Journal of the American College of Radiology

Health Care Legislation: A Cautionary Tale of Unintended Consequences

James H. Thrall — 2010-03-01

The consequences of perturbing large, complex socioeconomic systems are not readily predictable. Currently, Congress and the Obama Administration are engaged in making decisions that affect the nation's health care system, which encompasses one-sixth of the entire US economy. As the nation hurtles forward, dodging toward and away from health reform, it is interesting to look back at prior health reform efforts for lessons learned and to use those insights to also look forward in time to try to predict areas that may be at risk.

Between a Rock and a Hard Place…

Bruce J. Hillman — 2010-03-01

When judging a theory, I ask myself whether, if I were God, I would have arranged the world in such a way.—Albert Einstein In his article on the instability of radiologists' professional services agreements with hospitals in this issue of JACR, Larry Muroff, MD, asks and answers a rhetorical question about why hospitals are canceling contracts: “Why is this happening? The simple answer is, ‘Because it can.'” The article is an excellent discussion of what is becoming a frighteningly frequent occurrence affecting many of our colleagues. The author explains the roots of the problem and steps practices can take to minimize the chances that their hospitals will seek to find alternative sources for radiology services.

Appropriateness Criteria and Patient Expectations

Paul A. Larson — 2010-03-01

The ACR began the development of the first version of its Appropriateness Criteria® (AC) in 1993. The stated goal of the AC is “to assist radiologists and referring physicians in making appropriate decisions for given patient clinical conditions” []. As of the October 2008 release, the AC addressed 159 clinical conditions with more than 800 variants. With ever increasing emphasis on the cost of medical care and the contribution of radiologic procedures, especially those in diagnostic imaging, to that cost, the AC continue to grow in importance. The ACR promotes appropriate utilization as a keystone in its strategy to control imaging costs and reform health care delivery.

Rodney Dangerfield, MD, DABR

Paul H. Ellenbogen — 2010-03-01

I get no respect. The way my luck is running, if I was a politician I would be honest.With my old man I got no respect. I asked him, how can I get my kite in the air? He told me to run off a cliff.—Rodney Dangerfield

Extracardiac and Extracolonic Findings: Extra Important

Ezequiel Silva — 2010-03-01

New Current Procedural Terminology® (CPT®) codes to describe coronary CT angiography (CCTA) and CT colonography (CTC) went into effect on January 1, 2010. The reporting requirements for these category I codes are similar to the category III codes they replace. Specifically, physicians providing these services are required to comment on extracardiac and extracolonic findings, collectively called ECFs in this column. Because these studies are targeted to diseases of the heart and colon, it is common for cardiologists, gastroenterologists, and other nonradiology specialists to interpret their specialties' organs without radiologists. However, such specialists, who lack training or experience interpreting ECFs, may rely on radiologists to interpret the rest of the studies. Another variant is for radiologists to provide complete interpretations of the studies while specialists provide “overreads” of their specialties' organs. Arrangements involving such split interpretations are common and may be necessary for the delivery of optimum care. The exact models for these split-interpretation contractual arrangements are beyond the scope of this column, and legal counsel should be sought in arranging them. However, I will discuss the clinical relevance of ECFs and the rules that govern their reporting. Important federal regulatory and compliance standards are highlighted that may affect arrangements in which split interpretations are used.

Responding to an Accusation of Malpractice

Richard B. Gunderman — 2010-03-01

In May 2006, a Florida woman found her husband, a physician, hanging from a nylon rope in their bedroom closet, a suicide. Earlier in the day, the physician had listened in a courtroom as a jury pronounced its verdict, finding him liable in a malpractice lawsuit alleging that he had failed to remove a sponge at the conclusion of a surgical procedure and that the presence of the foreign body subsequently caused the plaintiff, a former patient, infection and pain. According to the physician's wife, her husband was distraught at the prospect of paying three-quarters of the $1 million verdict—the proportion that exceeded his insurance limits—out of his own pocket. Yet financial implications are often only the tip of the iceberg in terms of the distress that such suits inflict on physicians.

Why Radiologists Lose Their Hospital Contracts: Is Your Contract Secure?

Lawrence R. Muroff — 2010-03-01

Previously, a hospital contract meant tenure for the incumbent group of radiologists; however, those days are long gone. Exclusive contracts have morphed into exclusive contracts with carve-outs. Turf erosion has become a fact of life for radiology practices. Now radiologists are losing their hospital contracts in record numbers. Group size, though helpful for a variety of reasons, does not ensure that a practice will be secure in its hospital setting. The reasons that groups lose their hospital contracts are varied, and in this paper, the author discusses the most common ones. Suggestions to help practices avoid this unfortunate fate are presented.

Trends in PET Scanner Ownership and Leasing by Nonradiologist Physicians

Rajan Agarwal, David C. Levin, Laurence Parker, Vijay M. Rao — 2010-03-01

Purpose: The aim of this study was to examine growth trends in ownership or leasing of private-office PET scanners by nonradiologist physicians.Materials and Methods: The Medicare Part B Physician/Supplier Procedure Summary Master Files for 2002 through 2007 were used to collect the following data for each PET-related Current Procedural Terminology® code: 1) annual procedure volume, 2) places of service for the procedures, and 3) specialties of the physicians filing the claims. To determine ownership or leasing, only technical and global claims that occurred in the nonhospital, private-office setting were included in the study. Professional component–only claims were not included. Procedure volume and growth trends were compared between radiologists and other specialties.Results: Between 2002 and 2007, radiologist-owned Medicare PET scans increased by 259%, whereas nonradiologist-owned or nonradiologist-leased scans grew by 737%. Five specialty groups accounted for 95% of all nonradiologist PET volume in 2007: internal medicine subspecialties (28,324 studies in 2007), medical oncology (14,320 studies), cardiology (13,724 studies), radiation oncology (9,563 studies), and primary care (2,398 studies). In 2002, of all Medicare PET examinations performed on units owned or leased by physicians, the share for nonradiologists was 13%; their share rose to 24% in 2007.Conclusion: Although a large percentage of PET scans in private offices are done by radiologists, the growth rate among nonradiologists was far higher between 2002 and 2007 (259% for the former, 737% for the latter). The disproportionately rapid growth of PET scans performed on units owned by nonradiologists raises concern about self-referral at a time when policymakers are struggling to contain costs and reduce radiation exposure.

Analysis of Appropriateness of Outpatient CT and MRI Referred From Primary Care Clinics at an Academic Medical Center: How Critical Is the Need for Improved Decision Support?

Bruce E. Lehnert, Robert L. Bree — 2010-03-01

Purpose: The aim of this study was to retrospectively analyze a large group of CT and MRI examinations for appropriateness using evidence-based guidelines.Methods: The authors reviewed medical records from 459 elective outpatient CT and MR examinations from primary care physicians. Evidence-based appropriateness criteria from a radiology benefit management company were used to determine if the examination would have met criteria for approval. Submitted clinical history at the time of interpretation and clinic notes and laboratory results preceding the date of the imaging study were examined to simulate a real-time consultation with the referring provider. The radiology reports and subsequent clinic visits were analyzed for outcomes.Results: Of the 459 examinations reviewed, 284 (62%) were CT and 175 (38%) were MRI. Three hundred forty-one (74%) were considered appropriate, and 118 (26%) were not considered appropriate. Examples of inappropriate examinations included brain CT for chronic headache, lumbar spine MR for acute back pain, knee or shoulder MRI in patients with osteoarthritis, and CT for hematuria during a urinary tract infection. Fifty-eight percent of the appropriate studies had positive results and affected subsequent management, whereas only 24% of inappropriate studies had positive results and affected management.Conclusion: A high percentage of examinations not meeting appropriateness criteria and subsequently yielding negative results suggests a need for tools to help primary care physicians improve the quality of their imaging decision requests. In the current environment, which stresses cost containment and comparative effectiveness, traditional radiology benefit management tools are being challenged by clinical decision support, with an emphasis on provider education coupled with electronic order entry systems.

Augmenting the Impact of Technology Adoption With Financial Incentive to Improve Radiology Report Signature Times

2010-03-01

Purpose: Radiology report signature time (ST) can be a substantial component of total report turnaround time. Poor turnaround time resulting from lengthy ST can adversely affect patient care. The combination of technology adoption with financial incentive was evaluated to determine if ST improvement can be augmented and sustained.Methods: This prospective study was performed at a 751-bed, urban, tertiary care adult teaching hospital. Test-site imaging volume approximated 48,000 examinations per month. The radiology department has 100 trainees and 124 attending radiologists serving multiple institutions. Over a study period of 4 years and 4 months, three interventions focused on radiologist signature performance were implemented: 1) a notification paging application that alerted radiologists when reports were ready for signature, 2) a picture archiving and communications systems (PACS)-integrated speech recognition report generation system, and 3) a departmental financial incentive to reward radiologists semiannually for ST performance. Signature time was compared before and after the interventions. Wilcoxon and linear regression statistical analyses were used to assess the significance of trends.Results: Technology adoption (paging plus speech recognition) reduced median ST from >5 to <1 hour (P < .001) and 80th-percentile ST from >24 to 15 to 18 hours (P < .001). Subsequent addition of a financial incentive further improved 80th-percentile ST to 4 to 8 hours (P < .001). The gains in median and 80th-percentile ST were sustained over the final 31 months of the study period.Conclusions: Technology interventions coupled with financial incentive can result in synergistic and sustainable improvement in radiologist report-signing behavior. The addition of a financial incentive leads to better performance than that achievable through technology alone.

Added Value of Selected Images Embedded Into Radiology Reports to Referring Clinicians

2010-03-01

Purpose: The aim of this study was to evaluate the added utility of embedding images for findings described in radiology text reports to referring clinicians.Methods: Thirty-five cases referred for abdominal CT scans in 2007 and 2008 were included. Referring physicians were asked to view text-only reports, followed by the same reports with pertinent images embedded. For each pair of reports, a questionnaire was administered. A 5-point, Likert-type scale was used to assess if the clinical query was satisfactorily answered by the text-only report. A “yes-or-no” question was used to assess whether the report with images answered the clinical query better; a positive answer to this question generated “yes-or-no” queries to examine whether the report with images helped in making a more confident decision on management, whether it reduced time spent in forming the plan, and whether it altered management. The questionnaire asked whether a radiologist would be contacted with queries on reading the text-only report and the report with images.Results: In 32 of 35 cases, the text-only reports satisfactorily answered the clinical queries. In these 32 cases, the reports with attached images helped in making more confident management decisions and reduced time in planning management. Attached images altered management in 2 cases. Radiologists would have been consulted for clarifications in 21 and 10 cases on reading the text-only reports and the reports with embedded images, respectively.Conclusions: Providing relevant images with reports saves time, increases physicians' confidence in deciding treatment plans, and can alter management.

Supporting the Academic Mission

N. Reed Dunnick — 2010-03-01

The mission of an academic radiology department includes not only high-quality patient care, but also the educating of a broad variety of health care professionals, the conducting of research to advance the field, and volunteering service to the medical center and our professional societies. While funding is available for the research and educational aspects, it is insufficient to cover the actual costs. Furthermore, it is becoming increasingly difficult to make up the deficit by using a portion of the clinical revenues. Development and revenues derived from intellectual property are becoming essential to support the academic mission.

Flying in the Plane You Service: Patient-Centered Radiology

Stephen J. Swensen, C. Daniel Johnson — 2010-03-01

If you were about to undergo a radiologic procedure, what 5 things would you want? The authors propose a construct for patient-centered radiology. Five wishes of a prospective radiology patient are described: 1) the information to choose, 2) the right examination, 3) a safe examination, 4) effective communication of correctly interpreted results, and 5) a fair price. The authors posit that the American practice of radiology would be considerably different if our profession practiced patient-centered radiology.

Outsourcing Off-Hour Imaging Services

Cynthia S. Sherry — 2010-03-01

Ironically, they're the same: my best decision was also my worst decision! About 4 years ago, I decided (along with my 24-person radiology group) to outsource our off-hours ER business offshore. We discussed and analyzed the merits and demerits of this solution to our mounting discontent with night call, and though there was a minor element of internal dissent, the large majority ultimately decided in favor of giving it a try.

Ruminations From a European Chairperson

Johan G. (Hans) Blickman — 2010-03-01

Some time ago in this journal [], I tried to put on paper my experiences in choosing to become a chairman in Europe, after many years as an academic radiologist in the United States. In the intervening 5 years, I have had an interesting experience with a number of twists and turns that might bear relating. The whole experience certainly did not quite go the way I had envisioned, yet there may be things to learn from this contribution to “A View From Abroad.” I will try to share the lessons I learned, while not forgetting the background as to why and how. Even though it is thus a “personal” narrative, in this increasingly international world, perhaps future “crossovers” can take heed, think long and hard before deciding, and then hopefully prosper.

Creating a New Curriculum to Prepare for the 2013 ABR Testing Changes: An Academic Residency Perspective

Brandi T. Nicholson, Michael A. Cohen, Jennifer A. Harvey, Spencer B. Gay — 2010-03-01

In response to the ABR testing changes set to take place in 2013, we formed the 2010 Resident Education Committee. The goal of the committee was to address the impacts these changes would have on our training program. Specifically, we wanted to ensure that our residents are adequately prepared for the “core examination” at 36 months of training, which will test all 11 clinical categories as well as physics and be first taken by the class entering in 2010. Our primary focuses were to maintain the educational ideals of resident training and to incorporate the various interpretations and mandates of the governing bodies.

ACR Membership Benefits to Medical Physicists

James M. Hevezi — 2010-03-01

As a longtime member of the American Association of Physicists in Medicine and the current chair of the ACR Commission on Medical Physics, I would like to offer the following observation: the expertise and perspective that the medical physicist community contributes to the practice of radiology is so valuable to the ACR and the American Roentgen Ray Society (ARRS) that the importance of your participation in its deliberations and work cannot be overstated. The American Association of Physicists in Medicine, the ACR, and the ARRS play important roles in the way our profession develops, how radiology affects the field of medicine, and the impact of outside forces on our specialty.

Frank Hussey Sr

Otha Linton — 2010-03-01

The second generation of radiologists in Chicago, those who started in the 1920s, were a remarkable group of doctors who moved from general practice to the growing specialty qualifications that made their chosen discipline a solid part of Chicago medicine. They opted for radiology without formal residencies and learned by preceptorships and their own experience. One of the long-serving leaders of that generation was Frank L. Hussey Sr, whose career in radiology lasted about 50 years. During most of those years, he was a clinical practicing radiologist; a teacher of residents, medical students, and x-ray technologists; a leader in radiology societies; a close negotiator with hospital administrators; and a smooth contact with local politicians. Many of his learning and practice patterns were accepted by other young doctors seeking careers in radiology.

Erratum

2010-03-01

The article titled, “A Prior Authorization Program of a Radiology Benefits Management Company and How It Has Affected Utilization of Advanced Diagnostic Imaging,” by David C. Levin, MD, Robert L. Bree, MD, Vijay M. Rao, MD, Jean Johnson, MBA, MHA, published in the January issue of JACR (2010;7:33-38).