Trickle-Down Economics of Medical Imaging

Trickle-Down Economics of Medical Imaging

Saurabh Jha, MBBS, MRCS

February 05, 2015

Medical Imaging and the Price of Corn

After the Napoleonic wars, the price of corn in England became unaffordable. The landowners were blamed for the high price, which some believed was a result of the unreasonably high rents for farm land. Economist David Ricardo disagreed.

According to Ricardo, detractors had the directionality wrong. It was the scarcity of corn (the high demand relative to its supply) that induced demand for the most fertile land. That is, the rent did not increase the price of corn. The demand for corn raised the rent. Rent was a derived demand.

Directionality is important. Getting directionality wrong means crediting the rooster for sunrise and blaming umbrellas for thunderstorms. It also means that focusing on medical imaging will not touch healthcare costs if factors more upstream are at play.

Medical imaging is a derived demand. The demand for healthcare induces demand for imaging. Demand is assured by the unmoored extent to which we go for marginal increases in survival.

The Demand for Imaging in Stroke

The treatment of ischemic stroke using thrombolytics and intra-arterial therapy (IAT) is instructive on how imaging can be induced. Lytics improve outcomes but must be administered relatively rapidly after onset of symptoms. IAT, which is treatment at the site of arterial blockage, allows the clock to tick for a bit longer and has recently been shown to be beneficial.

In the MR CLEAN[1] study, patients with acute ischemic stroke with radiographically proven occlusion in the proximal anterior circulation were randomly assigned to IAT or usual care. IAT included local thrombolysis, mechanical break up of thrombus, or stent placement. In both treatment and control groups, most patients also received thrombolysis with alteplase (Activase®).

The results published in the New England Journal of Medicine [1] showed that patients who received IAT within 6 hours of stroke onset had a clinically significant increase in functional independence at 3 months without higher mortality.

Counting the CTs and CT Angiograms

However, patients don’t walk into the emergency department saying, “Good evening, doctor, I have an occlusion in the proximal internal carotid artery. Can we get moving, please?” Sometimes they have classic signs and symptoms of stroke in the distribution of the target artery. Often they have more vague signs and symptoms that could be due to other causes.

Thrombolytics aren’t candy that you distribute willy-nilly. They have serious side effects such as bleeding in the brain. They can worsen the neurologic deficit. They can kill, even when used correctly.

Patients first need a CT of the head—not to pick up early stroke; that’s a clinical diagnosis. A CT is done to make sure that the stroke is not caused by a bleed. Hemorrhagic strokes are less common than ischemic strokes but common enough to warrant routine use of CT for this distinction.

The other reason for CT is to ensure that if the stroke is indeed ischemic, there is not so much brain edema that thrombolysis will lead to bleeding. The risk for bleeding in an ischemic stroke increases in edematous brains.

For IAT, we need to know who has a treatable lesion. Signs and symptoms don’t tell us with certainty who has a culprit lesion in the proximal internal carotid arteries, and neither does standard CT of the head. Patients need CT angiogram not only to identify those who have a treatable blockage but also to find out who doesn’t have a treatable lesion. We can’t tell this without doing a CT angiogram.

Obviously, this means that more patients will get a CT angiogram than are eligible for IAT. Many more will get a CT angiogram than will actually benefit from IAT. (Not everyone deemed to benefit from IAT will actually benefit.)

Okay, so CT of the head is done in all, and CT angiograms are done in many. Is it time to check out with the radiology cashier? No. We are far from done with imaging.

Imaging for Complication Monitoring

After thrombolysis, patients will have another CT of the head to make sure that the clot buster did not cause a bleed. They will be managed in the neuro-intensive care unit (ICU). The level of care will be higher. The sensitivity to mild variation in objective ICU parameters will be intense. Surveillance CTs of the head will be frequent.

There is a plausible risk for bleeding elsewhere after thrombolysis, such as in the abdomen. How do we know whether the patient has bled? Signs and symptoms aren’t reliable. Remember, these patients have neurologic deficits, which bar some from verbalizing clearly.

A fall in hemoglobin and hematocrit could herald a bleed, even if more often than not these indices fall because of the fluid status. Patients in whom these indices have dropped may need a CT of the abdomen to look for bleeding. The cheaper noncontrast CT will suffice in most but not all patients. Some may have active bleeding warranting interventional radiology, which requires a CT angiogram for diagnosis.

IAT involves a puncture of the femoral artery and then navigation of a catheter through the aorta, which is not without complications such as seroma, which may resolve spontaneously. Less commonly, patients might develop a false aneurysm of the femoral artery or an arteriovenous fistula. Patients need an ultrasound and/or CT or MR angiogram of the femoral arteries when there is suspicion of dangerous complications.

The aorta and carotid arteries are tricky territories to navigate. The surgeon might tear the arterial wall. The tear might propagate. These patients need a CT angiogram of the chest and neck. The surgeon might feel that he or she was a bit too enthusiastic breaking up the clot and fear that the artery has been torn. These patients will get a CT angiogram as well. Better safe than sorry.

Broken thrombus could embolize and infarct new areas of the brain, causing new neurologic deficits. In those instances, an MRI of the brain, a CT angiogram of the head, or, more likely, both may be ordered. Of note, in the treatment arm of the MR CLEAN trial, new strokes were reported in 13 of 233 participants.

We are not yet done with imaging.

The CT dye load and natural variation may elevate the creatinine, prompting an ultrasound of the kidneys to exclude a postobstructive, and treatable, renal impairment. Patients will receive countless chest and abdominal x-rays when support lines are inserted and manipulated, in accordance with principles of safety.

A few CTs of the chest may be ordered because a radiologist could not “exclude pneumonia with absolute certainty” in someone with left partial lung collapse, which everyone in the hospital has, particularly when an intern puts in the clinical information, “new fever, exclude pneumonia, kindly.”

Cost and Quality Considerations

Stroke doesn’t sleep at night, and neither do its costs. Radiology departments must be staffed to provide timely access and reports. CT angiograms are complex studies. Trained radiologists, and perhaps expert 3D technologists, must be available 24/7. The window for IAT is 6 hours from stroke onset—the urgency at 5 hours, 30 minutes will be intense.

The medical imaging consequent to applying thrombolysis and/or IAT for stroke in practice is substantial. Any other industry would proudly showcase this exemplar of trickle-down economics. However, patients don’t pay large marginal costs for small marginal benefit. The costs are diffused. But costs are costs. Healthcare is neither a free market nor a market that is free.

How should payers reimburse the derived demand for imaging? They can say: “Stroke team, here is how many quality-adjusted life years (QALYs) the population gained. Thanks for your contribution, radiologists. Here is your share. Yes, I know it isn’t a lot, and your efforts were enormous, but you must admit, the net QALYs are a bit modest.”

That is if the absurdly but rationally high amount of medical imaging as a result of thrombolysis/IAT for stroke were reimbursed in a bundled payment for stroke. This is fine, but is it fair that the average returns on imaging are diminished because of increasing complexity of treatment and diminishing returns on QALYs, factors over which radiologists have little control?

Or should radiologists say to payers, “You want to improve survival in stroke patients using aggressive, expensive, and dangerous therapy. Here is an estimation of the costs of the imaging. Now put your money where your coverage is.”?

Regardless of the payment method, whether bundled pay for outcomes such as QALYs or itemized fee for service, it should be apparent that thrombolysis and IAT for stroke will substantially increase use of imaging. But imaging should not be blamed for increasing costs; that credit should be given to science and humanity for the high costs of stroke treatment.

When clot busting for stroke becomes practice du jour, the population will no longer resemble the trials. The MR CLEAN study was conducted in The Netherlands. This is the United States. Patients will be older and sicker; they will incur more complications, induce more imaging, and derive even less treatment benefit, statistically speaking. Any bundled payment determined by outcomes will become smaller with more and more activity in the bundle. The math of such a payment scheme can’t last for too long.


  1. Berkhemer OA, Fransen PS, Beumer D, et al; MR CLEAN Investigators. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015;372:11-20. Abstract

EHR Clinical Decision Support Functions Linked to Better Care Quality | Blue Horseshoe Blogger

EHR Clinical Decision Support Functions Linked to Better Care Quality


EHR Clinical Decision Support Functions Linked to Better Care Quality

California Healthline, iHealthBeat, Monday, November 3, 2014

Meaningful use standards that require clinical decision support functions could significantly improve quality of care, according to a study published in the American Journal of Managed CareHealth IT Analytics reports.

Under the 2009 economic stimulus package, providers who demonstrate meaningful use of certified electronic health records can qualify for Medicaid and Medicare incentive payments.

Details of Study

For the study, researchers analyzed data from the 2006 to 2009 National Ambulatory and National Hospital Ambulatory Medical Care surveys on adult primary care visits to practices that met the requirement for Stage 1 of the meaningful use program. These practices had EHR systems with at least one of five CDS functions:

  • Electronic problem lists;
  • Lab result reports;
  • Notifications for out-of-range labs;
  • Reminders for preventive care; or
  • Warnings for drug interactions.

The researchers then divided the visits into three categories:

  • Visits to practices with all CDS functions enabled;
  • Visits to practices with at least one CDS function disabled; and
  • Visits to practices with at least one missing CDS function (Bresnick,Health IT Analytics, 10/31).

Please click below to continue reading…


The study found that 86% of patients who visited primary care clinics with all five types of CDS functions had controlled blood pressure, compared with 82% of patients who visited clinics with at least one missing function and 83% of patients who visited clinics that had disabled at least one function.

Further, researchers found that:

  • CDS functions were associated with blood pressure control and fewer visits for adverse drug events;
  • CDS functions were associated with better performance on indicators of quality of care and clinical decision support functions related to such quality measures (Mishuris et al., AJMC, 10/28); and
  • Decisions to disable CDS functions were associated with reduced quality of care improvements (Health IT Analytics, 10/31).

However, the researchers said they were unable to determine an association between disabling particular CDS functions and cancer screening, health education or influenza vaccinations because of limited data (AJMC, 10/28).


The researchers said, “Overall, meaningful use standards that include [CDS functions] appear to have a significant positive effect on some national quality-of-care indicators and health outcomes.”

They added, “It will be important to evaluate the evolving impact of meaningful use as the stages continue to be more widely implemented and better integrated with care processes; we anticipate further gains in healthcare quality indicators and outcomes as a result” (Health IT Analytics, 10/31).

Source: iHealthBeat, Monday, November 3, 2014

CDS functions within the EHR have shown the ability to improve the quality and safety of patient care. I personally feel that these functions serve as a safety net for providers and can help catch potential errors before they are made.

What are your thoughts on CDS functions, and do you feel it is appropriate for practices to have the option of disabling any of the CDS functions available?

Thanks for reading and please share your thoughts!

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Emergency departments continue to drive CT use

Emergency departments continue to drive CT use

By Eric Barnes, staff writer

November 11, 2014 — Bucking an overall downward trend in utilization of advanced imaging services, emergency departments (EDs) are still seeing growth in imaging, especially in CT use, which has tripled over the past decade, according to a new article in the Journal of the American College of Radiology.

Researchers from Thomas Jefferson University (TJU) looked at emergency department utilization of imaging tests from 2002 through 2012, parsing Medicare Part B data to determine the frequency of imaging exams by modality. They found that x-ray and CT were the most widely used modalities in the ED, and both rose over the decade, though x-ray’s ascent has been slower: Radiography use rose by more than one-fourth, but CT utilization nearly tripled (JACR, November 2014, Vol. 11:11, pp. 1044-1047).

“Imaging rates in every modality nationwide at all venues where imaging is done have flattened out or started to come down,” lead author Dr. David C. Levin, professor emeritus of radiology at TJU, told “The emergency department is the only place where imaging rates have continued to go up, and this paper shows they’re going up in every modality, especially plain films and CT.”

Rising imaging use soon halted

At the turn of the 21st century, imaging was the fastest-growing segment among all physician services. But the growth alarmed policymakers and payors, and within a few years various techniques were adopted to control utilization.

Dr. David C. Levin

Dr. David C. Levin from Thomas Jefferson University.

Steps to curb imaging ran the gamut and included reimbursement cuts, code bundling and higher deductibles, co-payments for patients, and computerized decision support, Levin and colleagues wrote.

On the whole, the effort has been a success. Growth in advanced imaging has all but stopped or has even reversed, the authors wrote. But imaging occurs in four kinds of service venues: hospital outpatient facilities, private offices, hospital inpatient facilities, and emergency departments. And little research has been done to ascertain precisely where the changes in imaging rates have occurred.

A previous study did show, however, that imaging rates were rising in emergency departments through 2008.

“The feeling among some radiologists at present is that although overall imaging utilization is flat or showing a decline, its use in the ED may be continuing to increase,” Levin and colleagues Dr. Vijay Rao and Laurence Parker, PhD, wrote. “In this study, we extend the review of ED imaging trends through 2012 and attempt to determine if this impression is correct.”

Data came from Medicare Part B Physician/Supplier Procedure Summary Master Files from 2002 through 2012. The files cover all services to 36.9 million beneficiaries in the Medicare fee-for-service population, but not the nearly 14,000 inMedicare Advantage plans.

Exam volume, location, place of service, and specialty provider were all included; the researchers grouped every code by modality for plain radiography, CT, noncardiac ultrasound, MRI, and nuclear medicine. Interventional codes were excluded. Rates were calculated per 1,000 beneficiaries, and ED trends were compared with non-ED trends.

The researchers found that x-ray use rose slowly and steadily between 2002 and the end of 2012, from 248.7 exams per 1,000 beneficiaries to 320 exams per 1,000.

Over the same decade, CT use rose rapidly every year except for a one-year decline in 2011, resuming its rise in 2012. During the entire study period, CT rose from 57.2 exams per 1,000 beneficiaries to 147.9 exams in 2012 — growth of 158%.

“In 2011, instead of going up, [CT] went down,” Levin said. “That was an artifact of code bundling in CT of the abdomen and pelvis.”

Even ultrasound use increased over the decade, though it rose considerably less than x-ray and CT, increasing from 9.5 exams per 1,000 beneficiaries in 2002 to 21.0 in 2012, for a growth rate of 121%. Ultrasound was not burdened by code bundling.

Finally, the utilization rate for nuclear medicine fell from 2.8 exams per 1,000 beneficiaries to 2.1 in 2012, a drop of 25%, largely due to code bundling in myocardial perfusion imaging.

ED imaging exam rates per 1,000 Medicare beneficiaries
Exam 2002 rate per 1,000 2012 rate per 1,000
CT 57.2 147.9
Plain radiography 248.7 320.0
Ultrasound 9.5 21.0
MRI 1.4 5.1
Nuclear medicine 2.8 2.1

Why the spike in CT use?

“The ED has become very crowded and busy; I think the ED doctors are under a lot of pressure to turn patients around, and they know CT is a good tool to make accurate diagnoses and make a disposition of the case to discharge the patient when they want a definitive diagnosis,” Levin said. “I don’t fault them for that — they’re under the gun.”

In cardiac imaging, for example, multiple studies have shown that a negative coronary CT angiography (CCTA) exam means that chest pain patients can be safely discharged if they do not have evidence of significant stenosis.

“I think those studies are right on the mark,” Levin said. “Every chest pain patient who walks in where there’s any kind of clinical suspicion for that should immediately go for CCTA right off the bat,” he said. “If they get a CT scan, the ED physician will know immediately if they have something serious.”

The scan length can, of course, be extended to a triple rule-out exam when there is also suspicion of aortic dissection or pulmonary embolism, and it will reveal any other cause of chest pain that might be present, such as pleural effusion or pneumothorax, Levin said.

What about overuse?

Medicare data show that in 2012, 18.4 million imaging studies were performed in emergency departments, constituting 14% of all Medicare fee-for service imaging, the authors wrote.

It is concerning that imaging rates continue to grow, and the results suggest that radiologists should work more closely with their ED colleagues to exert tighter control over imaging utilization.

The solutions include more diligent application of clinical rules for imaging, such as the Wells criteria for suspected pulmonary embolism, or the Canadian C-spine rule for cervical spine trauma, the authors wrote. ED physicians should be better educated about American College of Radiology (ACR) appropriateness criteria, and cooperation between radiologists and ED physicians should be better tailored to emergency or trauma situations.

Use of computerized clinical decision support will also be helpful, along with greater familiarity among radiologists and ED physicians with exams that are potentially unnecessary or overused according to the Choosing Wisely initiative.

But while Levin said he is sure there are instances when CT is overused in the ED, he doesn’t think of it as a global problem.

“I think, in general, recognizing the fact that ED docs have been really under the gun, they’ve been swamped with more and more patients, and there’s always the fear of malpractice liability lurking in the shadows, we have to be sympathetic,” Levin said.

In any case, the 2013 data will be out within a month, and it will be interesting to see if current trends continue, he said.

CT, MRI use declined in ED after 2007, August 20, 2014

Study shows combined thoracic CT use has dropped, August 14, 2014

Study tracks ebb and flow of imaging use in private sector, May 20, 2014

Outpatient echo code bundling has unintended effects, May 15, 2014

Radiologists hit hard by CT code bundling, April 29, 2014

Copyright © 2014

Does malpractice reform affect defensive medicine practices? | Medical Economics

Does malpractice reform affect defensive medicine practices?

Study looks at physician behavior in emergency departments before, after reform legislation

Physicians and health policy experts have long assumed that doctors are driven to practice defensive medicine because they fear being sued for malpractice. But a recent study of what happened in states that made it more difficult to sue some physicians casts doubt on that assumption.

The study examines the impact of changes in the behavior of emergency department (ED) physicians following the reform of malpractice laws in in three states: Texas, which in 2003 changed its malpractice standard for emergency care to “willful and wanton negligence;” and Georgia and South Carolina, which changed their standards to “gross negligence” in 2005.“From a legal standpoint, these two standards are considered synonymous and are widely considered to be a very high bar for plaintiffs,” the study’s authors write.

Malpractice insurance: Understanding the importance of coverage limits

The researchers looked at the numbers of computed tomography and magnetic resonance imaging procedures and inpatient admissions ED physicians ordered for a random sample of Medicare fee-for-service patients in the three states between 1997 and 2011. They focused on the imaging procedures because ED physicians frequently self-report them as examples of defensive medicine practices. Researchers also studied per-visit charges as a proxy for the intensity of the level of services provided to the patients.

The authors then compared patient-level outcomes before and after passage of malpractice reform both among the three reform states and in surrounding states, with the goal of isolating the specific impact of the reform legislation from other trends and from patient characteristics. The goal was to arrive at what the authors term “policy-attributable changes” in ED physician behavior.

After subjecting the data to regression analysis, the researchers found no decrease in rates of CT or MRI use or hospital admission in any of the three reform states, and no reduction in per-visit charges in Texas or South Carolina. Georgia experienced a 3.6% reduction in per-visit charges.

The authors note that ED physicians frequently cite the use of advanced imaging as example of a defensive medicine practice. “Our results challenge the validity of these assertions, or at least suggest that the use of emergency department imaging is unlikely to be affected by malpractice reform alone,” they write.

READ: Competition driving malpractice premiums down

Although the study focused on ED physicians, the results have wider implications for the debate over shielding doctors from malpractice suits would reduce defensive medicine practices, and thereby reduce the nation’s overall medical costs, says Daniel Waxman, MD, PhD, the lead author and an adjunct natural scientist at the RAND Corporation. “People have said over and over that malpractice reform is an important way to save money, and I think the interesting part of this study suggests that’s a blind alley,” Waxman says.

The study, “The Effect of Malpractice Reform on Emergency Department Care,” appears in the October 16 issue of the New England Journal of Medicine. – European Society of Radiology calls for safer and more appropriate use of imaging

ESR calls for safer and more appropriate use of imaging

by Lauren Dubinsky , Staff Writer
The European Society of Radiology announced earlier this week that it launched a “Call for Action” as part of its EuroSafe Imaging campaign that began in March. ESR started the campaign in an effort to reduce the increasing number of radiological exams that are conducted every year.

“This initiative is necessary, but also is very timely, because we are now facing, worldwide, a challenge to deal with the potential risks of radiation in health care without compromising the benefits, and this is the reason why I think it is very appropriate that this initiative is taken by the professionals; the radiologists,” Dr. Maria Del Rosario Perez of the World Health Organization, said in a statement.

The campaign backs the Bonn Call for Action that the WHO and the International Atomic Energy Agency launched in 2012, which is a proposal for the priorities that stakeholders should focus on regarding radiation protection in the medical industry for the next decade.

The “Call for Action” consists of 12 points that include advocating for the appropriate use of imaging, ensuring that radiation doses are within diagnostic reference levels, utilizing the “as low as reasonably achievable” principle, promoting the use of the latest equipment, empowering patients and teaming up with other stakeholders.

The ESR has already started making headway by working on introducing a new clinical decision support system for imaging referral guidelines. It will be a software tool that will help referring physicians recommend the most appropriate radiological exams for their patients.

The society is also working on developing templates for internal clinical audit. They already offer e-learning resources on radiation protection and special education sessions as well as the Patient Advisory Group for Medical Imaging to empower patients.

“We believe that this holistic approach is an important step towards joining forces for patient safety in Europe,” Guy Frija, founder of EuroSafe Imaging, chair of the EuroSafe Imaging Steering Committee and ESR past president, said in a statement. “And we believe too that the use of up-to-date equipment is of utmost importance for improving the safety of X-ray examinations. The ESR urges the European Commission to develop a European plan for the improvement of X-ray equipment, including CT across Europe.”

Standardization: An Answer to Three of Radiology’s Vexing Problems | Radiology Business

Standardization: An Answer to Three of Radiology’s Vexing Problems

 - Inspection

In healthcare, the bar for quality is being set ever higher. One key approach to attaining quality is standardization: Just as other industries have embraced Lean, Six Sigma, and the Toyota Production System, each of which leverages standardization as a tool to achieve quality improvement, imaging service providers are establishing standards for multiple aspects of imaging services delivery in the quest to enhance patient care as well as safety.

Consider the example of the University of Florida College of Medicine inGainesville, whose primary teaching hospital, Shands at the University of Florida (UF Shands), now utilizes standardized names for each imaging procedure, an initiative referred to as Standardized Nomenclature for Imaging Procedures (SNIPs), along with standardized reports. SNIPs serve to define consistent, predictable protocols, as well as to facilitate the assessment and comparison of clinical outcomes. They indicate modalities and anatomy; contain specific indications for imaging protocols; and are applied in ordering, requesting authorization for, scheduling, performing, interpreting, and billing studies. In ordering studies, clinicians choose a particular SNIP, which links to the appropriate exam and report template.

Anthony A. Mancuso, MD, professor and radiology department chair, says that the absence of such protocols generally leads to discrepancies between the clinical indicators for performing a given study and the caliber/relevance of the information it yields, in turn compromising quality as well as patient safety. “The construct of the protocol must be targeted to the specific clinical indications, or scenario,” Mancuso asserts. “Otherwise, there is no assurance that the exact answers being sought in an exam will show up in the report, and there is the risk of missing important findings (as well as of doing harm to the patient) because of the mismatch.”

Careful consideration

Mancuso emphasizes that properly formulating the SNIPS necessitated a meticulous approach by a team of colleagues. Notably, the team conducted a careful assessment of whether individual clinical indications should be classified under a single protocol, or under multiple protocols. “It’s not like there is a SNIP for every indication, and some indications do fit under one protocol,” Mancuso says. “However, the complexity was such that we did end up, for example, with more than 20 head and neck SNIPS, 30 SNIPS for the brain, and 10 to 15 SNIPS for the spine.”

Meanwhile, the standardization of reports—called structured reports at UF Shands—is an ongoing cooperative endeavor involving clinicians, radiologists, and, in some instances, specialists from several other departments, among them cardiology, surgery, neurosurgery, and otolarangology. To ensure that the purpose of standardization—specifically, quality attainment—is indeed fulfilled, clinicians have been and continue to be asked for specific feedback “about what they want to see in and know from individual reports,” Mancuso states. For instance, some clinicians were queried as to details to be incorporated in a structured report of a pancreatic cancer CT protocol.

Pushing the quality and safety envelope a few steps further, different series of questions, some developed based on input from radiologists alone and others, in tandem with additional suggestions from specialists outside the discipline, are also a component of each structured report. Dubbed “forced-choice observations,” these questions, which radiologists must answer, mesh tightly with individual protocols. Case in point: Some questions posed in a report of a children’s seizure protocol pertain to the normalcy of hippocampal formation and current hippocampal volume, as well to whether there is evidence of improper/abnormal brain development and/or long-term effects of seizures on the patient’s brain.

“Without this type of structured information, it is difficult for the clinician to determine if the radiologist who completed the report possesses knowledge in that domain and whether the data” are of real value, Mancuso states. “That all ties in to patient care.”

Yet another element of the standardized reports is a report acuity scale on which radiologists must rate the urgency with which referring physicians should review the findings. Ratings range from one to five, with a rating of one indicative of normal findings and a rating of two, indicative of the presence of a finding that merits review by the clinician, but may not necessarily warrant other action. A rating of three indicates the presence of actionable and non-actionable findings that should be reviewed within 24 hours if at all possible, while a rating of four or five means, respectively, that the findings must  be addressed within an eight-hour window from the time the report was received or immediately.

Mancuso concedes that there has been some resistance among UF Shands’ radiologists to the standardization of imaging protocols and reports alike; most or all of these physicians, he says, have pet imaging protocols and their own, personalized reporting style. On the imaging protocols side, the majority of complaints received concern the additional time and effort needed to ensure adherence.

But no exceptions to the rules are permitted. “Quite simply,” Mancuso notes, “we tell them this is a non-negotiable, because we owe it to our patients. They understand the logic in that argument.” To bolster efficiencies and soften radiologists’ resistant edge, the protocoling tool resides inside UF Health Shands’ RIS system. Toward the same end, each SNIP has an identifying number within the EHR, which in turn is linked to a CPT code; the latter is linked to a procedure code.

Meanwhile, radiologists’ objections to the reporting protocols center on a reluctance to deviate from preferred and, in many cases, long-ingrained approaches to preparation. Such objections are countered with the argument that reports generated in accordance with protocols are of higher and more consistent quality and hence, improve safety and caliber of patient care.

“However, it goes beyond this,” asserts Mancuso. “We continue to emphasize to our radiologists not only that standardization in reporting is what our clinicians want, but also that at some time, radiology will be held accountable for providing value —which comes partially from reporting consistency—and we need to be ready. Not to mention, again, that it’s just the right thing to do for our patients.”

To date, UF Shands has not attempted to quantify improvements resulting from having standardized either its imaging protocols or its reports. Nonetheless, Mancuso says, anecdotal evidence points to positive change. “Clinicians tell us they are getting what they want in terms of information,” he observes. “And where we previously received complaints” about reports pretty much daily, “we have not heard one in the past six months. Most importantly, we are doing what is right for our patients. ”

Not so incidental

Radiologists’ approach to the reporting and handling of incidental findings, known colloquially as incidentalomas, varies almost as much, if not as much, as their approach to the reporting of clinical findings in general. Again, quality implications come into play.

“Show a set of images with an indeterminate finding to several radiologists, and be prepared to hear multiple recommended courses of action,” states James A. Brink, MD, radiologist-in-chief at Massachusetts General Hospital (MGH) in Boston and the Juan M. Taveres Professor of Radiology at Harvard Medical School. “One might suggest follow-up scans at six-month intervals; another, more frequent follow-up scans. A third might advocate leaving things entirely alone, and another will say more invasive procedures need to be performed immediately. Under-recommend, and you may be denying the patient the care he or she really needs.”

On the other hand, over-recommend, and you risk subjecting the patient to stress and possible complications for a procedure that wasn’t needed in the first place, Brink says. “There also can be misunderstandings about the verbiage in reports.  And even if there are written guidelines, it isn’t always reasonable or feasible for radiologists to stop to find them or look them up. All of this can affect [the caliber of patient care].”

In 2009, Brink says, a study conducted at MGH revealed a 300% increase in the number of patients for whom follow-up imaging examinations had been recommended over the previous 15 years. A second internal study conducted last year showed that 50% of recommendations for patients in whom lung nodules had been detected via abdominal CT included errors in either under- or overutilization of follow-up CT procedures.

Algorithms for incidentalomas

To address such concerns and trends, a decision was made to devise standard algorithms for application by MGH’s radiologists in recommending a course of action for patients with pulmonary and adrenal nodules, and to incorporate these algorithms into a proprietary decision-support tool. Additional algorithms for handling and reporting on renal and craniovascular incidentalomas, among others, are currently being formulated. (So, too, are standardized diagnostic algorithms; for instance, a grading scale for lacerations of the spleen).

The decision-support tool runs on each of the radiology department’s workstations and is integrated with its speech-recognition software for ease of access and use. Radiologists locate the algorithms by clicking on the appropriate corresponding icon (pulmonary nodule or adrenal nodule). From there, they input into the system information about the nodule’s history, morphology, size, and growth pattern. Recommendations for follow-up are then generated; these, along with the historic, morphologic, and size data, are automatically entered into the radiology report.

Brink says an MGH team chose to introduce algorithms for addressing pulmonary and adrenal nodules, rather than for handling other types of incidentalomas, based on the belief that doing so would be the “most impactful, most do-able move.”  Both algorithms are drawn in part from content found within the American College of Radiology’s series of white papers on incidental findings; the pulmonary nodule algorithm also incorporates Fleischner Society recommendations for the management of small pulmonary nodules.

Future algorithms will take into account ACR principles, but will be derived from other sources where applicable. As an example of the latter, Brink cites an algorithm for determining follow-up protocols for liver lesions identified during MRI examinations of the breast; “the ACR’s principles apply to liver lesions found during dedicated imaging” of that particular organ, and a broader perspective is needed, he explains.

Several strategic steps have helped to foster stakeholder acceptance of the decision-support tool and algorithms. Notably, the latter were designed not only to be consensus-based and modifiable, but also  to reflect input from MGH’s radiology subspecialty chiefs, practicing radiologists, and referring physicians. “If you don’t build a standardized model that everyone trusts and feels comfortable with, you haven’t gained much in the way of value,” Brink says.

Although it is still in the “very early days,” he continues, the standardization initiative already appears to be a success. Adherence to radiology department guidelines for recommendations of follow-up imaging for pulmonary nodules now stands at 65%, up from 50% before the algorithms and decision-support tool made their appearance. In a recent internal study, concordance with the department’s guidelines increased by 96% in the 40% of cases in which the combination was used. Efforts to incent radiologists to use the two existing algorithms, and to leverage new ones as they emerge, are now underway.

Across a multi-site system

Imaging service providers like MGH and UF Shands clearly have much to gain from standardizing image acquisition and reporting protocols. The patient care benefits of radiation dose optimization also are significant and recognized beyond the walls of the radiology department, with additional advantages that bubble to the surface when dose metrics are standardized across health care providers’ systems rather than within individual hospitals alone.

Such is one of the major premises behind the University of California Dose Optimization and Standardization Endeavor (UC DOSE), undertaken by the University of California Health System with funding from the University of California’s Center for Healthcare Quality andInnovation.

Led by Rebecca Smith-Bindman, MD, professor of radiology and biomedical imaging, University of California, San Francisco (UC-SF), the project is aimed at standardizing and optimizing CT protocols across all five of the system’s academic medical centers: UC Davis Medical Center,UC Irvine Medical Center, UCLA Medical Center (Los Angeles), UC San Diego Medical Center, and UC San Francisco Medical Center.

Compliance with California State Bill 1237, which took effect on July 1, 2012 and requires the reporting of CT radiation doses in patients’ radiology reports, ranked among the health system’s rationales for moving UC DOSE forward. The law, however, was not the sole impetus for doing so, asserts J. Anthony Seibert, PhD, professor of radiology and assistant vice chair of radiology informatics, University of California, Davis (UC-Davis), who serves as that insitution’s co-principal investigator for the project at UC-Davis.

Says Seibert: “Sensationalized, high-profile incidents involving excessive radiation exposure—like the one at Cedars-Sinai Medical Center in Los Angeles in 2009—brought the issue of safety to the forefront. But it was also clear to us that standardization and optimization could break down barriers between our institutions. CT doses by protocol and indication are highly variable, both within and across institutions. When protocols are standardized, multiple hospitals within a system can be on the same page in imaging. Cross-system imaging services—for example, late-night reads for one institution by another—can be handled consistently, and care can be delivered at a lower cost.”

Under the project umbrella, a collaborative working group of radiologists, physicists, and CT technologists from all hospitals within the system authored a guidance document on dose reporting, and dose reporting procedures were automated via the implementation of a packaged software solution. Infrastructure (dose reporting software and database) and methods of capturing CT dose metric information—CTDIvol, dose-length product (DLP) and other dose-related indicators—for each type of CT examination across all UC medical centers were standardized and entered into a master database.

Additionally, CT acquisition protocols were optimized to achieve lower dose metric values while still providing acceptable image information and image quality. The latter was achieved by calling, for example, for CT tube current modulation, the application of iterative reconstruction algorithms, the elimination of unnecessary image acquisitions (like pre- and post contrast as opposed to one or the other) or the use of multi-phasic studies with one or more fewer phases.

“From the database, the exam-specific CT dose metric distributions provide average and percentile values, which are used to set local diagnostic reference levels and to identify outlier exams,” Seibert explains. He points out that such cross-hospital standardization paves the way for inter-institutional comparisons. These comparisons, in turn, bring to light opportunities for improvement that involve modifying and optimizing CT acquisition protocols to achieve low radiation dose without sacrificing the image quality deemed necessary for proper diagnosis. Deviations from the standards are reviewed, with areas of improvement sought in cases where they are deemed unjustifiable.

Getting buy-in

Concerted efforts were made to get radiologists on board with the project, as well as to ease implementation and encourage compliance. “Soliciting their input at every stage was and is crucial,” Seibert says. “Medical physicists understand what is being administered to patients, but radiologists’ involvement is critical because they are the ones who will be reading the exams. They need to see that their perspective is important.”

A system-wide meeting held last year offered educational sessions on dose reduction, along with opportunities for attendees to upload their protocols and benchmark them against those shared by others. Earlier this year, Smith-Bindman organized a two-day retreat to bring together radiology decision-makers from all UC medical centers. The goal of the meeting was to arrive at a consensus concerning the most common ways to image chest, abdomen/pelvis, and head, and to discuss low-dose protocols for lung and colon screening.

To spark discussions and encourage participation, radiologists from the various sites were asked to share CT images from their current clinical practice. Overall goals were discussed as a group, with additional breakout sessions focusing on neurologic, chest, and body imaging as needed to reach consensus. Both events helped to foster trust by allowing participants to see the data showing variation in radiation doses and then discuss low-dose protocols.

“Sharing is a powerful motivator (for compliance),” states John Boone, PhD, FAAPM, FSBI, FACR, professor of radiology and biomedical imaging, vice chair of radiology research, and co-principal UC-DOSE project investigator, UC-Davis. “It’s an entirely different scenario when you find out that your protocol has several times the dosage of someone else’s. You think that maybe your personal preference isn’t optimal, after all. What we’ve found is that you can discuss metrics and the whole dosing issue on the phone until the cows come home, but unless it is also done face-to-face, things don’t stick as well as they should.”

Moreover, a meeting of various radiology section chiefs from within the University of California Health System and principal investigators from each of its five sites to discuss dose metrics and the results of the project to date was held this past April. A follow-up meeting is scheduled for October of 2014. A virtual symposium, “The UCSF Symposium on Radiation Safety and Computed Tomography,” is available to radiologists, as well as to physicists, CT technicians, and the general public, at

Next up for UC DOSE participants is the standardization of CT scanning protocols, a task Siebert and Boone deem challenging because of the variety of scanners deployed across the system as well as because of variances in procedure nomenclature. “What is called a ‘head scan’ at UC-Davis may be called a ‘routine brain scan’ at one of our other hospitals,” Seibert notes. “There are different doses for different nomenclatures. Standardizing here—and matching nomenclatures with the intent of a protocol—will result in much better comparisons of procedures, too.”

Anecdotal evidence points squarely to system-wide radiation dose reduction, without “any untoward loss of image quality” and with a higher standard of safety for patients, Siebert and Boone say. Feedback from radiologists indicates that the caliber of CT images produced is more than appropriate for their needs. Identification of trends—for example, variations in DLP levels—has helped to reduce dosing discrepancies.

“We’ve sliced into the pie,” Seibert concludes. “Maybe it’s a small slice—but it is a very important one for the safety and quality of imaging going forward.”

Anesthesiology News – Intervention Reduces Inappropriate Pre-Op Chest X-Rays in Low-Risk Patients

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Policy & Management
Intervention Reduces Inappropriate Pre-Op Chest X-Rays in Low-Risk Patients

New Orleans—Chest x-rays often are included in routine preoperative testing for patients undergoing low-risk elective surgery but are infrequently indicated. An educational intervention successfully lowered the frequency with which this “inappropriate” test is ordered, and in so doing helped decrease the utilization rates of several other types of preoperative testing as well.

“Like most institutions, we were looking at costs and recognized we might not be operating as efficiently as possible,” said Jonathan P. Wanderer, MD, assistant professor of anesthesiology at Vanderbilt University, Nashville, Tenn. “As part of that, we’ve been implementing changes when medical practice suggests we should be doing things differently than we currently are. And one area where that’s clear is chest x-rays, which used to be part and parcel of the preoperative workup, but from a screening standpoint don’t have that much value.”


An electronic learning module was created that specified indications for preoperative chest x-rays; all surgical providers were required to complete the module during August 2012. The researchers then identified and analyzed preoperative testing orders between February 2009 and March 2014, including chest x-ray, electrocardiogram (EKG), basic metabolic panel (BMP), packed cell volume (PVC), platelets, comprehensive metabolic panel, complete blood count (CBC), partial thromboplastin time/prothrombin time (PTT/PT), type and screen, urinalysis and “other labs.” The procedures were then stratified according to American Society of Anesthesiologists (ASA) physical status and surgical risk classifications.

In all, 43,320 anesthetic records were identified before the intervention date, compared with 24,013 after. The rate of requested chest x-rays fell from 33% to 20% (P<0.001). More telling was the fact that during the last six months of data, chest x-rays were requested in only 16% of surgical cases. In the subpopulation of low-risk patients (ASA physical status 1) undergoing low-risk surgery, chest x-ray rates fell from 8% to 2% (P<0.001).

“Subsequent analysis revealed that there were a handful of clinicians who were responsible for almost all the remaining orders,” Dr. Wanderer told Anesthesiology News. “So we’ve been working with them directly, and have effectively dropped the rate even further. So I think we’re now down to the point where we’re ordering them when there’s an acute disease process or surgical procedure where imaging will be helpful.”

Perhaps not surprisingly, EKG, PCV, BMP, PTT/PT, comprehensive metabolic panel, CBC, urinalysis and platelets all showed statistically significant reductions in relative frequencies after the intervention date. Interestingly, type and screens and “other labs” showed statistically significant increases in relative frequencies after the intervention date.

Dr. Wanderer, who is reporting his findings here at the ASA’s 2014 annual meeting (abstract A1140), had only good things to report about the program’s success, which he said demonstrates that changing physician behavior may not be as difficult as some believe. “Some of our practices get backed into our routine procedures and aren’t really second-guessed,” he said. “We learned that some of the check boxes that were being selected during the preoperative workup weren’t an intentional decision by the surgeon, but were almost filled out by default.”

And because these practice patterns are certainly not limited to Vanderbilt, employing similar steps may help other institutions achieve the same benefits. “We’re now taking a closer look at our rationale for ordering EKGs, another area where we found that we could change our practice,” he added. “We’ve again ended up having conversations with our colleagues and convinced them that we needed a reason to order the test rather than just doing it routinely. And that has resulted in practice changes by merely asking the question: If we do this test, what value are we likely to get from it?”

Charles B. Watson, MD, emeritus chair of anesthesia and deputy surgeon-in-chief at Bridgeport Hospital in Bridgeport, Conn., explained that because of the low incidence of positive findings from age-related or routine chest x-rays, his institution does not perform routine chest x-rays unless the patient has known active disease or new findings suggestive of pulmonary pathology. “The ASA has published guidelines on preoperative testing since the early 2000s and not identified routine testing of healthy individuals as useful [Anesthesiology 2012;116:522-538],” he said.

As Dr. Watson explained, educating medical practitioners on the benefits of avoiding routine chest x-rays can sometimes take years, as it did at his institution. “Information was circulated by email, policy documents to offices and physicians, and in meetings/surgical conferences over the years,” he said. “Now, our staff rarely order chest films, and only with positive clinical findings. The surgical motivation for screening patients for active symptoms of pulmonary disease is the understanding that last-minute chest films will likely delay their procedures.”

—Michael Vlessides

Stress tests with imaging spike, with 30% of dubious value | Cardiovascular Business

Stress tests with imaging spike, with 30% of dubious value

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Use of cardiac stress tests with imaging in patients without a diagnosis of coronary heart disease surged in the U.S. over an 18-year span, according to a study published in the Oct. 7 issue of the Annals of Internal Medicine . Almost one in three of those tests was ruled as rarely appropriate.

Many studies that assessed trends over time in cardiac stress test use relied on Medicare data, and analyses designed to spot disparities focused on gender rather than race or ethnicity. To broaden the scope, Joseph A. Lapado, MD, of New York University Langone Medical Center in New York City, and colleagues used two national databases: the National Ambulatory Medical Survey and the National Medical Care Survey.

For their study, they looked at data from visits between 1993 and 2010 to office-based physicians and hospital-based outpatient clinics by patients who did not have a diagnosis of coronary heart disease. Within those visits, they identified if a cardiac stress test was performed or ordered.

They also assessed the appropriateness of the test, based on criteria established by various medical societies. They defined a test as rarely appropriate if the patient had no chest pain or angina as a reason for the visit or had ischemic equivalents.

Lapado et al found that the average annual rate of visits that led to a cardiac stress test being done or referred grew from 28 per 10,000 visits in 1993-1995 to 45 per 10,000 visits in 2008-2010. They saw no trend toward more frequent testing after adjusting for patient characteristics, risk factors and provider characteristics.

Cardiac stress tests with imaging commanded an increasing proportion of all stress tests over time. In 1993-1995, 59 percent of all tests used imaging. That grew to 87 percent in 2008-2010.

They determined that at least 30 percent of cardiac stress tests with imaging and 14 percent of stress tests without imaging were rarely appropriate, for a cost of $507.1 million ($494 attributed to tests with imaging, 2013 dollars). In addition, the imaging tests exposed patients to an estimated 10.2 million mSv of unnecessary radiation a year, and potentially 491 cases of future cancers.

The upward trend in cardiac stress test use carried through all races and ethnicities, although test rates were lower in Hispanics than other groups.

“[W]e provide novel evidence that national growth in cardiac stress test use can largely be explained by changes in population demographics, clinical risk factors, and provider characteristics rather than changes in physician ordering behavior,” they wrote. “In contrast to overall growth, the brisk increase in the use of imaging in cardiac stress tests was largely unexplained by these factors, and a substantial portion was for patients in whom imaging is rarely appropriate.”

Their findings suggest that at least in the case of cardiac stress tests, physician decision making is not contributing to health disparities. “However, reducing disparities in the burden of cardiovascular disease remains an important concern.”

More appropriate use of cardiac stress testing with imaging could reduce health costs


More appropriate use of cardiac stress testing with imaging could reduce health costs

October 8th, 2014 in Cardiology / 

In a new study recently published in the Annals of Internal Medicine, researchers at NYU Langone Medical Center concluded that overuse of cardiac stress testing with imaging has led to rising healthcare costs and unnecessary radiation exposure to patients.

In what is believed to be the first comprehensive examination of trends in cardiac stress testing utilizing imaging, researchers also showed that there are no significant racial or ethnic health disparities in its use. They also made national estimates of the cost of unnecessary cardiac stress testing with imaging and the health burden of this testing, in terms of cancer risk due to .

Cardiac stress testing, particularly with imaging, has been the focus of debate about rising , inappropriate use, and patient safety in the context of radiation exposure. Joseph Ladapo, MD, PhD, assistant professor in the Departments of Medicine and Population Health at NYU Langone, and the lead author of the study, and colleagues wanted to determine whether U.S. trends in cardiac stress testing with imaging may be attributable to population shifts in demographics, risk factors, and provider characteristics, and to evaluate whether racial/ethnic disparities exist in physician decision making.

They designed their study utilizing data from the National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) from 1993 to 2010. Patients chosen for the study were adults without  who were referred for cardiac stress tests.

Between 1993 to 1995 and 2008 to 2010, the annual number of ambulatory visits in the U.S. in which a cardiac stress test was ordered or performed increased by more than 50%. Cardiac stress tests with imaging comprised a growing portion of all of these tests—increasing from 59% in 1993 to 1995 to 87% in 2008 to 2010. At least 34.6%—or one million tests—were probably inappropriate, the researchers concluded, with associated annual costs and harms of $501 million and 491 future cases of cancer.

The authors also concluded that there was no evidence of a lower likelihood of black patients receiving a cardiac stress test with imaging (odds ratio, 0.91 [95% CI, 0.69 to 1.21]) than their white counterparts—although some modest evidence of disparity in Hispanic patients was found (odds ratio, 0.75 [CI, 0.55 to 1.02]).

The investigators concluded that the national growth in cardiac stress testing can be attributed largely to population and provider characteristics—but the use of imaging cannot. Physician decision making about cardiac stress testing also does not result in racial/ethnic disparities in cardiovascular disease.

“Cardiac stress testing is an important clinical tool,” says Dr. Ladapo, “but we are over using imaging for reasons unrelated to clinical need. This is causing preventable harm and increasing healthcare costs.

“Reducing unnecessary testing also will concomitantly reduce the incidence of radiation related cancer,” he adds. “We estimate that about 500 people get cancer each year in the US from radiation received during a cardiac stress test when, in fact, they most probably didn’t need any radiological imaging in the first place. While this number might seem relatively small, we must remember that ‘first, do no harm’ is one of the guiding principles in medicine.”

So what can be done to reduce unnecessary cardiac stress testing with imaging? “More efforts, such as clinical decision support, are needed to reduce unnecessary cardiac stress testing,” Dr. Ladapo concludes, suggesting greater use of stress testing without radiological imaging, such as regular exercise treadmill tests or stress testing with ultrasound imaging as opposed to CT imaging.

As to the reason why certain racial and ethnic minorities have poorer rates of treatment for cardiovascular disease and generally have poorer cardiovascular health outcomes compared to white patients, Dr. Ladapo concludes that no one has really explored whether there could be disparities in cardiac stress testing, which is a mainstay of diagnosing patients with heart disease in this country. “If we know that one minority group has a higher incidence of poorer outcomes from heart disease, perhaps we need to examine if they would benefit from more appropriate use of  testing,” he offers. “Perhaps one contributing reason they have poorer outcomes is because we are not testing them appropriately.”

Provided by New York University School of Medicine

“More appropriate use of cardiac stress testing with imaging could reduce health costs.” October 8th, 2014.

2014 Patient-centric Imaging Awards | Health Imaging

Radiology Order Entry Clinical Decision Support

Mount Sinai Medical Center, New York City


Radiology orders on inpatients are entered through our EHR. Previously, providers could enter the clinical indication from a structured list or via free text, but there was a desire for clinical decision support at the time of order entry to diminish inappropriate utilization of radiology services.


We deployed a radiology order entry clinical decision support system, targeted at CT and MRI, to implement ACR appropriateness guidelines within our EHR environment. A structured list of “clinical Indications” provided by the decision support system replaced our homegrown list. Providers were presented with this list.

Implementing such a program has several steps.  We are midway through the overall process. The first part of the process involved change management principles.  Along with our EHR team, we educated our provider staff to changes in the Radiology Ordering interface that were needed to implement this system.  We made some modifications to our user interface to address initial concerns.

For nine months, we ran the system in the background—that is the system provided an appropriateness score of 1-9, 9 being the strongest indication of an exam being appropriate. This was a data collection phase to understand the ordering practices and patterns of our providers.  We did not show the providers the decision support scores during that phase.


We learned that on a weekly basis, approximately 10 percent the exams ordered received a low score between 1-3. Just over 2 months ago, we turned on display of the decision support score, showing providers the score when it is between 1-4 and suggesting alternative exams through the automated interface. We are just beginning to analyze the data to look for change in ordering patterns.

We have anecdotal comments that this has been helpful. After 4 to 6 months, we will analyze the data to determine if there is a change in overall performance

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