Faculty Bibliography

PURPOSE/OBJECTIVE:To evaluate whole-lesion 3D-histogram apparent diffusion coefficient (ADC) metrics for assessment of pancreatic malignancy. METHODS:Forty-two pancreatic malignancies (36 pancreatic adenocarcinoma [PDAC], 6 pancreatic neuroendocrine [PanNET]) underwent abdominal magnetic resonance imaging (MRI) with diffusion-weighted imaging before endoscopic ultrasound biopsy or surgical resection. Two radiologists independently placed 3D volumes of interest to derive whole-lesion histogram ADC metrics. Mann-Whitney tests and receiver operating characteristic analyses were used to assess metrics' diagnostic performance for lesion histology, T-stage, N-stage, and grade. RESULTS:), for reader 1 a threshold <1.17 achieved sensitivity 87% and specificity 67%, and for reader 2 a threshold <1.04 achieved sensitivity 87% and specificity 83%. No metric was associated with T-stage (P > .195) or grade (P > .215). CONCLUSION/CONCLUSIONS:outperformed standard mean for lesion histology and nodal status, supporting the role of histogram analysis.

PURPOSE/OBJECTIVE:The aim of this study was to examine changing characteristics of utilization and potential disparities in US emergency department (ED) patients undergoing CT of the abdomen and pelvis (CTAP) for suspected urolithiasis. METHODS:A retrospective study was conducted among all patients from 2006 to 2015 with a primary diagnosis of suspected urolithiasis within the Nationwide Emergency Department Sample, the largest publicly available all-payer ED database in the United States. The annual numbers of ED visits for suspected urolithiasis and associated CTAP examinations per visit were determined. The compound annual growth rate for CTAP was calculated. Using multivariate logistic regression analyses, patient demographics and payer and hospital characteristics were evaluated as potential independent predictors of utilization. RESULTS:Nationwide, the number of ED visits per year for suspected urolithiasis increased from 1,057,119 in 2006 to 1,246,041 in 2014 (relative +17.9%), while the annual use of CTAP increased from 24.6% to 49.4% per visit (relative +100.8%; CAGR +8.0%). Multivariate analysis showed higher CTAP use associated with higher patient household income ZIP code quartile (odds ratio [OR] for wealthiest/poorest, 1.48), private payer (ORs, 1.21 vs Medicare and 1.22 vs Medicaid), Northeast geographic region (ORs, 5.07 vs Midwest, 4.16 vs West, and 1.77 vs South), hospital urban status (OR, 1.42), and nonteaching hospitals (OR, 1.20) (P < .05 for all). CONCLUSIONS:The relative use of CTAP in ED patients presenting with suspected urolithiasis doubled between 2006 and 2014 and showed marked geographic variation. Among ED patients with suspected urolithiasis, CTAP was more frequent in patients from higher household income ZIP codes, with private insurance, in the Northeast, and at urban and nonteaching hospitals.

OBJECTIVE. The objective of this study was to assess clinical practice characteristics of radiologists on the basis of American Board of Radiology (ABR) interventional radiology (IR) certification status. MATERIALS AND METHODS. Medicare-participating radiologists were linked with ABR diplomates using the ABR's public search engine. Radiologists with an interventional radiology/diagnostic radiology (IR/DR) certificate (offered since 2017) were deemed currently IR-certified (n = 2840), and those assigned a vascular and interventional radiology subspecialty certificate (now defunct by the ABR) were deemed previously IR-certified (n = 900). Physician characteristics were obtained from Centers for Medicare & Medicaid Services (CMS) data. RESULTS. Overall, the mean percentage work effort in IR was higher for radiologists currently IR-certified than it was for radiologists who were previously IR-certified (65.9% vs 30.6%). Although 41.2% of currently IR-certified diplomates had more than 90% IR work effort, 35.7% had 50% or less IR work effort. Radiologists with current IR certification versus those with previous IR certification were more likely to be in an academic practice (25.1% vs 8.4%), a larger practice (in a practice with ≥ 100 members, 41.2% vs 22.4%), and earlier career stages (≤ 20 years in practice, 46.5% vs 0.6%). Of the 10 services most commonly billed by currently versus previously IR-certified radiologists, two and zero, respectively, were invasive procedures. Of identified CMS-participating radiologists with more than 50% IR effort, 27.2% (727/2670) were neither previously nor currently IR-certified. CONCLUSION. Although radiologists maintaining IR certification have higher IR work effort than those whose IR certification has lapsed, they are heterogeneous with overall sizable noninvasive diagnostic imaging practices. Approximately one-quarter of radiologists with predominant IR practices have never obtained IR certification. Because current IR/DR maintenance of certification testing exclusively addresses IR practice, attention is warranted to ensure certification is relevant to all IR diplomates.

PURPOSE/OBJECTIVE:We update the prior AUA SOP for MRI of the prostate and summarize the available data about the technique and clinical use of MRI in the diagnosis and management of prostate cancer. This updated SOP provides practical recommendations for MRI use in the screening, diagnosis, staging, treatment, and surveillance of prostate cancer. MATERIALS AND METHODS/METHODS:A panel of clinicians from the AUA and SAR with expertise in the diagnosis and management of prostate cancer evaluated the current published literature on the use and technique MRI for this disease. When adequate studies were available for analysis, recommendations were made on the basis of data and when adequate studies were not available, recommendations were made on the basis of expert consensus. RESULTS:Prostate MRI should be performed according to technical specifications, technique standards, and interpreted according to standard reporting. Data support the use of MRI in men with a previous negative biopsy and ongoing concerns about increased risk of prostate cancer. Sufficient data now also exist to support the recommendation of MRI prior to biopsy for all men, without previous history of biopsy, under consideration for prostate biopsy. There is currently insufficient evidence to recommend MRI for screening, staging or surveillance of prostate cancer. CONCLUSIONS:Utility of prostate MRI in the risk stratification, diagnosis, and treatment pathway of men with prostate cancer is expanding. When a quality prostate MRI is obtained, current evidence now supports its use in men at risk of harboring prostate cancer prior to their first biopsy, as well as in men with a rising PSA following an initial negative standard prostate biopsy procedure.

BACKGROUND AND PURPOSE/OBJECTIVE:Insight into the status of neuroradiology subspecialty certification across the United States could help to understand neuroradiologists' perceived value of subspecialty certification as well as guide efforts to optimize pathways for broader voluntary certification participation. Our aim was to assess board certification characteristics of practicing US neuroradiologists. MATERIALS AND METHODS/METHODS:The American Board of Radiology public search engine was used to link Medicare-participating radiologists with American Board of Radiology diplomates. Among linked diplomates, 4670 neuroradiologists were identified on the basis of 3 criteria: current or prior neuroradiology subspecialty certification or currently >50% clinical work effort in neuroradiology based on work relative value unit-weighted national Medicare claims ("majority-practice neuroradiologists"). Subspecialty certification status was studied in each group, using Centers for Medicare & Medicaid Services data to identify additional physician characteristics. RESULTS:Of 3769 included radiologists ever subspecialty certified, 84.1% are currently subspecialty certified. Of 1777/3769 radiologists ever subspecialty-certified and with lifetime primary certificates (ie, nonmandated Maintenance of Certification), only 66.6% are currently subspecialty certified. Of 3341 included majority-practice neuroradiologists, 73.0% were ever subspecialty certified; of these, 89.1% are currently subspecialty certified. Of 3341 majority-practice neuroradiologists, the fraction currently subspecialty certified was higher for those in academic (81.3%) versus nonacademic (58.2%) practices, larger versus smaller practices (72.1% for those in ≥100 versus 36.1% for <10-member practices), US regions other than the West (64.1%-70.6% versus 56.5%), fewer years in practice (77.5% for 11-20 years versus 31.3% for >50 years), and time-limited (73.5%) versus lifetime (54.9%) primary certificates. CONCLUSIONS:More than one-quarter of majority-practice neuroradiologists never obtained neuroradiology subspecialty certification. Even when initially obtained, that certification is commonly not maintained, particularly by lifetime primary certificate diplomates and those in nonacademic and smaller practices. Further investigation is warranted to better understand neuroradiologists' decisions regarding attaining and maintaining subspecialty certification.

OBJECTIVE. Physicians across specialties have expressed concerns about Maintenance of Certification (MOC) programs of American Board of Medical Specialties member boards, calling for research about MOC acceptance, adoption, and value. The purpose of this study was to characterize diagnostic radiologists' participation in the American Board of Radiology (ABR) MOC program, the framework for its new Online Longitudinal Assessment program. MATERIALS AND METHODS. Practicing U.S. radiologists were identified from the Centers for Medicare & Medicaid Services Physician and Other Supplier Public Use File. Corresponding ABR diplomate certification information was obtained through the ABR public search engine. Focused on diagnostic radiologists (defined as those whose only ABR certificate is in diagnostic radiology), MOC participation rates were calculated across various physician characteristics for those whose participation was mandated by the ABR (time-limited certificates) and for those whose participation was not mandated (lifetime certificates). RESULTS. Among 20,354 included diagnostic radiologists, 11,479 (56.4%) participated in MOC. Participation rates were 99.6% (10,058/10,099) among those whose MOC was ABR mandated and 13.9% (1421/10,225) among those whose participation was not mandated (p < 0.001). The rates of nonmandated participation were higher (all p < 0.001) for academic than for non-academic radiologists (28.0% vs 11.3%), subspecialists than for generalists (17.0% vs 11.5%), and those in larger practice groups (< 10 members, 5.0%; 10-49 members, 12.6%; ≥ 50 members, 20.7%). State-level rates of nonmandated participation varied from 0.0% (South Dakota, Montana) to 32.6% (Virginia) and positively correlated with state population density (r = 0.315). CONCLUSION. Although diagnostic radiologists with time-limited certificates nearly universally participate in MOC, those with lifetime certificates (particularly general radiologists and those in smaller and nonacademic practices) participate infrequently. Low rates of nonmandated participation may reflect diplomate dissatisfaction or negative perceptions about MOC.

OBJECTIVE. Nonphysician providers (NPPs) increasingly perform imaging-guided procedures, but their roles interpreting imaging have received little attention. We characterize diagnostic imaging services rendered by NPPs (i.e., nurse practitioners and physician assistants) in the Medicare population. MATERIALS AND METHODS. Using 1994-2015 Medicare Physician/Supplier Procedure Summary Master Files, we identified all diagnostic imaging services, including those billed by NPPs, and categorized these by modality and body region. Using 2004-2015 Medicare Part B 5% Research Identifiable File Carrier Files, we separately assessed state-level variation in imaging services rendered by NPPs. Total and relative utilization rates were calculated annually. RESULTS. Between 1994 and 2015 nationally, diagnostic imaging services increased from 339,168 to 420,172 per 100,000 Medicare beneficiaries (an increase of 24%). During this same period, diagnostic imaging services rendered by NPPs increased 14,711% (from 36 to 5332 per 100,000 beneficiaries) but still represented only 0.01% and 1.27% of all imaging in 1994 and 2015, respectively. Across all years, radiography and fluoroscopy constituted most of the NPP-billed imaging services and remained constant over time (e.g., 94% of all services billed in 1994 and 2015), representing only 0.01% and 2.1% of all Medicare radiography and fluoroscopy services. However, absolute annual service counts for NPP-billed radiography and fluoroscopy services increased from 10,899 to 1,665,929 services between 1994 and 2015. NPP-billed imaging was most common in South Dakota (7987 services per 100,000 beneficiaries) and Alaska (6842 services per 100,000 beneficiaries) and was least common in Hawaii (231 services per 100,000 beneficiaries) and Pennsylvania (478 services per 100,000 beneficiaries). CONCLUSION. Despite increasing roles of NPPs in health care across the United States, NPPs still rarely interpret diagnostic imaging studies. When they do, it is overwhelmingly radiography and fluoroscopy. Considerable state-to-state variation exists and may relate to local care patterns and scope-of-practice laws.

PURPOSE/OBJECTIVE:To analyze the changes in the work profiles of radiologists and the reporting time after the implementation of professional subspecialization in the radiology department of a Swiss university hospital. METHODS:In a retrospective analysis, the overall number of different radiologic examinations performed in the department of radiology of the largest Swiss university hospital was documented for 2014 and 2016 before and after the implementation of subspecialized reporting (subspecialities: abdominal, musculoskeletal, cardiothoracic, emergency, and pediatric imaging) in May 2015. For six selected radiologists, the number and types of reported examinations as well as the related radiology report turnaround times (RTATs) were analyzed in detail and compared between the two 1-year periods. RESULTS:Overall, there was a significant increase of 10.3% in the total number of examinations performed in the whole department in 2016 compared with 2014. For four of the six radiologists, the range of different types of examinations significantly decreased with the introduction of subspecialized reporting (p < 0.05). Furthermore, there was a significant change in the subset of the ten most commonly reported types of examinations reported by each of the six radiologists. Mean overall RTATs significantly increased for five of the six radiologists (p < 0.05). CONCLUSIONS:Implementation of subspecialized reporting led to a change in the structure and a decrease in the range of different examination types reported by each radiologist. Mean RTAT increased for most radiologists. Subspecialized reporting allows the individual radiologist to focus on a special field of professional competence but can result in longer overall RTAT.

PURPOSE/OBJECTIVE:To assess characteristics of physicians and other providers frequently ordering intravenous pyelography (IVP). METHODS:The 2014 Medicare Referring Provider Utilization for Procedures data set was used to identify providers who ordered more than 10 IVP examinations ("high-ordering providers") in Medicare beneficiaries. The Medicare Provider and Other Supplier Public Use File and Physician Supplier Procedure Summary Master Files were used to obtain physician characteristics and total service counts, respectively. RESULTS:Of 18,344 IVPs performed in 2014 in Medicare fee-for-service beneficiaries, 6,321 (34.5%) were ordered by just 233 high-ordering providers. Of these, 220 (94.4%) were urologists. These urologists represented just 2.4% of all 8,981 Medicare-participating urologists and ordered an average of 27.1 IVPs (maximum 239). Urologists ordering IVPs (versus those not ordering IVPs) were more likely (P < .05) to practice in rural areas (6.4% versus 2.7%), be in practice more than 15 years (87.4% versus 71.2%), and be in practices with 100 members or fewer (71.3% versus 55.5%). They were also less likely (P < .05) to be female (3.2% versus 7.4%) and in academic practices (5.1% versus 10.7%). High-IVP-ordering urologists were more likely to practice in the South (54.1% versus 36.9%) or Midwest (30.0% versus 21.3%) and less likely to practice in the Northeast (5.0% versus 23.1%) or West (10.9% versus 18.6%). CONCLUSION/CONCLUSIONS:Although uncommonly performed, IVPs continue to be used in the Medicare population. Providers most likely to frequently order IVPs were later-career urologists in smaller and rural practices in the South. Targeting education and appropriate use criteria initiatives to high-ordering providers may help optimize utilization.