Faculty Bibliography

OBJECTIVE: The objective of the present study is to assess the feasibility of a novel claims-based classification system for payer identification of academic radiologist subspecialties. MATERIALS AND METHODS: Using a categorization scheme based on the Neiman Imaging Types of Service (NITOS) system, we mapped the Medicare Part B services billed by all radiologists from 2012 to 2014, assigning them to the following subspecialty categories: abdominal imaging, breast imaging, cardiothoracic imaging, musculoskeletal imaging, nuclear medicine, interventional radiology, and neuroradiology. The percentage of subspecialty work relative value units (RVUs) to total billed work RVUs was calculated for each radiologist nationwide. For radiologists at the top 20 academic departments funded by the National Institutes of Health, those percentages were compared with subspecialties designated on faculty websites. NITOS-based subspecialty assignments were also compared with the only radiologist subspecialty classifications currently recognized by Medicare (i.e., nuclear medicine and interventional radiology). RESULTS: Of 1012 academic radiologists studied, the median percentage of Medicare-billed NITOS-based subspecialty work RVUs matching the subspecialty designated on radiologists' own websites ranged from 71.3% (for nuclear medicine) to 98.9% (for neuroradiology). A NITOS-based work RVU threshold of 50% correctly classified 89.8% of radiologists (5.9% were not mapped to any subspecialty; subspecialty error rate, 4.2%). In contrast, existing Medicare provider codes identified only 46.7% of nuclear medicine physicians and 39.4% of interventional radiologists. CONCLUSION: Using a framework based on a recently established imaging health services research tool that maps service codes based on imaging modality and body region, Medicare claims data can be used to consistently identify academic radiologists by subspecialty in a manner not possible with the use of existing Medicare physician specialty identifiers. This method may facilitate more appropriate performance metrics for subspecialty academic physicians under emerging value-based payment models.

On 8 November 2016 the American electorate voted Donald Trump into the Presidency and a majority of Republicans into both houses of Congress. Since many Republicans ran for elected office on the promise to 'repeal and replace' Obamacare, this election result came with an expectation that campaign rhetoric would result in legislative action on healthcare. The American Health Care Act (AHCA) represented the Republican effort to repeal and replace the Affordable Care Act (ACA). Key elements of the AHCA included modifications of Medicaid expansion, repeal of the individual mandate, replacement of ACA subsidies with tax credits, and a broadening of the opportunity to use healthcare savings accounts. Details of the bill and the political issues which ultimately impeded its passage are discussed here.

PURPOSE: To examine changes in the utilization of procedures related to treatment of chronic venous insufficiency (CVI) in the Medicare population. MATERIALS AND METHODS: Service-specific claims data for phlebectomy, sclerotherapy, and radiofrequency (RF) and laser ablation were identified by using Medicare Physician Supplier Procedure Summary master files from 2005 through 2014. Longitudinal national utilization rates were calculated by using annual Medicare enrollment data from 2005 through 2013. Procedure volumes by specialty group and site of service were analyzed. RESULTS: Total annual claims for these procedures in the Medicare fee-for-service beneficiaries increased from 95,206 to 332,244 (Compound Annual Growth Rate [CAGR], 15%) between 2005 and 2014. Per 1,000 beneficiaries, overall utilization increased annually from 2.8 in 2005 to 9.4 in 2013. Most procedures were performed in the private office setting (92% in 2014). In 2014, radiologists had a 10% relative market share, compared with vascular surgeons, other surgeons, and cardiologists, who had 26%, 25%, and 14% market shares, respectively. Cardiologists had the fastest relative growth, with a CAGR of 51% compared with 23% for radiology, 12% for vascular surgery, and 13% for other surgery. Total venous RF ablation services grew with a CAGR of 31%, with radiology and cardiology growing most rapidly (40% and 79%, respectively). Total venous laser ablation services grew with a CAGR of 22%, with radiology growing 15% and cardiology growing most rapidly at 44%. CONCLUSIONS: Utilization of CVI procedures in the Medicare population increased markedly from 2005 through 2014. The overwhelming majority are performed in the private office setting by nonradiologists.

Active surveillance (AS) has emerged as a beneficial strategy for management of low risk prostate cancer (PCa) and prevention of overtreatment of indolent disease. However, selection of patients for AS using traditional 12-core transrectal prostate biopsy is prone to sampling error and presents a challenge for accurate risk stratification. In fact, around a third of men are upgraded on repeat biopsy which disqualifies them as appropriate AS candidates. This uncertainty affects adoption of AS among patients and physicians, leading to current AS protocols involving repetitive prostate biopsies and unclear triggers for progression to definitive treatment. Prostate magnetic resonance imaging (MRI) has the potential to overcome some of these limitations through localization of significant tumors in the prostate. In conjunction with MRI-targeted prostate biopsy, improved sampling and detection of clinically significant PCa can help streamline the process of selecting suitable men for AS and early exclusion of men who require definitive treatment. MRI can also help minimize the invasive nature of monitoring for disease progression while on AS. Men with stable MRI findings have high negative predictive value for Gleason upgrade on subsequently biopsy, suggesting that men may potentially be monitored by serial MRI examinations with biopsy reserved for significant changes on imaging. Targeted biopsy on AS also allows for specific sampling of concerning lesions, although further data is necessary to evaluate the relative contribution of systematic and targeted biopsy in detecting the 25-30% of men who progress on AS. Further research is also warranted to better understand the nature of clinically significant cancers that are missed on MRI and why certain men have progression of disease that is not visible on prostate MRI. Consensus is also needed over what constitutes progression on MRI, when prostate biopsy can be safely avoided, and how to best utilize this additional information in current AS protocols. Despite these challenges, prostate MRI, either alone or in conjunction with MRI-targeted prostate biopsy, has the potential to significantly improve our current AS paradigm and rates of AS adoption among patients moving forward.

Advancements in magnetic resonance imaging (MRI) and MRI-ultrasound (US)-fusion targeted biopsy have resulted in a paradigm shift in the diagnosis of prostate cancer by overcoming the limitations of systematic biopsy. Prebiopsy MRI and MRI-US-fusion biopsy results in an increased detection of clinically significant disease, reduction in the detection of indolent disease, and allows for tumor localization during targeted biopsy. With these advantages, we have adopted a prebiopsy MRI and MRI-US-fusion biopsy diagnostic care pathway for all men at risk for prostate cancer and have performed more than 1900 biopsies to date. Herein we present our institutional development of MRI-US-fusion biopsy and highlight our results in those men who have had a previous negative biopsy, no prior biopsy, and those with a prior cancer diagnosis who may be candidate for active surveillance. Risk stratification with biomarkers and nomograms may allow for further counseling on the need for biopsy and the risk of harboring clinically significant disease.

PURPOSE: To assess the effects of temporal resolution (RT ) in dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) on qualitative tumor detection and quantitative pharmacokinetic parameters in prostate cancer. MATERIALS AND METHODS: This retrospective Institutional Review Board (IRB)-approved study included 58 men (64 +/- 7 years). They underwent 3T prostate MRI showing dominant peripheral zone (PZ) tumors (24 with Gleason >/= 4 + 3), prior to prostatectomy. Continuously acquired DCE utilizing GRASP (Golden-angle RAdial Sparse Parallel) was retrospectively reconstructed at RT of 1.4 sec, 3.7 sec, 6.0 sec, 9.7 sec, and 14.9 sec. A reader placed volumes-of-interest on dominant tumors and benign PZ, generating quantitative pharmacokinetic parameters (ktrans , ve ) at each RT . Two blinded readers assessed each RT for lesion presence, location, conspicuity, and reader confidence on a 5-point scale. Data were assessed by mixed-model analysis of variance (ANOVA), generalized estimating equation (GEE), and receiver operating characteristic (ROC) analysis. RESULTS: RT did not affect sensitivity (R1all : 69.0%-72.4%, all Padj = 1.000; R1GS>/=4 + 3 : 83.3-91.7%, all Padj = 1.000; R2all : 60.3-69.0%, all Padj = 1.000; R2GS>/=4 + 3 : 58.3%-79.2%, all Padj = 1.000). R1 reported greater conspicuity of GS >/= 4 + 3 tumors at RT of 1.4 sec vs. 14.9 sec (4.29 +/- 1.23 vs. 3.46 +/- 1.44; Padj = 0.029). No other tumor conspicuity pairwise comparison reached significance (R1all : 2.98-3.43, all Padj >/= 0.205; R2all : 2.57-3.19, all Padj >/= 0.059; R1GS>/=4 + 3 : 3.46-4.29, all other Padj >/= 0.156; R2GS>/=4 + 3 : 2.92-3.71, all Padj >/= 0.439). There was no effect of RT on reader confidence (R1all : 3.17-3.34, all Padj = 1.000; R2all : 2.83-3.19, all Padj >/= 0.801; R1GS>/=4 + 3 : 3.79-4.21, all Padj = 1.000; R2GS>/=4 + 3 : 3.13-3.79, all Padj = 1.000). ktrans and ve of tumor and benign tissue did not differ across RT (all adjusted P values [Padj ] = 1.000). RT did not significantly affect area under the curve (AUC) of Ktrans or ve for differentiating tumor from benign (all Padj = 1.000). CONCLUSION: Current PI-RADS recommendations for RT of 10 seconds may be sufficient, with further reduction to the stated PI-RADS preference of RT