Journal of the American College of Radiology

Recognition of Exceptional Manuscript Review for 2011

2012-02-01

JACR could not exist without the volunteer efforts of referees to advise the editor-in-chief on the journal's content and how submitted manuscripts could be improved. This year, on the basis of the number and excellence of their reviews during 2011, the journal recognizes the following individuals for exceptional effort in refereeing manuscripts submitted to JACR:

Is Quality Good Enough?

John A. Patti — 2012-02-01

I recently received a letter from an ACR member that began: “Dear Dr. Patti, I read your comments in JACR every month and appreciate what you have to say. I strongly agree with any and all sentiments urging radiologists to rise to the highest level of quality possible. In our rapidly changing world, with rising health care costs and outsourcing potential, we see obvious threats in front of us. However, I'm here to tell you that demanding the best and achieving it is not enough. For the last two years my group was the #1 ranked department in the annual medical staff Press-Ganey surveys. To my knowledge, we have the universal support of the entire medical staff. Despite this highest quality ranking, our group fell under the eye of the administration and was recently unceremoniously discarded after 39 years of staffing.” []

The Garden Party

Bruce J. Hillman — 2012-02-01

But it's all right now, I learned my lesson well. You see, you can't please everyone, so you got to please yourself. —Rick Nelson I am fortunate to receive e-mails from readers commenting on my monthly editorials. Most of them are complimentary. Some even tell me what I left out or how I could have written the piece better (sometimes they are right). Most months, I get at least a couple of these critiques. Every once in a while, I am surprised to get as many as 5 or 6. To me, that qualifies an editorial as a cult classic, since I figure most radiologists are too busy to read, let alone write.

Evidence in Diagnostic Imaging: Going Beyond Accuracy

Martin H. Reed — 2012-02-01

Because of the increasing concern about its excessive and inappropriate use, guidelines have been developed for the appropriate use of diagnostic imaging []. Guidelines for diagnostic imaging are also incorporated into more comprehensive clinical practice guidelines [].

Radiology Advocacy Group

Howard B. Fleishon, Melody Ballesteros, Ted Burnes — 2012-02-01

Radiologists need to arm themselves not only with their voices but with their laptops as well, as ACR continues to fight the onslaught of cuts, attacks, and transgressions against the profession. Over the past 5 years, radiology has been the low-hanging fruit Congress and federal regulators have picked to offset their health care priorities.

Erratum

2012-02-01

In the December Washington Watch column (‘McAllen Revisited’ JACR 2011;8:826), Dr. Pentecost's address was mistakenly listed as Kaiser Permanente rather than Magellan Health. The contact information for Michael J. Pentecost, MD, is: Magellan Health, 6950 Columbia Gateway Drive, Columbia, Maryland 21046; e-mail: pentecost.michael@gmail.com. The error is regretted.

Aspirin and Angioplasty

Michael J. Pentecost — 2012-02-01

Every August for 30 years, the Federal Reserve Bank of Kansas City has convened a meeting in Jackson Hole, Wyoming. Attracting some of the world's best minds in finance and economics, the policy symposium covers topics such as emerging markets, economic growth, and global competiveness.

ACR Appropriateness Criteria® Acute Trauma to the Knee

2012-02-01

There are more than 1 million visits to the ER annually in the United States for acute knee trauma. Many of these are twisting injuries in young patients who can walk and bear weight, and emergent radiography is not required. Several clinical decision rules have been devised that can considerably reduce the number of radiographic studies ordered without missing a clinically significant fracture. Although fractures are seen on only 5% of emergency department knee radiographs, 86% of knee fractures result from blunt trauma. In patients with falls or twisting injuries who have focal tenderness, effusion, or inability to bear weight, radiography should be the first imaging study performed. If radiography shows no fracture, MRI is best for evaluating for a suspected meniscal or ligament tear or patellar dislocation. Patients with knee dislocation should undergo radiography and MRI, as well as fluoroscopic angiography, CT angiography, or MR angiography. The ACR Appropriateness Criteria® are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Impact of Generational Differences on the Future of Radiology: Proceedings of the 11th Annual ACR Forum

2012-02-01

The 2011 ACR Forum focused on the impact of generational differences on the future of radiology, seeking to inform ACR leadership and members on how best to address the influence of the new integrated workforce on the specialty of radiology and on individual practices.

New Pathways to Medicare Coverage for Innovative PET Radiopharmaceuticals: Report of a Medical Imaging & Technology Alliance (MITA) Workshop

2011-12-21

PET and PET/CT have revolutionized the diagnosis, staging, and monitoring of treatment effect or recurrence for a wide range of cancers and shown promise for improving health outcomes for patients with cardiovascular and central nervous system diseases. However, this technology is challenged by insurance coverage policies that hinder patients' access to PET and discourage technologic innovation. Recently, the Medical Imaging & Technology Alliance (MITA), a Washington-based industry association, convened a workshop to consider new pathways for making decisions on Medicare coverage of new PET radiopharmaceuticals and imaging procedures that are currently subject to a national noncoverage decision, or “exclusionary rule.” Stakeholders from the government, medical professional societies, academia, patient groups, and industry gathered to brainstorm alternatives to the national noncoverage decision and evaluate their potential to improve access and enhance innovation. Ultimately, MITA, on behalf of the PET community, expects to use the outcomes of the workshop to propose that the Centers for Medicare and Medicaid Services reconsider this current national noncoverage decision for PET and adopt a new framework for coverage.

Quantitatively and Qualitatively Augmenting Medical Student Knowledge of Oncology and Radiation Oncology: An Update on the Impact of the Oncology Education Initiative

2012-02-01

Purpose: The Oncology Education Initiative was established in 2007 in an effort to advance oncology and radiation oncology education at the undergraduate level. As a continuation of the initiative, the aim of this study was to determine whether these structured didactics would continue to increase overall medical student knowledge about oncologic topics. Methods: Preclerkship and postclerkship tests examining concepts in general oncology, radiation oncology, breast cancer, and prostate cancer were administered. The 21-question, multiple-choice examination was administered at the beginning and end of the radiology clerkship, during which a 1.5-hour didactic session was given by an attending radiation oncologist. Changes in individual question responses, student responses, and overall categorical responses were analyzed. All hypothesis tests were two tailed with a significance level of .05. Results: In the 2009-2010 academic year, 155 third-year and fourth-year students had average examination score improvements from 62% to 68.9% (P < .0001). Every topic (100%) showed improvement in scores, with the largest absolute improvement seen in the radiation oncology category, which increased from 56.5% to 71.8% (P < .0001). As the year proceeded, average examination scores increased among third-year students and decreased among fourth-year students. Conclusions: In the successive years since its inception, the Oncology Education Initiative continues to show a significant improvement in medical students' knowledge of cancer. The initiative has also succeeded in providing radiation oncology education to all graduating medical students at the authors' institution. Dedicated oncology education in the undergraduate medical curriculum provides students with a better understanding of multidisciplinary oncology management.

Practice Analysis: A Basis for Content Validity for American Board of Radiology Examinations in Diagnostic Radiology

2012-02-01

The ABR performs practice analysis every 3 years, according to its strategic plan, in an effort to strengthen the content validity of its qualifying and certifying examinations as well as its maintenance of certification examinations. A nationwide survey of diagnostic radiologists was conducted in July 2010 for the purpose of determining the critically important and frequently performed activities in 12 clinical categories. The survey instrument was distributed electronically to 17,721 members of the ACR, with a unique identification code for each individual. A 5-point scale was established for both frequency and importance variables. The frequency scale ranged from 1 to 5 as follows: 1 = not applicable, 2 = occasionally, 3 = monthly, 4 = weekly, and 5 = daily. The scale for importance also ranged from 1 to 5: 1 = not applicable, 2 = not important, 3 = somewhat important, 4 = important, and 5 = essential. A total of 2,909 diagnostic radiologists (19.32%) participated. Of these, 2,233 (76.76%) indicated that they spent ≥50% of their time in clinical practice. Because of its brevity of the list of the activities, results for the gastrointestinal category are presented in this article. The list of activities weighted according to importance and frequency is presented in this article and, as illustrated, could become the foundation for developing a more detailed blueprint for the gastrointestinal category certifying examinations in diagnostic radiology. Findings on demographic information are also presented.

Adoption and Meaningful Use of Computerized Physician Order Entry With an Integrated Clinical Decision Support System for Radiology: Ten-Year Analysis in an Urban Teaching Hospital

2012-02-01

Purpose: The aim of this study was to assess whether an integrated imaging computerized physician order entry (CPOE) system with embedded decision support for imaging can be accepted clinically. Methods: The study was performed in a health care delivery network with an affiliated academic hospital. After pilot testing and user feedback, a Web-enabled CPOE system with embedded imaging decision support was phased into clinical use between 2000 and 2010 across outpatient, emergency department, and inpatient settings. The primary outcome measure was meaningful use, defined as the proportion of imaging studies performed with orders electronically created (EC) or electronically signed by an authorized provider. The secondary outcome measure was adoption, defined as the proportion of imaging studies that were ordered electronically, irrespective of who entered the order in the CPOE system. Univariate and multivariate regression analyses were performed to estimate trends and the significance of practice settings, examination modality, and body part to outcome measures. Chi-square statistics were used to assess differences across specialties. Results: A total of 4.1 million imaging studies were performed during the study period. From 2000 to 2010, significant increases in meaningful use (for EC studies, from 0.4% to 61.9%; for electronically signed studies, from 0.4% to 92.2%; P < .005) and the adoption of CPOE (from 0.5% to 94.6%, P < .005) were observed. The use of EC studies was greatest in the emergency department and inpatient settings. Meaningful use varied across specialties; surgical subspecialties had the lowest rates of EC studies. Conclusions: Imaging CPOE with embedded decision support integrated into the IT infrastructure of the health care enterprise and clinicians' workflow can be broadly accepted clinically.

Percutaneous Needle vs Surgical Breast Biopsy: Previous Allegations of Overuse of Surgery Are in Error

David C. Levin, Laurence Parker, Gordon F. Schwartz, Vijay M. Rao — 2012-02-01

Purpose: A recent paper in the American Journal of Surgery reported that surgery is used for 30% of breast biopsies, an excessive number. The investigators' stated biopsy volume included Current Procedural Terminology® code 19125 (“excision of breast lesion identified by preoperative placement of radiological marker, open”). However, this code may often be used when a surgeon's primary intention is not biopsy but rather excision of a lesion. Therefore, the reported results may overstate the percentage of biopsies performed as surgical procedures. The aim of this study was to more accurately assess the use of percutaneous core needle biopsy (PNB) compared with surgical biopsy. Methods: The nationwide Medicare Part B databases for 2004 to 2009 were used. Trends in use of codes 19100 (PNB without imaging), 19102 and 19103 (PNB with imaging), 19101 (open biopsy), and the aforementioned 19125 were determined. Results: From 2004 to 2009, the volumes of PNB with imaging (codes 19102 and 19103) increased substantially, while the volume of code 19125 decreased substantially. If one includes all 19125 claims as biopsies, the 2009 frequency of surgical biopsies was 18%. If one considers all 19125 claims as excisions, the frequency of surgical biopsies was 2%. Conclusions: The previously published statement in the American Journal of Surgery that 30% of breast biopsies are done surgically is erroneous. Medicare data indicate that the true surgical breast biopsy figure is somewhere between 2% and 18%. Given that the recommended rate is 10%, it seems that surgeons and radiologists are collaborating well and that surgical breast biopsy is not being overused.

Dramatically Increased Musculoskeletal Ultrasound Utilization From 2000 to 2009, Especially by Podiatrists in Private Offices

2012-02-01

Purpose: Over the past two decades, musculoskeletal (MSK) ultrasound has emerged as an effective means of diagnosing MSK pathologies. However, some insurance providers have expressed concern about increased MSK ultrasound utilization, possibly facilitated by the low cost and ready availability of ultrasound technology. The purpose of this study was to document trends in MSK ultrasound utilization from 2000 to 2009 within the Medicare population. Methods: Source data were obtained from the CMS Physician/Supplier Procedure Summary Master Files from 2000 to 2009, and records were extracted for procedures for extremity nonvascular ultrasound. We analyzed annual volume by provider type using specialties, practice settings, and geographic regions where the studies were performed. Results: In 2000, Medicare reimbursed 56,254 MSK ultrasound studies, which increased to 233,964 in 2009 (+316%). Radiologists performed the largest number of MSK ultrasound studies in 2009, 91,022, an increase from 40,877 in 2000. Podiatrists utilized the next highest number of studies in 2009, 76,332, an increase from 3,920 in 2000. Overall, private office MSK ultrasound procedures increased from 19,372 in 2000 to 158,351 in 2009 (+717%). In 2009, podiatrists performed the largest number of private office procedures (75,544) and accounted for 51.5% of the total private office growth from 2000 to 2009. Radiologist private office procedures totaled 19,894 in 2009, accounting for 9.2% of the total private office MSK ultrasound growth. Conclusions: The MSK ultrasound volume increase among nonradiologists, especially podiatrists, was far higher than that among radiologists from 2000 and 2009, with the highest growth in private offices. These findings raise concern for self-referral.

Moral Hazard: Why Consequences Matter

Douglas Green, Michael F. McNeeley — 2012-02-01

In March 2008, the US Federal Reserve assumed responsibility for nearly $30 billion in toxic assets in the Bear Stearns portfolio, thereby enabling JPMorgan Chase to purchase the brokerage at minimal risk. This extraordinary intervention was intended to prevent a systemic disruption of global financial markets but had the secondary effect of making Bear Stearns investors partially whole. Critics charged that this bailout created an expectation that the government would backstop failing financial firms. As the argument went, the government's implicit guarantee would remove the perception of risk, thereby encouraging bankers to take on more dangerous investments. In response to these criticisms, Treasury Secretary Henry Paulson repeatedly stressed that the government had no such intentions. Indeed, that September, the larger Lehman Brothers firm was allowed to fail.

JACR Journal Club: The University of Iowa Experience

Justin Boatsman, D. Lee Bennett, Jeffrey Meier, David Zander — 2012-02-01

Residency programs are designed to take medical students and turn them into capable, practicing physicians. For most diagnostic radiology residents, that usually means becoming private practice or academic radiologists. The vast majority of didactics are focused on diagnosis. Most programs are proficient at teaching things such as how to work up an adrenal lesion, and the ABR tests residents to make sure they are safe. However, are graduating residents fully prepared to jump out of the nest?

The Safety Attitudes Questionnaire in Radiology: A Cornerstone of a Successful Quality Program

Olayemi M. Ikusika, Laura Joseph, Paul Nagy — 2012-02-01

What are the quality initiatives in your radiology practice this year? Many quality programs in radiology are merely reactive, responding to complaints from hospital administrators and enterprise physicians or even from the dreaded Joint Commission's requests for improvements. Although it is important to be responsive to complaints, it is a failure of leadership not to identify and correct poor quality before your customers detect it. A reactive program is driven by external stimuli to force change. A proactive program creates a vision and environment for change. An effective instrument to help create a vision is the Safety Attitudes Questionnaire (SAQ) [] for radiology. The SAQ is a validated means of measuring safety culture and does several things to help create a proactive quality program. Careful planning needs to accompany and follow the SAQ to make it a meaningful component of your quality program.

Optimizing CT Dose and Image Quality for Radiotherapy Patients

James M. Hevezi, Mahadevappa Mahesh — 2012-02-01

With the successes of CT dose reduction programs such as Image Gently® [] and Image Wisely™ [], many organizations have signed on to these programs, and CT protocols across the country have been adjusted to match CT dose to the image quality necessary for a given diagnostic examination. Most of the protocols call for lower doses compared with the technique in use previously to scan patients, again on the basis of obtaining sufficient image quality to allow a diagnosis to be made. With the increased media attention to CT protocol errors and misadministrations using high-dose CT techniques and the increased frequency of physicians' ordering CT studies to obtain diagnoses, there has been a plethora of articles suggesting CT dose reduction strategies in the recent literature [].

John F. Roach

Otha Linton — 2012-02-01

In the 1960s, John F. Roach, professor and chairman of radiology at the Albany Medical College, future president of the American Board of Radiology (ABR), and a member of the American Board of Medical Specialties (ABMS), found himself in the dilemma to accept an American Board of Nuclear Medicine and also preserve nuclear imaging as diagnostic radiology.