Faculty Bibliography

RATIONALE AND OBJECTIVES/OBJECTIVE:The present study aims to assess associations of Medicare beneficiary screening mammography rates with local mammography facility and radiologist availability. MATERIALS AND METHODS/METHODS:Mammography screening rates for Medicare fee-for-service beneficiaries were obtained for US counties using the County Health Rankings data set. County-level certified mammography facility counts were obtained from the United States Food and Drug Administration. County-level mammogram-interpreting radiologist and breast imaging subspecialist counts were determined using Centers for Medicare & Medicaid Services fee-for-service claims files. Spearman correlations and multivariable linear regressions were performed using counties' facility and radiologist counts, as well as counts normalized to counties' Medicare fee-for-service beneficiary volume and land area. RESULTS:Across 3035 included counties, average screening mammography rates were 60.5% ± 8.2% (range 26%-88%). Correlations between county-level screening rates and total mammography facilities, facilities per 100,000 square mile county area, total mammography-interpreting radiologists, and mammography-interpreting radiologists per 100,000 county-level Medicare beneficiaries were all weak (r = 0.22-0.26). Correlations between county-level screening rates and mammography rates per 100,000 Medicare beneficiaries, total breast imaging subspecialist radiologists, and breast imaging subspecialist radiologists per 100,000 Medicare beneficiaries were all minimal (r = 0.06-0.16). Multivariable analyses overall demonstrated radiologist supply to have a stronger independent effect than facility supply, although effect sizes remained weak for both. CONCLUSION/CONCLUSIONS:Mammography facility and radiologist supply-side factors are only weakly associated with county-level Medicare beneficiary screening mammography rates, and as such, screening mammography may differ from many other health-care services. Although efforts to enhance facility and radiologist supply may be helpful, initiatives to improve screening mammography rates should focus more on demand-side factors, such as patient education and primary care physician education and access.

PURPOSE/OBJECTIVE:To assess changing utilization of pre-biopsy prostate MRI in Medicare beneficiaries. MATERIALS AND METHODS/METHODS:Men undergoing prostate biopsy were identified in 5% Medicare Research Identifiable Files from October 2010 through September 2015. Rates of pre-biopsy prostate MRI (any pelvic MRI ≤6 months before biopsy with a prostate indication diagnosis code) were assessed. Temporal changes and variation by geography and among populations were determined. RESULTS:In male Medicare beneficiaries, pre-biopsy MRI utilization rates increased from 0.1% in 2010 to 0.7% in 2011, 1.2% in 2012, 2.9% in 2013, 4.7% in 2014, and 10.3% in 2015. In 2015, pre-biopsy prostate MRI rates varied significantly by patient age (5.7% for >80 years vs. 8.4%-9.3% for other age ranges, p=0.040), race (5.8% in blacks vs. 10.1% in whites, p=0.009), and geographic region (from 6.3% in the Midwest to 12.5% in the Northeast; p<0.001). Rates were highest in Wyoming (25.0%), New York (23.7%), and Minnesota (20.5%), but <1% in ten states. CONCLUSION/CONCLUSIONS:Historic Medicare claims provide novel insights into dramatically increasing adoption of MRI prior to prostate biopsy. Following earlier minimal usage, utilization increased sharply beginning in 2013, exceeding 10% in 2015. However, substantial racial and geographic variation in adoption exists. Continued educational, research, and policy efforts are warranted to optimize the role of pre-biopsy MRI and minimize sociodemographic and geographic disparities.

PURPOSE/OBJECTIVE:The aim of this study was to assess radiologists' performance on Medicare quality measures and identify physician characteristics potentially influencing such scores. METHODS:Medicare quality scores reported by US radiologists in 2015 were obtained from CMS. Associations were explored with publicly available physician characteristic data. RESULTS:Overall, 15,045 radiologists reported 40,427 Medicare quality scores encompassing 25 claims measures, 18 registry measures, and 2 qualified clinical data registry (QCDR) measures. Claims measures included reporting fluoroscopic times (n = 10,152; mean score, 80.3 ± 27.6), carotid ultrasound stenosis (n = 8,940; mean score, 86.8 ± 20.6), inappropriate mammography use of "probably benign" (n = 8,083; mean score, 0.4 ± 3.3), mammography reminders (n = 7,229; mean score, 86.6 ± 29.0), bone scintigraphy correlation (n = 2,712; mean score, 76.0 ± 27.0), and line-related infection prevention (n = 2,226; mean score, 83.3 ± 27.4). Registry measures were reported by ≤17 radiologists. The two QCDR measures were dose index registry participation (n = 246; mean score, 99.5 ± 1.4) and mammography recall rate (n = 77; mean score, 9.0 ± 5.6). Higher scores were observed for radiologists in larger practices (strongest independent predictor), in subspecialized practices, in academic practices, in the South and West, and with fewer years in practice. The fluoroscopic exposure times measure had the best performance scores by musculoskeletal and interventional radiologists, carotid Doppler measure by abdominal radiologists, mammography measures by breast radiologists, bone scintigraphy measure by musculoskeletal and nuclear medicine radiologists, and line infection measure by interventionalists. The dose registry participation QCDR measure had near perfect performance across generalists and subspecialists. CONCLUSIONS:Current Medicare performance metrics favor radiologists in larger practices and subspecialized radiologists, possibly reflecting support infrastructures and the narrow focus of most metrics, respectively. These findings may assist targeted data-driven reporting by radiologists and guide efforts to refine existing and develop new metrics.

Imaging is critically important for the diagnosis, staging, and management of men with high-risk prostate cancer. Conventional imaging modalities, including computed tomography and radionuclide bone scan have been employed for local and metastatic staging, but their performance has generally been poor. Sodium fluoride positron emission tomography is recommended when there is high suspicion for bone metastases despite a negative or indeterminate bone scan. Magnetic resonance imaging has advantages in local staging but its value depends on the extent of disease. Whole body positron emission tomography/magnetic resonance imaging could provide both local and distant staging although the technology is not yet widely disseminated. None of the existing positron emission tomography agents are recommended in practice guidelines, however, among them, prostate specific membrane antigen-based tracers seem to hold the most promise based on sensitivity and specificity.

PURPOSE/OBJECTIVE:To study opioid prescribing behavior of US interventional radiologists (IRs). METHODS:Using Medicare Physician and Other Supplier Public Use File claims, we identified 2,133 radiologists whose practice in 2015 comprised predominantly interventional radiology. Cross-linking the Medicare Part D Prescriber File, their opioid prescription writing behavior was characterized. RESULTS:Most (52.2%) IRs wrote 10 or fewer prescriptions total for Medicare beneficiaries. Of the 47.8% who wrote >10 prescriptions, 87.4% prescribed an opioid, most commonly hydrocodone with acetaminophen, at least once (71.3%, 1-10 opioid prescriptions; 27.4%, 11-100; 1.3%, ≥101). Overall, 23.0% of all prescriptions by those IRs writing >10 were for opioids, with an average 8.0-day prescription. Average opioid prescriptions per IR were significantly (P ≤ .015) independently associated with their providing clinical evaluation and management (E&M) services (9.7 opioid prescriptions per IR with demonstrable E&M encounters versus 2.2 if not), practice size (12.6 for practices with ≤ 10 members versus 3.7-4.8 for larger groups), and geography (8.3 in the South versus 3.6-4.0 elsewhere). Rates were highest in Georgia (39.5) and lowest in Delaware (2.0). Higher opioid prescribing rates showed additional univariable associations with more years in practice and nonacademic practices. CONCLUSION/CONCLUSIONS:Most IRs write few, if any, prescriptions for Medicare beneficiaries. Of those who do, the large majority writes for opioids, at rates higher than national physician benchmarks. IRs' opioid prescribing varies significantly based on physician and practice characteristics and particularly whether the IR provides clinical E&M services. In light of the nation's opioid epidemic, these observations may guide education, practice improvement, and policy efforts to optimize opioid prescribing.

PURPOSE/OBJECTIVE:The aims of this study were to compare the number of unique Medicare fee-for-service beneficiaries served by radiologists and other physicians and to identify characteristics of radiologists serving the most number of unique patients. METHODS:Medicare Physician and Other Supplier Public Use Files were used to identify all physicians who provided services to Medicare fee-for-service beneficiaries for the entirety of 2013. The average number of unique beneficiaries served was computed per specialty. The number of unique beneficiaries served was further stratified among radiologists in terms of physician and practice characteristics. RESULTS:Among 56 unique physician specialties, diagnostic radiologists on average served the most unique beneficiaries (3,150 ± 2,344). Among radiologists, the number of unique beneficiaries varied in association with numerous characteristics and was larger for male (3,214) versus female (2,521) radiologists, rural (3,551) versus urban (3,092) radiologists, nonacademic (3,427) versus academic (1,932) radiologists, generalist (3,866) versus subspecialist (1,981) radiologists, and radiologists in the South (3,716) versus other geographic regions (range, 2,432-3,217). The number of unique beneficiaries served increased significantly with smaller group practice size (2,218 for ≥100 group members versus 3,669 for ≤9 members). Among subspecialists, the number of unique beneficiaries was largest for breast imagers (2,594). CONCLUSIONS:The large number of unique beneficiaries served by radiologists highlights their important role in orchestrating patient care and their immense opportunities to expand the face of the specialty. An understanding of which radiologists serve the largest numbers of unique patients may help radiology practices target patient engagement and other Imaging 3.0™ efforts.

OBJECTIVE:The purpose of this study is to assess the utility of texture analysis of multiple MRI sequences for the differentiation of uterine leiomyomas and leiomyosarcomas. MATERIALS AND METHODS/METHODS:Seventeen leiomyosarcomas and 51 leiomyomas undergoing MRI before resection were included. Whole-lesion volumes of interest were placed on T2-weighted images, contrast-enhanced T1-weighted images, and apparent diffusion coefficient (ADC) maps. The diagnostic performance of histogram metrics was assessed. RESULTS:achieved sensitivity of 82.4% and specificity of 74.5%. CONCLUSION/CONCLUSIONS:For whole-lesion histogram metrics obtained on various MRI sequences, T2-weighted images provided the highest, and ADC maps the lowest, performance for differentiating uterine leiomyomas and leiomyosarcomas. Metrics reflecting percentiles from the bottom half of the histogram distribution outperformed the standard mean. Models combining the T2-weighted imaging whole-lesion metrics and patient age achieved particularly high diagnostic performance. Although these findings require validation in larger studies, they have implications for facilitating improved treatment selection for these two entities.