Faculty Bibliography

RATIONALE AND OBJECTIVES: To retrospectively assess the appropriateness of outpatient abdominal and pelvic computed tomography (CT) and magnetic resonance imaging (MRI) examinations using the American College of Radiology Appropriateness Criteria (AC). MATERIALS AND METHODS: A total of 570 adult outpatient abdominopelvic CT (304) and MRI (266) studies performed in a 1-month period with available documentation of the clinical encounter generating the imaging order were included. On the basis of review of the imaging report and patient record, examinations were classified in terms of match to a specific AC variant, appropriateness score, and the presence of a significant result. Data were analyzed using Fisher's exact test. RESULTS: Forty-five percent of examinations matched an AC variant: 52% of CT and 38% of MRI (P < .001). Ninety-two percent of examinations matching the AC were appropriate: 96% of CT and 86% of MRI (P = .009). Appropriate examinations were more likely to provide a significant result than not appropriate studies (48% vs. 24%, P = .041). Although a significant result was related to the primary study indication more frequently in appropriate than not appropriate examinations, this difference was not significant (93% vs. 80%, respectively, P = .204). The most common indications not matching an AC were colon cancer follow-up (n = 14) and melanoma follow-up (n = 14) among CT, and hepatocellular carcinoma screening (n = 31) and elevated prostate-specific antigen (PSA) without prior biopsy (n = 14) among MRI. CONCLUSIONS: Most examinations matching the AC were appropriate, and appropriate examinations were more likely to have a significant result. However, most examinations, including 62% of MRI, had no relevant clinical condition, highlighting a critical area for future AC expansion and modification.

PURPOSE: To describe the performance of the nation's hospitals in terms of the Hospital Outpatient Quality Reporting Program's imaging efficiency measures. METHODS: Data were obtained from the Hospital Compare website and reflect outpatient Medicare claims of 4,118 hospitals for 5 imaging efficiency metrics: (1) frequency of combination abdominal CT (performed with and without intravenous contrast); (2) combination chest CT (performed with and without intravenous contrast); (3) simultaneous brain/sinus CT; (4) mammography follow-up (diagnostic imaging after screening mammography); and (5) lumbar spine MRI for low back pain without prior conservative therapy. Metrics were summarized and compared with other hospital characteristics. RESULTS: Median frequency was 36.7% for lumbar spine MRI for low back pain and ranged from 1.6% to 7.8% for the remaining measures; however, extreme outliers were observed (maximal frequencies of 79.2%-95.2% for mammography follow-up and combination chest and abdominal CT). Essentially no correlation was found among measures, aside from combination abdominal and chest CT. For some measures, relatively poor performance was more commonly observed among critical access hospitals and physician-owned/proprietary hospitals, and less commonly observed among U.S. News & World Report "best" hospitals and primary residency teaching sites. Frequencies for combination abdominal and chest CT improved from 2013 to 2014 among hospitals with relatively poorer performance. CONCLUSIONS: Although the imaging efficiency measures help identify individual hospitals and hospital categories with relatively inefficient imaging practices, they do not readily identify distinctly positively performing hospitals. Excess utilization was suggested for lumbar spine MRI. Frequency of combination abdominal and chest CT examinations improved over a short time interval.

Radiologists are increasingly recognizing their role as direct service providers to patients and seeking to offer an exceptional patient experience as part of high-quality service delivery. Patients' perceptions of service delivery are derived from the chain of numerous individual real-time encounters that occur throughout their visit. These so-called "moments of truth" define the overall experience and form the lasting impression of the given practice in their mind. Providing excellent service can be difficult to achieve in practice given its intangible nature as well as the heterogeneity and unpredictability of the large number of patients, frontline staff, and environmental circumstances that define the patient experience. Thus, broad commitment and team effort among all members of a radiology practice are required. This article explores important areas to be considered by a radiology practice to ensure positive and meaningful patient experiences. Specific ways in which every member within the practice, including schedulers, receptionists, technologists, nurses, and radiologists, can contribute to achieving high-quality patient service are discussed. Examples of patient-oriented language that may be useful in particular scenarios in radiology practice are given. The role of the practice's physical facility, including all aspects of its aesthetics and amenities, as well as of Internet services, in shaping the patient experience is also described. Throughout this work, a proactive approach to promoting a service-oriented organizational culture is provided. By improving the patient experience, these strategies may serve to enhance patients' perceptions of radiology and radiologists.

PURPOSE: To report design of a simplified external transmit-receive coil array for 7 Tesla (T) prostate MRI, including demonstration of the array for tumor localization using T2-weighted imaging (T2WI) at 7T before prostatectomy. MATERIALS AND METHODS: Following simulations of transmitter designs not requiring parallel transmission or radiofrequency-shimming, a coil array was constructed using loop elements, with anterior and posterior rows comprising one transmit-receive element and three receive-only elements. This coil structure was optimized using a whole-body phantom. In vivo sequence optimization was performed to optimize achieved flip angle (FA) and signal to noise ratio (SNR) in prostate. The system was evaluated in a healthy volunteer at 3T and 7T. The 7T T2WI was performed in two prostate cancer patients before prostatectomy, and localization of dominant tumors was subjectively compared with histopathological findings. Image quality was compared between 3T and 7T in these patients. RESULTS: Simulations of the B1 + field in prostate using two-loop design showed good magnitude (B1 + of 0.245 A/m/w1/2 ) and uniformity (nonuniformity [SD/mean] of 10.4%). In the volunteer, 90 degrees FA was achieved in prostate using 225 v 1 ms hard-pulse (indicating good efficiency), FA maps confirmed good uniformity (14.1% nonuniformity), and SNR maps showed SNR gain of 2.1 at 7T versus 3T. In patients, 7T T2WI showed excellent visual correspondence with prostatectomy findings. 7T images demonstrated higher estimated SNR (eSNR) in benign peripheral zone (PZ) and tumor compared with 3T, but lower eSNR in fat and slight decreases in tumor-to-PZ contrast and PZ-homogeneity. CONCLUSION: We have demonstrated feasibility of a simplified external coil array for high-resolution T2-weighted prostate MRI at 7T.J. Magn. Reson. Imaging 2013. (c) 2013 Wiley Periodicals, Inc.

PURPOSE: To assess impact of two-channel parallel transmission (pTx) with focused excitation [zoomed echo-planar imaging (EPI)] on image quality of prostate diffusion-weighted imaging (DWI) at 3T. METHODS: 27 male volunteers (27 +/- 8 years) underwent 3T prostate MRI using 2-channel radiofrequency-transmit system and 18-channel torso receive coil. Scans included EPI-DWI sequence (b values 50, 500, 1000 s/mm2) acquired both with standard sinc pulse and 2-channel pTX with focused excitation, each acquired at large-field-of-view (FOV) (20 x 20 cm) and small-FOV (14 x 14 cm). An abdominal radiologist scored b-1000 images and ADC maps for image quality measures. Sequences were compared using paired Wilcoxon tests. RESULTS: pTx with focused excitation showed significant improvements compared with standard DWI on b-1000 images at large-FOV for the absence of wrap and overall image quality (p /= 0.175), while showing significant improvements on the ADC maps in terms of reduced distortion, absence of ghosting, and absence of wrap (p = 0.010-0.030). CONCLUSION: Zoomed DWI using 2-channel pTx reduced artifacts and improved image quality for 3T prostate DWI; benefit was most apparent for small-FOV images.

Quantitative imaging (QI) is increasingly applied in modern radiology practice, assisting in the clinical assessment of many patients and providing a source of biomarkers for a spectrum of diseases. QI is commonly used to inform patient diagnosis or prognosis, determine the choice of therapy, or monitor therapy response. Because most radiologists will likely implement some QI tools to meet the patient care needs of their referring clinicians, it is important for all radiologists to become familiar with the strengths and limitations of QI. The Association of University Radiologists Radiology Research Alliance Quantitative Imaging Task Force has explored the clinical application of QI and summarizes its work in this review. We provide an overview of the clinical use of QI by discussing QI tools that are currently used in clinical practice, clinical applications of these tools, approaches to reporting of QI, and challenges to implementing QI. It is hoped that these insights will help radiologists recognize the tangible benefits of QI to their patients, their referring clinicians, and their own radiology practice.

PURPOSE: To evaluate sustainability of impact of rapid, focused process improvement (PI) events on process and performance within an academic radiology department. METHODS: Our department conducted PI during 2011 and 2012 in CT, MRI, ultrasound, breast imaging, and research billing. PI entailed participation by all stakeholders, facilitation by the department chair, collection of baseline data, meetings during several weeks, definition of performance metrics, creation of an improvement plan, and prompt implementation. We explore common themes among PI events regarding initial impact and durability of changes. We also assess performance in each area pre-PI, immediately post-PI, and at the time of the current study. RESULTS: All PI events achieved an immediate improvement in performance metrics, often entailing both examination volumes and on-time performance. IT-based solutions, process standardization, and redefinition of staff responsibilities were often central in these changes, and participants consistently expressed improved internal leadership and problem-solving ability. Major environmental changes commonly occurred after PI, including a natural disaster with equipment loss, a change in location or services offered, and new enterprise-wide electronic medical record system incorporating new billing and radiology informatics systems, requiring flexibility in the PI implementation plan. Only one PI team conducted regular post-PI follow-up meetings. Sustained improvement was frequently, but not universally, observed: in the long-term following initial PI, measures of examination volume showed continued progressive improvements, whereas measures of operational efficiency remained stable or occasionally declined. CONCLUSIONS: Focused PI is generally effective in achieving performance improvement, although a changing environment influences the sustainability of impact. Thus, continued process evaluation and ongoing workflow modifications are warranted.

Academic radiology is poised to play an important role in the development and implementation of quantitative imaging (QI) tools. This article, drafted by the Association of University Radiologists Radiology Research Alliance Quantitative Imaging Task Force, reviews current issues in QI biomarker research. We discuss motivations for advancing QI, define key terms, present a framework for QI biomarker research, and outline challenges in QI biomarker development. We conclude by describing where QI research and development is currently taking place and discussing the paramount role of academic radiology in this rapidly evolving field.