Social Determinants of Health Framework to Identify and Reduce Barriers to Imaging in Marginalized Communities.

Social determinants of health (SDOH) are conditions influencing individuals' health based on their environment of birth, living, working, and aging. Addressing SDOH is crucial for promoting health equity and reducing health outcome disparities. For conditions such as stroke and cancer screening where imaging is central to diagnosis and management, access to high-quality medical imaging is necessary. This article applies a previously described structural framework characterizing the impact of SDOH on patients who require imaging for their clinical indications. SDOH factors can be broadly categorized into five sectors: economic stability, education access and quality, neighborhood and built environment, social and community context, and health care access and quality. As patients navigate the health care system, they experience barriers at each step, which are significantly influenced by SDOH factors. Marginalized communities are prone to disparities due to the inability to complete the required diagnostic or screening imaging work-up. This article highlights SDOH that disproportionately affect marginalized communities, using stroke and cancer as examples of disease processes where imaging is needed for care. Potential strategies to mitigate these disparities include dedicating resources for clinical care coordinators, transportation, language assistance, and financial hardship subsidies. Last, various national and international health initiatives are tackling SDOH and fostering health equity.

Standardized reporting for Head CT Scans in patients suspected of traumatic brain injury (TBI): An international expert endeavor.

BACKGROUND AND PURPOSE: Traumatic brain injury (TBI) is a major source of health loss and disability worldwide. Accurate and timely diagnosis of TBI is critical for appropriate treatment and management of the condition. Neuroimaging plays a crucial role in the diagnosis and characterization of TBI. Computed tomography (CT) is the first-line diagnostic imaging modality typically utilized in patients with suspected acute mild, moderate and severe TBI. Radiology reports play a crucial role in the diagnostic process, providing critical information about the location and extent of brain injury, as well as factors that could prevent secondary injury. However, the complexity and variability of radiology reports can make it challenging for healthcare providers to extract the necessary information for diagnosis and treatment planning. METHODS/RESULTS/CONCLUSION: In this article, we report the efforts of an international group of TBI imaging experts to develop a clinical radiology report template for CT scans obtained in patients suspected of TBI and consisting of fourteen different subdivisions (CT technique, mechanism of injury or clinical history, presence of scalp injuries, fractures, potential vascular injuries, potential injuries involving the extra-axial spaces, brain parenchymal injuries, potential injuries involving the cerebrospinal fluid spaces and the ventricular system, mass effect, secondary injuries, prior or coexisting pathology).

Understanding Bias in Artificial Intelligence: A Practice Perspective.

In the fall of 2021, several experts in this space delivered a Webinar hosted by the American Society of Neuroradiology (ASNR) Diversity and Inclusion Committee, focused on expanding the understanding of bias in artificial intelligence, with a health equity lens, and provided key concepts for neuroradiologists to approach the evaluation of these tools. In this perspective, we distill key parts of this discussion, including understanding why this topic is important to neuroradiologists and lending insight on how neuroradiologists can develop a framework to assess health equity-related bias in artificial intelligence tools. In addition, we provide examples of clinical workflow implementation of these tools so that we can begin to see how artificial intelligence tools will impact discourse on equitable radiologic care. As continuous learners, we must be engaged in new and rapidly evolving technologies that emerge in our field. The Diversity and Inclusion Committee of the ASNR has addressed this subject matter through its programming content revolving around health equity in neuroradiologic advances.

Clinical and Economic Profile of Homeless Young Adults with Stroke in the United States, 2002-2017.

Homelessness is a major social determinant of health. We studied the clinical and economic profile of homeless young adults hospitalized with stroke. We studied the National Inpatient Sample database (2002-2017) to evaluate trends of stroke hospitalization, clinical outcomes, and health expenditure in homeless vs non-homeless young adults (<45 years). We identified 3134 homeless individuals out of 648,944 young adults. Homeless patients were more likely to be men, Black adults and had a higher prevalence of cardiometabolic risk factors and psychiatric disorders than non-homeless adults. Both homeless and non-homeless adults had a similar prevalence of ischemic and hemorrhagic stroke. Between 2002 and 2017, hospitalization rates per million increased for both non-homeless (295.8-416.8) and homeless adults (0.5-3.6) (P ≤ 0.01). Between 2003 and 2017, the decline in in-hospital mortality was limited to non-homeless adults (11%-9%), while it has increased in homeless adults (3%-11%) (P < 0.01). The prevalence of acute myocardial infarction (6.8% vs 3.3%, P < 0.01), and acute kidney injury (13.1% vs 9.4%, P < 0.01) was also higher in homeless vs. non-homeless adults. The length of stay and inflation-adjusted care cost were comparable between both study groups. Finally, a higher proportion of homeless patients left the hospital against medical advice than non-homeless adults. Homeless young stroke patients had significant comorbidities, increased hospitalization rates, and adverse clinical outcomes. Therefore, public health interventions should focus on multidisciplinary care to reduce health care disparities among young homeless adults.

Quality outcomes of reinterpretation of brain CT studies by subspecialty experts in stroke imaging.

OBJECTIVE: The purposes of this study were to determine the clinical importance and relative value of reinterpretation of brain CT studies by subspecialty experts by assessing the accuracy of interpretation by general radiologists at primary stroke centers and to assess interpretive quality outcomes as a function of change in the treatment of patients with stroke diagnoses or acute presentations of suspected stroke. MATERIALS AND METHODS: Computerized medical records for the years 2009-2010 at four major community hospitals were queried for primary interpretation of brain CT studies of stroke patients with an acute presentation of either stroke or suspected stroke as diagnosed by board-certified general radiologists (nonneuroradiologists). A central database was queried that allowed one to query by clinical history or symptoms. Secondary interpretation of images of the identified patient sample was then performed by three experienced neuroradiologists. Each case was initially interpreted as an emergency or urgent study by a general radiologist. The reinterpretations performed by a neuroradiologist were scored as concordant or discordant. The discordant studies were categorized as a major discordance if there was a change in clinical management or as a minor discordance if there was no effect on or change in clinical management. The assessment was limited to brain CT studies without contrast administration. CT angiography and perfusion CT studies were not included in the analysis. Patients with hemorrhagic stroke, brain tumors, abscesses, and AIDS or HIV infection were excluded to limit the assessment to ischemic nonhemorrhagic disease. RESULTS: Of the 560 studies reviewed, 14 studies (2.5%) were identified as discordant. Of those discordant studies, four (0.7% of the original 560) were categorized as major discrepancies necessitating a change in clinical management. Ten (1.78%) were categorized as minor discrepancies, for which there was no change in management. There were no permanent adverse outcomes with respect to morbidity and mortality as a result of a discrepant interpretation, as determined by chart review or communication with the attending or referring physician by the secondary reader. CONCLUSION: Most of the interpreted head CT cases read by board-certified general radiologists for patients presenting with stroke or stroke symptoms did not result in discordant interpretations as verified by subspecialty experts. Discordant interpretations did not result in changes in clinical management in most cases. Double reading of head CT scans for these patients by subspecialty experts appears to be an inefficient method of substantially improving imaging health quality outcomes in stroke.

Contemporary national trends and disparities for head CT use in emergency department settings: Insights from National Hospital Ambulatory Medical Care Survey (NHAMCS) 2007-2017.

BACKGROUND: The exponential growth in CT utilization in emergency department (ED) until 2008 raised concerns regarding cost and radiation exposure. Head CT was one of the commonest studies. This led to mitigating efforts such as appropriate use guidelines, policy and payment reforms. The impact of these efforts is not fully understood. In addition, disparities in outcomes of acute conditions presenting to the ED is well known however recent trends in imaging utilization patterns and disparities are not well understood. In this study, we describe nationwide trends and disparities associated with head CT in ED settings between 2007 and 2014. METHODS: We analyzed 2007-2017 National Hospital Ambulatory Medical Care Survey (NHAMCS) with the primary goal to assess the rate and patterns of head CT imaging in ED. RESULTS: There were an estimated 117 million in 2007 and 139 million ED visits in 2017. There was a 4% increase in the any CT use in 2017 compared to 2007. No significant change in head CT utilization rate was seen. The 2007 head CT rate was 6.7% (95% CI: 6.1-7.3) compared to 7.7% (95% CI: 6.8-8.6) in 2017. Trauma, Headache and Dizziness are the top three indications for head CT use in the ED respectively. On adjusted analyses, significantly higher head CT utilization was seen in elderly, (age>65 yrs) and significantly lower utilization rate was seen in Non-Hispanic Black and Medicaid patients, and patients in rural locations. CONCLUSIONS: Previously reported exponential growth of CT use in ED is no longer seen. In particular, there was no significant change in ED head CT use between 2007 and 2017. Headache and Dizziness remain commonly used indications despite limited utility in most clinical scenarios, indicating continued need for appropriate use of imaging. There is significantly lower CT utilization in Non-Hispanic Black, Medicaid patients and those in rural locations, suggesting disparities in diagnostic work-up in marginalized and rural populations. This underscores the need for standardizing care regardless of race, insurance status and location.

COVID-19-related state-wise racial and ethnic disparities across the USA: an observational study based on publicly available data from The COVID Tracking Project.

OBJECTIVE: To evaluate COVID-19 infection and mortality disparities in ethnic and racial subgroups in a state-wise manner across the USA. METHODS: Publicly available data from The COVID Tracking Project at The Atlantic were accessed between 9 September 2020 and 14 September 2020. For each state and the District of Columbia, % infection, % death, and % population proportion for subgroups of race (African American/black (AA/black), Asian, American Indian or Alaska Native (AI/AN), and white) and ethnicity (Hispanic/Latino, non-Hispanic) were recorded. Crude and normalised disparity estimates were generated for COVID-19 infection (CDI and NDI) and mortality (CDM and NDM), computed as absolute and relative difference between % infection or % mortality and % population proportion per state. Choropleth map display was created as thematic representation proportionate to CDI, NDI, CDM and NDM. RESULTS: The Hispanic population had a median of 158% higher COVID-19 infection relative to their % population proportion (median 158%, IQR 100%-200%). This was followed by AA, with 50% higher COVID-19 infection relative to their % population proportion (median 50%, IQR 25%-100%). The AA population had the most disproportionate mortality, with a median of 46% higher mortality than the % population proportion (median 46%, IQR 18%-66%). Disproportionate impact of COVID-19 was also seen in AI/AN and Asian populations, with 100% excess infections than the % population proportion seen in nine states for AI/AN and seven states for Asian populations. There was no disproportionate impact in the white population in any state. CONCLUSIONS: There are racial/ethnic disparities in COVID-19 infection/mortality, with distinct state-wise patterns across the USA based on racial/ethnic composition. There were missing and inconsistently reported racial/ethnic data in many states. This underscores the need for standardised reporting, attention to specific regional patterns, adequate resource allocation and addressing the underlying social determinants of health adversely affecting chronically marginalised groups.

Computed tomography imaging in the management of headache in the emergency department: cost efficacy and policy implications.

PURPOSE: To evaluate the economic impact and diagnostic utility of computed tomography (CT) in the management of emergency department (ED) patients presenting with headache and nonfocal physical examinations. METHODS AND MATERIALS: Computerized medical records from 2 major community hospitals were retrospectively reviewed of patients presenting with headache over a 2.5-year period (2003-2006). A model was developed to assess test outcomes, CT result costs, and average institutional costs of the ED visit. The binomial probabilistic distribution of expected maximum cases was also calculated. RESULTS: Of the 5510 patient records queried, 882 (16%) met the above criteria. Two hundred eighty-one patients demonstrated positive CT findings (31.8%), but only 9 (1.02%) demonstrated clinically significant results (requiring a change in management). Most positive studies were incidental, including old infarcts, chronic ischemic changes, encephalomalacia, and sinusitis. The average cost of the head CT exam and ED visit was $764 (2006 dollars). This was approximately 3 times the cost of a routine outpatient visit (plus CT) for headache ($253). The incremental cost per clinically significant case detected in the ED was $50078. The calculated expected maximum number of clinically significant positive cases was almost 50% lower than what was actually detected. CONCLUSION: Our results indicate that emergent CT imaging of nonfocal headache yields a low percentage of positive clinically significant results, and has limited cost efficacy. Since the use of CT for imaging patients with headache in the ED is widespread, the economic implications are considerable. Health policy reforms are indicated to better direct utilization in these patients.

Quality outcomes of reinterpretation of brain CT imaging studies by subspecialty experts in neuroradiology.

PURPOSE: To determine the clinical importance and relative value of reinterpreting brain CT imaging studies by subspecialty experts regarding changes in clinical management. METHODS: Computerized records were queried at two institutions during the years 2002-2003 for both primary interpretation by board-certified nonneuroradiologists and secondary interpretation by three neuroradiologists. A total of 1,081 cases were reviewed. Each case was initially interpreted as an emergent or urgent study. The reinterpreted studies were scored as concordant or discordant by the subspecialty experts. The discordant studies were then categorized as a "major discordance" if there was a change in clinical management, or as a "minor discordance" if there was no impact or change in clinical management. RESULTS: Of the 1,081 studies reviewed, 14 studies were identified as discordant (1.3%). Of those discordant studies, four were categorized as major discrepancies necessitating a change in clinical management (0.4 %). Ten were categorized as minor discrepancies (0.9%). There were no permanent adverse outcomes with respect to morbidity and mortality as a result of any discrepancy. CONCLUSION: The vast majority of interpreted head CT cases read by board-certified general radiologists do not result in discordant interpretations as verified by subspecialty experts. Discordant interpretations did not result in changes in clinical management in most cases. Double reading of head CTs by subspecialty experts appears to be an inefficient method of substantially improving imaging health quality outcomes.

ACR Appropriateness Criteria on low back pain.

Acute low back pain with or without radiculopathy is one of the most common health problems in the United States, with high annual costs of evaluation and treatment, not including lost productivity. Multiple reports show that uncomplicated acute low back pain or radiculopathy is a benign, self-limited condition that does not warrant any imaging studies. Guidelines for recognition of patients with more complicated status can be used to identify those who require further evaluation for suspicion of more serious problems and contribute to appropriate imaging utilization.