Faculty Bibliography

PURPOSE: Prior studies have shown higher screening mammography rates for beneficiaries in capitated managed care Medicare Advantage (MA) plans compared with traditional fee-for-service Medicare. The aim of this study was to explore variation in screening mammography rates at the level of MA managed care plans. METHODS: Using the 2016 MA Healthcare Effectiveness Data and Information Set Public Use File, screening mammography rates were identified for all 385 reporting MA plans. Associations were explored with a range of plan characteristics from this file, as well as from the CMS Part C and Part D Medicare Star Ratings Data File, Medicare Advantage Plan Directory, and Medicare Monthly Enrollment by Plan File. RESULTS: Overall MA plan screening rates were high (mean, 72.6 +/- 9.4%) but varied substantially among plans (range, 14.3%-91.8%). Screening rates were higher in nonprofit versus for-profit plans (77.3% versus 71.8%, P < .001), as well as in health maintenance organization or local preferred provider organization plans versus private fee-for-service or regional preferred provider organization plans (71.9%-73.2% versus 65.5%-66.8%, P = .001). Among parent organizations with five or more plans, screening rates were highest for Kaiser Foundation (median, 88.4%) and lowest for Molina Healthcare (median, 65.3%). Screening rates showed small but significant associations with plans' contract lengths, enrolled populations, and counties served. Screening rates showed strong associations (r = 0.796-0.798) with colorectal cancer screening and annual flu vaccine rates and showed moderate associations (r = 0.283-0.365) with ambulatory and preventive care visits, osteoporosis screenings, body mass index assessments, and nonrecommended prostate-specific antigen screenings after age 70. CONCLUSIONS: Screening mammography rates vary considerably among MA plans. With increased federal interest in promoting the MA program, enhanced transparency will be necessary to ensure appropriate Medicare beneficiary participation decision making.

The annual cost of healthcare delivery in the USA now exceeds US$3 trillion. Fee for service methodology is often implicated as a cause of this exceedingly high figure. The Affordable Care Act created the Center for Medicare and Medicaid Innovation (CMMI) to pilot test value based alternative payments for reimbursing physician services. In 2015, the Medicare Access and CHIP Reauthorization Act (MACRA) was passed into law. MACRA has dramatic implications for all US based healthcare providers. MACRA permanently repealed the Medicare Sustainable Growth Rate so as to stabilize physician part B Medicare payments, consolidated pre-existing federal performance programs into the Merit based Incentive Payments System (MIPS), and legislatively mandated new approaches to paying clinicians. Neurointerventionalists will predominantly participate in MIPS. MIPS unifies, updates, and streamlines previously existing federal performance programs, thereby reducing onerous redundancies and overall administrative burden, while consolidating performance based payment adjustments. While MIPS may be perceived as a straightforward continuation of fee for service methodology with performance modifiers, MIPS is better viewed as a stepping stone toward eventually adopting alternative payment models in later years. In October 2016, the Centers for Medicare and Medicaid Services (CMS) released a final rule for MACRA implementation, providing greater clarity regarding 2017 requirements. The final rule provides a range of options for easing MIPS reporting requirements in the first performance year. Nonetheless, taking the newly offered 'minimum possible' approach toward meeting the requirements will still have negative consequences for providers.

RATIONALE AND OBJECTIVES: Emerging alternative metrics leverage social media and other online platforms to provide immediate measures of biomedical articles' reach among diverse public audiences. We aimed to compare traditional citation and alternative impact metrics for articles in popular general radiology journals. MATERIALS AND METHODS: All 892 original investigations published in 2013 issues of Academic Radiology, American Journal of Roentgenology, Journal of the American College of Radiology, and Radiology were included. Each article's content was classified as imaging vs nonimaging. Traditional journal citations to articles were obtained from Web of Science. Each article's Altmetric Attention Score (Altmetric), representing weighted mentions across a variety of online platforms, was obtained from Altmetric.com. Statistical assessment included the McNemar test, the Mann-Whitney test, and the Pearson correlation. RESULTS: Mean and median traditional citation counts were 10.7 +/- 15.4 and 5 vs 3.3 +/- 13.3 and 0 for Altmetric. Among all articles, 96.4% had >/=1 traditional citation vs 41.8% for Altmetric (P < 0.001). Online platforms for which at least 5% of the articles were represented included Mendeley (42.8%), Twitter (34.2%), Facebook (10.7%), and news outlets (8.4%). Citations and Altmetric were weakly correlated (r = 0.20), with only a 25.0% overlap in terms of articles within their top 10th percentiles. Traditional citations were higher for articles with imaging vs nonimaging content (11.5 +/- 16.2 vs 6.9 +/- 9.8, P < 0.001), but Altmetric scores were higher in articles with nonimaging content (5.1 +/- 11.1 vs 2.8 +/- 13.7, P = 0.006). CONCLUSIONS: Although overall online attention to radiology journal content was low, alternative metrics exhibited unique trends, particularly for nonclinical articles, and may provide a complementary measure of radiology research impact compared to traditional citation counts.

In early 2015, Sylvia Burwell, Secretary of the Department of Health and Human Services, described the federal administration's goals for delivery of health care in the United States. Prominently featured was a conversion from volume to value through the incorporation of Alternative Payment Models. The Department of Health and Human Services laid the framework, but recognized significant knowledge gaps in how providers and institutions would develop Alternative Payment Models. To that end, the Health Care Payment Learning and Action Network was conceived. On March 25, 2015, the Health Care Payment Learning and Action Network held its first meeting, which included a broad swath of industry participants. This collaboration was considered mission critical to achieving success in the goals of advancing Alternative Payment Models. This article highlights the Health Care Payment Learning and Action Network and the framework it is proposing for Alternative Payment Models that would have meaningful implications for radiologists.

OBJECTIVE: Prior studies in prostate diffusion-weighted magnetic resonance imaging (MRI) have largely explored the impact of b-value and diffusion directions on estimated diffusion coefficient D. Here we suggest varying diffusion time, t, to study time-dependent D(t) in prostate cancer, thereby adding an extra dimension in the development of prostate cancer biomarkers. METHODS: Thirty-eight patients with peripheral zone prostate cancer underwent 3-T MRI using an external-array coil and a diffusion-weighted image sequence acquired for b = 0, as well as along 12 noncollinear gradient directions for b = 500 s/mm using stimulated echo acquisition mode (STEAM) diffusion tensor imaging (DTI). For this sequence, 6 diffusion times ranging from 20.8 to 350 milliseconds were acquired. Tumors were classified as low-grade (Gleason score [GS] 3 + 3; n = 11), intermediate-grade (GS 3 + 4; n = 16), and high-grade (GS >/=4 + 3; n = 11). Benign peripheral zone and transition zone were also studied. RESULTS: Apparent diffusion coefficient (ADC) D(t) decreased with increasing t in all zones of the prostate, though the rate of decay in D(t) was different between sampled zones. Analysis of variance and area under the curve analyses suggested better differentiation of tumor grades at shorter t. Fractional anisotropy (FA) increased with t for all regions of interest. On average, highest FA was observed within GS 3 + 3 tumors. CONCLUSIONS: There is a measurable time dependence of ADC in prostate cancer, which is dependent on the underlying tissue and Gleason score. Therefore, there may be an optimal selection of t for prediction of tumor grade using ADC. Controlling t should allow ADC to achieve greater reproducibility between different sites and vendors. Intentionally varying t enables targeted exploration of D(t), a previously overlooked biophysical phenomenon in the prostate. Its further microstructural understanding and modeling may lead to novel diffusion-derived biomarkers.

The current fee-for-service system for health care reimbursement in the United Stated is argued to encourage fragmented care delivery and a lack of accountability that predisposes to insufficient focus on quality as well as unnecessary or duplicative resource utilization. Episode payment models (EPMs) seek to improve coordination by linking payments for all services related to a patient's condition or procedure, thereby improving quality and efficiency of care. The CMS Innovation Center has implemented a broadening array of EPMs. Early models with relevance to radiologists include Bundled Payment for Care Improvement (involving 48 possible clinical conditions), Comprehensive Care for Joint Replacement (involving knee and hip replacement), and the Oncology Care Model (involving chemotherapy). In July 2016, CMS expanded the range of EPMs through three new models with mandatory hospital participation addressing inpatient and 90-day postdischarge care for acute myocardial infarction, coronary artery bypass graft, and surgical hip and femur fracture treatment. Moreover, some of the EPMs include tracks that allow participating entities to qualify as an Advanced Alternative Payment Model under the Medicare Access and CHIP Reauthorization Act (MACRA), reaping the associated reporting and payment benefits. Even though none of the available EPMs are radiology specific, the models will nevertheless likely influence reimbursements for some radiologists. Thus, radiologists should partner with hospitals and other specialties in care coordination through these episode-based initiatives, thereby having opportunities to apply their imaging expertise to help lower spending while improving quality and overall levels of health.

Purpose To compare standard diffusion-weighted (DW) imaging and diffusion kurtosis (DK) imaging for prostate cancer (PC) detection and characterization in a large patient cohort, with attention to the potential added value of DK imaging. Materials and Methods This retrospective institutional review board-approved study received a waiver of informed consent. Two hundred eighty-five patients with PC underwent 3.0-T phased-array coil prostate magnetic resonance (MR) imaging, including a DK imaging sequence (b values 0, 500, 1000, 1500, and 2000 sec/mm2) before prostatectomy. Maps of apparent diffusion coefficient (ADC) and diffusional kurtosis (K) were derived by using maximal b values of 1000 and 2000 sec/mm2, respectively. Mean ADC and K were obtained from volumes of interest (VOIs) placed on each patient's dominant tumor and benign prostate tissue. Metrics were compared between benign and malignant tissue, between Gleason score (GS) /= 3 + 4 tumors, and between GS /= 4 + 3 tumors by using paired t tests, analysis of variance, receiver operating characteristic (ROC) analysis, and exact tests. Results ADC and K showed significant differences for benign versus tumor tissues, GS /= 3 + 4 tumors, and GS /= 4 + 3 tumors (P < .001 for all). ADC and K were highly correlated (r = -0.82; P < .001). Area under the ROC curve was significantly higher (P = .002) for ADC (0.921) than for K (0.902) for benign versus malignant tissue but was similar for GS /= 3 + 4 tumors (0.715-0.744) and GS /= 4 + 3 tumors (0.694-0.720) (P > .15). ADC and K were concordant for these various outcomes in 80.0%-88.6% of patients; among patients with discordant results, ADC showed better performance than K for GS /= 4 + 3 tumors (P = .016) and was similar to K for other outcomes (P > .136). Conclusion ADC and K were highly correlated, had similar diagnostic performance, and were concordant for the various outcomes in the large majority of cases. These observations did not show a clear added value of DK imaging compared with standard DW imaging for clinical PC evaluation. (c) RSNA, 2017 Online supplemental material is available for this article.

To use Twitter to assess the immediate public response to the United States Preventive Services Task Force (USPSTF) 2013 draft guidelines on lung cancer screening with low-dose chest CT (LDCT). The number of tweets including the phrases "lung cancer screening," "lung CT," "chest CT," "low dose computed tomography," "low dose CT," or "LDCT" was recorded for 6 days before and after guidelines release. A systematic sample of 172 tweets from the week following release was coded for user type, tweet opinion, linked article source, and article opinion. Following guidelines' release, the number of daily tweets increased from 13 +/- 8 to 311 +/- 395. The 172 tweets in the week following release were tweeted by 166 unique users including: news organizations/online news gathering accounts (34.9%), general public (21.7%), physicians (12.0%, 6 radiologists), and businesses (11.4%). 23.3% of tweets provided opinion on the guidelines (50.0% favorable, 27.5% concerned toward screening). Most (91.3%) tweets contained links to a total of 46 unique articles, which were authored by lay press (41.3%), non-peer-reviewed medical press (32.6%), and hospital/medical practice websites (10.9%). Among these, 50.0% were favorable, citing mortality reduction (87.0%), published data supporting screening (50.0%), and early detection (43.5%), while 28.3% expressed concern, including false positives (58.9%) and radiation risk (39.1%). Twitter activity rose rapidly after the USPSTF draft guidelines on LDCT. Most users were non-physicians and frequently cited non-peer-reviewed articles. Users maintained an overall favorable view of screening, while expressing various concerns. Considerable opportunity exists for greater radiologist engagement in this online public dialog.

PURPOSE: To assess the impact of patient race and age on the performance of apparent diffusion coefficient (ADC) values for assessment of prostate cancer aggressiveness. MATERIALS AND METHODS: 457 prostate cancer patients who underwent 3T phased-array coil prostate MRI including diffusion-weighted imaging (DWI; maximal b-value 1000 s/mm2) before prostatectomy were included. Mean ADC of a single dominant lesion was measured in each patient, using histopathologic findings from the prostatectomy specimen as reference. In subsets defined by race and age, ADC values were compared between Gleason score (GS) /= 4 + 3 tumors. RESULTS: 81% of patients were Caucasian, 12% African-American, 7% Asian-American. 13% were <55 years, 42% 55-64 years, 41% 65-74 years, and 4% >/=75 years. 63% were GS /= 4 + 3. ADC was significantly lower in GS >/= 4 + 3 tumors than in GS /= 4 + 3 as well as optimal ADC threshold was Caucasian: 0.73//=75 years, 0.79//=75 years than <55 years or 55-64 years (100.0% vs. 53.6%-73.3%; P < 0.001). CONCLUSION: Patients' race and age may impact the diagnostic performance and optimal threshold when applying ADC values for evaluation of prostate cancer aggressiveness.