005. In both digital and film mammography, screening increased more rapidly than diagnostic mammography. CONCLUSIONS: The utilization rate of all mammography showed a substantial 48% increase between 1996 and 2005, and an 11% increase in screening mammography was seen between 2000 and 2005. Although the increase in mammography utilization is encouraging, the 2005 rate of 39,363 per 100,000 female Medicare beneficiaries seems to be well below American Cancer Society recommendations.

Ownership or leasing of MRI facilities by nonradiologist physicians is a rapidly growing trend.

PURPOSE: To study growth trends in the ownership of magnetic resonance imaging (MRI) examinations by nonradiologist physicians who either own the equipment outright or are involved in scan leasing arrangements. METHODS AND MATERIALS: Medicare Part B data sets from 2000 through 2005 were reviewed, and procedure codes for MRI examinations were selected. The focus was on only those procedures performed at nonhospital, private-office facilities. Using Medicare's physician specialty codes, all such studies were categorized according to the specialties of the physicians who performed them. Ownership was determined by including only those claims for global or technical-component-only reimbursement. Physicians owning or leasing MRI facilities would use one or the other of these two types of claims. Professional-component-only claims were not included. Procedure volumes and growth trends were compared among radiologists and other specialists. RESULTS: From 2000 to 2005, private-office MRI examinations performed by radiologists increased by 83%. During the same period, private-office MRI examinations performed by nonradiologist physicians, either through owning or leasing the equipment, increased by 254%. Excluding studies performed by independent diagnostic testing facilities (for which physician ownership cannot be determined), nonradiologists' share of the private-office MRI market rose from 11% in 2000 to 20% in 2005. The nonradiologic specialties most actively involved in performing MRI were orthopedic surgery (161,296 Medicare studies in 2005), neurology (63,363 studies), primary care (58,092 studies), internal medicine subspecialties (34,317 studies), and neurosurgery (20,712 studies). CONCLUSIONS: In the private-office setting in 2005, radiologists performed most MRI examinations. However, the growth rate from 2000 to 2005 among nonradiologist physicians was far higher, 254% compared with 83% among radiologists. Because scans performed by nonradiologists through ownership or leasing are subject to self-referral, the much more rapid growth among those physicians should be of concern to policymakers and payers.

Ownership or leasing of CT scanners by nonradiologist physicians: a rapidly growing trend that raises concern about self-referral.

PURPOSE: The aim of this study was to examine recent nationwide trends in the ownership or leasing of computed tomographic (CT) scanners in private offices by nonradiologist physicians. METHODS AND MATERIALS: The Medicare Part B fee-for-service data sets for 2001 though 2006 were used to identify all CT scans performed in nonhospital, private-office settings. Ownership or leasing of CT scans was determined by tabulating all global and technical-component-only claims. Professional-component claims were excluded. The specialty of the owner or lessee was determined using Medicare's physician specialty codes. Procedure volume trends and growth rates among all nonradiologist physicians as a group were compared with those among radiologists. Individual specialty volume trends and growth rates were also studied. RESULTS: From 2001 to 2006, Medicare private-office CT scan volume in facilities owned by radiologists increased by 85%. CT scan volume in facilities owned or leased by nonradiologist physicians as a group increased by 263%. The nonradiologic specialties with the largest volumes in 2006 were primary care (192,255 scans), internal medicine subspecialties other than cardiology and medical oncology (184,991 scans), urology (125,850 scans), cardiology (104,739 scans), and medical oncology (61,976 scans). Excluding CT scans performed in independent diagnostic testing facilities (for which physician ownership cannot be determined), nonradiologists' private-office CT market share rose from 16% in 2001 to 28% in 2006. CONCLUSIONS: The majority of Medicare private-office CT scans are done in facilities owned by radiologists. However, nonradiologist physicians are acquiring or leasing CT scanners in increasing numbers, and the growth trend is much more rapid among them than it is among radiologists (85% among radiologists from 2001 to 2006, compared with 263% among nonradiologists). As a result, nonradiologists' market share has increased considerably. At a time when both cost containment and reduction in radiation exposure are urgent priorities, the self-referral opportunities resulting from this trend should be of concern to payers and policymakers.

Recent trends in utilization rates of abdominal imaging: the relative roles of radiologists and nonradiologist physicians.

PURPOSE: To study recent trends in the utilization of abdominal imaging in the Medicare population. MATERIALS AND METHODS: The Medicare Part B databases for 1996 through 2005 were reviewed, and all Current Procedural Terminology, 4th ed, codes pertaining to noninvasive imaging of the abdomen and pelvis were identified. The codes were grouped into 6 categories: (1) computed tomography (CT) and CT angiography, (2) magnetic resonance (MR) and MR angiography, (3) ultrasound, (4) radionuclide imaging, (5) plain radiography, and (6) gastrointestinal fluoroscopy. Global and professional-component claims from all places of service were tabulated for the 6 categories. Utilization rates per 1,000 Medicare fee-for-service beneficiaries were calculated. Medicare physician specialty codes were used to identify examinations by radiologists and nonradiologist physicians. Overall utilization trends were studied, as were those among radiologists and nonradiologists. RESULTS: In 1996, an overall total of 451.8 abdominal imaging examinations were performed per 1,000 Medicare beneficiaries, increasing to 564.5 in 2005 (+25%). The greatest growth was seen in computed tomography and computed tomographic angiography, which rose from 99.4 examinations in 1996 to 239.3 in 2005 (+141%). Ultrasound increased from 126.6 examinations in 1996 to 142.2 in 2005 (+12%). Plain abdominal radiographic examinations decreased from 144.1 to 125.4 (-13%), and gastrointestinal fluoroscopic examinations decreased from 67.3 to 34.8 (-48%). The utilization of MR and MR angiography and radionuclide imaging was far lower. Radiologists' market share of abdominal imaging was 88% in 1996 and 90% in 2005. Between 1996 and 2005, the utilization rate among radiologists increased by 29%, compared with 11% among nonradiologist physicians. CONCLUSIONS: In recent years, the increase in the utilization rate of abdominal imaging among the Medicare population was relatively moderate (25% over 9 years). There was a substantial increase in the use of computed tomography and computed tomographic angiography and a smaller increase in the use of ultrasound. The use of plain radiography and gastrointestinal fluoroscopy declined. Radiologists strongly predominate in abdominal imaging, and this may be one reason why growth has been modest.