Faculty Bibliography

Purpose: To characterize Medicare services billed by current SSR members. Materials and Methods: With SSR Executive Committee permission, national provider identifiers (NPIs) were manually identified for all SSR members (who had all attested to >50% of one's practice in musculoskeletal [MSK] radiology). NPIs permitted member cross-linking to the 2015 CMS Physician and Other Supplier Public Use File to then identify all services each billed Medicare. Service codes were mapped to seven mapping-validated subspecialties (MSK, abdominal, breast, cardiothoracic, neuroradiology, nuclear medicine, and vascular-interventional radiology [VIR]) using the Neiman Imaging Types of Service classification system. Radiologists' percentages of work RVUs (wRVU) in each subspecialty were computed. Various subgroup analyses were performed. Results: Of 1,014 SSR members, 49.5% performed >=50% of their wRVUs in MSK. In terms of billed wRVUs, 53.4% of these radiologists mapped to a secondary subspecialty of neuroradiology in terms of billed wRVUs, 16.3% to abdominal, 11.8% to cardiothoracic, and 5.2% to VIR. Of all SSR members, 45.6% were generalists (i.e., no subspecialty crossed the majority wRVU threshold), but 37.4% of them performed a plurality of work in MSK. No other subspecialty accounted for greater than 2% of SSR members. A higher percentage of MSK wRVUs was significantly associated (p<0.001) with an academic affiliation (66.8% vs. 44.5%) as well as two different markers of greater SSR engagement: 1) attending the 2014 SSR meeting (63.5% vs. 49.9%) and 2) serving as an SSR committee member (75.7% vs. 51.6%). Of all other 27,618Medicare-participating radiologists nationally meeting inclusion criteria, 3.2% (879) had >=50% of their wRVUs in MSK but are not SSR members. Conclusion: Medicare claims-based practice classification provides unique insight into SSR membership. This information may help better understand current membership needs, plan future meeting content, and guide further society growth

PURPOSE/OBJECTIVE:The Medicare Access and CHIP Reauthorization Act (MACRA) provides CMS flexibility to evaluate radiologists using hospital outpatient quality measures in place of conventional physician measures. We explore radiologist characteristics associated with variation in performance in two such measures: abdomen and chest CT "double scan" rates (percentage of total examinations performed both with and without intravenous contrast). METHODS:Radiologists' claims for abdomen and chest CT examinations in a facility setting were identified using 2014 Medicare Physician and Other Supplier data. Individual radiologist double scan rates were computed. Associations were explored between rates and radiologist characteristics extracted from the CMS public data sets using multivariable regression with cross-validation. RESULTS:Radiologists' double scan rates averaged 5.9% ± 10.0% (0.0% for 52.8% of radiologists) for abdomen CT (19,867 radiologists) and 1.0% ± 4.7% (0.0% for 91.3% of radiologists) for chest CT (18,684). At multivariable analysis, abdomen rates were best predicted by geography (lowest in Northeast, greatest in West), practice size (greatest for small practices), and specialty practice pattern (lowest for general radiologists; greatest for nuclear medicine physicians). Agreement for double scan rates among radiologists within the same practice was moderate, though slightly higher for chest (intraclass correlation = 0.70) than abdomen (0.59). CONCLUSION/CONCLUSIONS:Radiologists' facility double scan rates vary systematically based on an array of professional characteristics. MACRA grants CMS the authority to use these measures for evaluating radiologists, thereby aligning Medicare's hospital and physician performance programs and better incentivizing population radiation dose and cost reduction. Greater variation in abdomen CT double scan rates, compared with ubiquitously excellent chest CT performance, supports a particular role for abdomen rates in distinguishing disparities in radiologist performance.

OBJECTIVE: To develop nomograms that predict the probability of overall PCa and clinically significant PCa (Gleason >/=7) on MRI targeted, and combined MRI-targeted and systematic, prostate biopsy. MATERIALS AND METHODS: From June 2012 to August 2014, MR-US fusion targeted prostate biopsy was performed on 464 men with suspicious regions identified on pre-biopsy 3T MRI along with systematic 12 core biopsy. Logistic regression modeling was used to evaluate predictors of overall and clinically significant PCa, and corresponding nomograms were generated for men who were not previously biopsied or had one or more prior negative biopsies. Models were created with 70% of a randomly selected training sample and bias-corrected using bootstrap resampling. The models were then validated with the remaining 30% testing sample pool. RESULTS: A total of 459 patients were included for analysis (median age 66 years, PSA 5.2 ng/ml, prostate volume 49 cc). Independent predictors of PCa on targeted and systematic prostate biopsy were PSA density, age, and MRI suspicion score. PCa probability nomograms were generated for each cohort using the predictors. Bias-corrected areas under the receiver-operating characteristic curves for overall and clinically significant PCa detection were 0.82 (0.78) and 0.91 (0.84) for men without prior biopsy and 0.76 (0.65) and 0.86 (0.87) for men with a prior negative biopsy in the training (testing) samples. CONCLUSION: PSA density, age, and MRI suspicion score predict prostate cancer on combined MRI-targeted and systematic biopsy. Our generated nomograms demonstrate high diagnostic accuracy and may further aid in the decision to perform biopsy in men with clinical suspicion of PCa.

OBJECTIVES: The aim of this study was to compare testicular metabolite concentrations between fertile control subjects and infertile men. MATERIALS AND METHODS: Single voxel proton magnetic resonance spectroscopy ((1)H-MRS) was performed in the testes with and without water suppression at 3 T in 9 fertile control subjects and 9 infertile patients (8 with azoospermia and 1 with oligospermia). In controls only, the T1 and T2 values of water and metabolites were also measured. Absolute metabolite concentrations were calculated using the unsuppressed water signal as a reference and correcting for the relative T1 and T2 weighting of the water and metabolite signals. RESULTS: Testicular T1 values of water, total choline, and total creatine were 2028 +/- 125 milliseconds, 1164 +/- 105 milliseconds, and 1421 +/- 314 milliseconds, respectively (mean +/- standard deviation). T2 values were 154 +/- 11 milliseconds, 342 +/- 53 milliseconds, and 285 +/- 167 milliseconds, respectively. Total choline concentration was lower in patients (mean, 1.5 mmol/L; range, 0.9-2.1 mmol/L) than controls (mean, 4.4 mmol/L; range, 3.2-5.7 mmol/L; P = 4 x 10(-)(5)). Total creatine concentration was likewise reduced in patients (mean, 1.1 mmol/L; range, undetectable -2.7 mmol/L) compared with controls (mean, 3.6 mmol/L; range, 2.5-4.7 mmol/L; P = 1.6 x 10(-)(4)). The myo-inositol signal normalized to the water reference was also lower in patients than controls (P = 4 x 10(-)(5)). CONCLUSIONS: Testicular metabolite concentrations, measured by proton spectroscopy at 3 T, may be valuable as noninvasive biomarkers of spermatogenesis.

OBJECTIVE: To determine if multiparametric MRI (mpMRI) identifies significant apical disease, thereby informing decisions regarding preservation of the membranous urethra. MATERIALS AND METHODS: Men undergoing radical prostatectomy between January 2012 and June 2016 who underwent a 12-core transrectal-ultrasound guided systematic biopsy, preoperative 3-T MRI, and sectioning of the prostate specimen with tumor foci mapping were extracted from a single surgeon's prospective longitudinal outcomes database. Apical systematic biopsy vs. mpMRI lesion were compared for predicting aggressive tumor in the prostatic apex defined as Prostate Cancer Grade Group >1. RESULTS: Of the 100 men who met eligibility criteria, 43 (43%) exhibited aggressive prostate cancer in the distal 5mm of the apex. A Likert score > 2 in the apical one-third of the prostate was found to be more reliable than any cancer found on apical systematic biopsy at detecting aggressive cancer in the apex. On multivariate regression that included Likert score in the apex, age, PSA, prostate size, and presence of any cancer on apical biopsy, only Likert score (p=.005) and PSA (p=.025) were significant and independent predictors of aggressive cancer in the distal apex. CONCLUSION: MRI is superior to systematic biopsy at identifying aggressive prostate cancer within the distal prostatic apex and may be useful for planning the extent of apical preservation during prostatectomy.

OBJECTIVE/OBJECTIVE:The objective of our study was to use a new modality and body region categorization system to assess changing utilization of noninvasive diagnostic imaging in the Medicare fee-for-service population over a recent 20-year period (1994-2013). MATERIALS AND METHODS/METHODS:All Medicare Part B Physician Fee Schedule services billed between 1994 and 2013 were identified using Physician/Supplier Procedure Summary master files. Billed codes for diagnostic imaging were classified using the Neiman Imaging Types of Service (NITOS) coding system by both modality and body region. Utilization rates per 1000 beneficiaries were calculated for families of services. RESULTS/RESULTS:Among all diagnostic imaging modalities, growth was greatest for MRI (+312%) and CT (+151%) and was lower for ultrasound, nuclear medicine, and radiography and fluoroscopy (range, +1% to +31%). Among body regions, service growth was greatest for brain (+126%) and spine (+74%) imaging; showed milder growth (range, +18% to +67%) for imaging of the head and neck, breast, abdomen and pelvis, and extremity; and showed slight declines (range, -2% to -7%) for cardiac and chest imaging overall. The following specific imaging service families showed massive (> +100%) growth: cardiac CT, cardiac MRI, and breast MRI. CONCLUSION/CONCLUSIONS:NITOS categorization permits identification of temporal shifts in noninvasive diagnostic imaging by specific modality- and region-focused families, providing a granular understanding and reproducible analysis of global changes in imaging overall. Service family-level perspectives may help inform ongoing policy efforts to optimize imaging utilization and appropriateness.

PURPOSE: The Medicare Access and CHIP Reauthorization Act (MACRA) Quality performance category is the successor to the Physician Quality and Reporting System (PQRS) program and now contributes to physicians' income adjustments based upon performance rates calculated for a minimum of six measures. We assess radiologists' frequency of reporting PQRS measures as a marker of preparedness for MACRA. METHODS: Medicare-participating radiologists were randomly searched through the Physician Compare website until identifying 1,000 radiologists who reported at least one PQRS measure. Associations were explored between the number of reported measures and radiologist characteristics. RESULTS: For PQRS-reporting radiologists, the number of reported PQRS measures was 1 (25.2%), 2 (27.3%), 3 (18.2%), 4 (19.3%), 5 (8.3%), and 6 (1.7%). The most commonly reported measures were "documenting radiation exposure time for procedures using fluoroscopy" (64.3%) and "accurate measurement of carotid artery narrowing" (56.8%). Reporting at least two measures was significantly (P < .001) more likely for nonacademic (77.3%) versus academic (44.9%) radiologists, generalists (82.7%) versus subspecialists (59.1%), and radiologists in smaller (/=100 members) (39.7%) practices. Reporting six measures was significantly (P < .05) more likely for generalists (2.6%) versus subspecialists (0.4%). CONCLUSION: Most PQRS-reporting radiologists reported only one or two measures, well below MACRA's requirement of six. Radiologists continuing such reporting levels will likely be disadvantaged in terms of potential payment adjustments under MACRA. Lower reporting rates for academic and subspecialized radiologists, as well as those in larger practices, may relate to such radiologists' reliance on their hospitals or networks for PQRS reporting. Qualified clinical data registries should be embraced to facilitate more robust measure reporting.

PURPOSE: This study aimed to assess variability in imaging facilities' adherence to the minimum technical standards for prostate magnetic resonance imaging acquisition established by Prostate Imaging-Reporting and Data System (PI-RADS) version 2 (v2). METHODS: A total of 107 prostate magnetic resonance imaging examinations performed at 107 unique imaging facilities after the release of PI-RADS v2 and that were referred to a tertiary care center for secondary interpretation were included. Image sets, DICOM headers, and outside reports were reviewed to assess adherence to 21 selected PI-RADS v2 minimum technical standards. RESULTS: Hardware arrangements were 23.1%, 1.5T without endorectal coil; 7.7%, 1.5T with endorectal coil; 63.5%, 3T without endorectal coil; and 5.8%, 3T with endorectal coil. Adherence to minimum standards was lowest on T2 weighted imaging (T2WI) for frequency resolution /=1400 s/mm2) images were included in 58.0% (calculated in 25.9%). Adherence to T2WI phase resolution and DWI inter-slice gap were greater (P < .05) at 3T than at 1.5T. Adherence did not differ (P > .05) for any parameter between examinations performed with and without an endorectal coil. Adherence was greater for examinations performed at teaching facilities for T2WI slice thickness and DCE temporal resolution (P < .05). Adherence was not better for examinations performed in 2016 than in 2015 for any parameter (P > .05). CONCLUSION: Facilities' adherence to PI-RADS v2 minimum technical standards was variable, being particularly poor for T2WI frequency resolution and DCE temporal resolution. The standards warrant greater community education. Certain technical standards may be too stringent, and revisions should be considered.