Faculty Bibliography

OBJECTIVE. The objective of this article is to assess radiologist concordance in characterizing thyroid nodules using the American College of Radiology Thyroid Imaging Reporting and Data System (TI-RADS), focusing on the effect of radiologist experience on reader concordance. MATERIALS AND METHODS. Three experienced and three less experienced radiologists assessed 150 thyroid nodules using the TI-RADS lexicon. Percent concordance was determined for various endpoints. RESULTS. Interreader concordance for the five TI-RADS categories was 87.2% for shape, 81.2% for composition, 76.1% for echogenicity, 72.9% for margins, and 69.8% for echogenic foci. Concordance for individual features was 96.3% for rim calcifications, 90.8% for macrocalcifications, 90.1% for spongiform, 83.5% for comet tail artifact, and 77.7% for punctate echogenic foci. Concordance for the TI-RADS level and recommendation for fine-needle aspiration (FNA) were 50.4% and 78.9%, respectively. Concordance was significantly (p < 0.05) higher for less experienced readers in identifying margins (84.3% vs 67.4%), echogenic foci (76.9% vs 69.3%), comet tail artifact (89.6% vs 79.2%), and punctate echogenic foci (85.3% vs 75.5%), and lower for peripheral rim calcifications (95.0% vs 97.8 %), but was not different (p > 0.05) for the remaining categories and features. CONCLUSION. A range of TI-RADS categories, features, and recommendations for FNA had generally moderate interreader agreement among six radiologists. Our results show that concordance for numerous characteristics was significantly higher for the less experienced versus the more experienced readers. These results suggest that less experienced readers relied more on the explicit TI-RADS criteria, whereas the experienced radiologists partially relied on their accumulated experience when forming impressions. However, the overall TI-RADS level and recommendation for FNA were unaffected, supporting the robustness of the TI-RADS lexicon and its continued use in practice.

PURPOSE/OBJECTIVE:To evaluate the effect of English proficiency on abdominal MRI imaging quality. METHODS:Three equal-sized cohorts of patients undergoing 3T abdominal MRI were identified based on English proficiency as documented in the EMR: Primary language of English; English as a second language (ESL)/no translator needed; or ESL, translator needed (42 patients per cohort for total study size of 126 patients). Three radiologists independently used a 1-5 Likert scale to assess respiratory motion and image quality on turbo spin-echo T2WI and post-contrast T1WI. Groups were compared using Kruskal-Wallis tests. RESULTS:For T2WI respiratory motion, all three readers scored the Translator group significantly worse than the English and ESL/no-Translator groups (mean scores across readers of 2.98 vs. 3.58 and 3.51; p values < 0.001-0.008). For T2WI overall image quality, all three readers also scored the Translator group significantly worse than the English and ESL/no-Translator groups (2.77 vs. 3.28 and 3.31; p values 0.002-0.005). For T1WI respiratory motion, mean scores were not significantly different between groups (English: 4.14, ESL/no-Translator: 4.02, Translator: 3.94; p values 0.398-0.597). For T1WI overall image quality, mean scores also were not significantly different (4.09, 3.99, and 3.95, respectively; p values 0.369-0.831). CONCLUSION/CONCLUSIONS:Abdominal MR examinations show significantly worse T2WI respiratory motion and overall image quality when requiring a translator, even compared with non-translator exams in non-English primary language patients. Strategies are warranted to improve coordination among MR technologists, translators, and non-English speaking patients undergoing abdominal MR, to ensure robust image quality in this vulnerable patient population.

RATIONALE AND OBJECTIVES/OBJECTIVE:To assess the prevalence and associated factors of burnout among U.S. academic radiologists. MATERIALS AND METHODS/METHODS:An online survey was sent to the radiologists who were full members of the Association of University Radiologists in December 2018. Burnout was measured using the abbreviated Maslach Burnout Inventory Human Services Survey. Survey respondents were also requested to complete questions on demographics, potential professional stressors, sense of calling, and career satisfaction. Associations between survey participants' characteristics and burnout were tested using logistic regression model. RESULTS:The survey response rate was 27% (228/831). Twenty-nine percent met all three criteria for high burnout, including high emotional exhaustion, high depersonalization, and low personal accomplishment. Seventy-nine percent had one or more symptoms of burnout. Numerous factors including work overload, inability to balance personal and professional life, lack of autonomy, lack of appreciation from patients and other medical staff were significantly associated (p < 0.05) with high burnout. Older age (OR, 0.95; 95%CI 0.92-0.98; p < 0.05), higher number of years of experience practicing as radiologists (OR, 0.95; 95%CI 0.92-0.98; p < 0.05), and holding academic rank of professor (OR, 0.25; 95%CI 0.11-0.56; p < 0.05) were factors associated with lower odds of experiencing burnout. Radiologists with high burnout were more likely to be dissatisfied with their career (OR, 2.28; 95%CI 1.70-3.07; p < 0.0001) and less likely to identify medicine as a calling. CONCLUSION/CONCLUSIONS:Multiple factors contribute to high burnout in academic radiologists. Familiarity with these factors may help academic radiology departments to develop strategies to promote health and wellness of their faculty.

OBJECTIVE. The purpose of this study is to assess the perceptions of radiologists and emergency medicine (EM) providers regarding the quality, value, and challenges associated with using outside imaging (i.e., images obtained at facilities other than their own institution). MATERIALS AND METHODS. We surveyed radiologists and EM providers at a large academic medical center regarding their perceptions of the availability and utility of outside imaging. RESULTS. Thirty-four of 101 radiologists (33.6%) and 38 of 197 EM providers (19.3%) responded. A total of 32.4% of radiologists and 55.3% of EM providers had confidence in the quality of images from outside community facilities; 20.6% and 44.7%, respectively, had confidence in the interpretations of radiologists from these outside facilities. Only 23.5% of radiologists and 5.3% of EM physicians were confident in their ability to efficiently access reports (for outside images, 47.1% and 5.3%). Very few radiologists and EM providers had accessed imaging reports from outside facilities through an available stand-alone portal. A total of 40.6% of radiologists thought that outside reports always or frequently reduced additional imaging recommendations (62.5% for outside images); 15.6% thought that reports changed interpretations of new examinations (37.5% for outside images); and 43.8% thought that reports increased confidence in interpretations of new examinations (75.0% for outside images). A total of 29.4% of EM providers thought that access to reports from outside facilities reduced repeat imaging (64.7% for outside images), 41.2% thought that they changed diagnostic or management plans (50.0% for outside images), and 50.0% thought they increased clinical confidence (67.6% for outside images). CONCLUSION. Radiologists and EM providers perceive high value in sharing images from outside facilities, despite quality concerns. Substantial challenges exist in accessing these images and reports from outside facilities, and providers are unlikely to do so using separate systems. However, even if information technology solutions for seamless image integration are adopted, providers' lack of confidence in outside studies may remain an important barrier.

RATIONALE AND OBJECTIVES/OBJECTIVE:In 2019, Centers for Medicare and Medicaid Services enforced regulation from the Affordable Care Act, requiring all U.S. hospitals to publish standard hospital charges annually. This study assesses top U.S academic hospitals' chargemasters for selected advanced diagnostic imaging services and the usability of publicly available information to allow consumers to determine out-of-pocket costs. MATERIALS AND METHODS/METHODS:Publicly available chargemasters and associated websites for the top 20 ranked hospitals in U.S. News and World Report were assessed for several features including: file format, inclusion of CPT codes, disclaimers on charges versus costs and professional fees, and tools allowing determination of actual out-of-pocket costs for selected advanced diagnostic imaging examinations. RESULTS:All hospitals had publicly available chargemasters, 90% of which were in Microsoft Excel format. Ten percent of chargemasters included CPT codes. All chargemaster websites had disclaimers regarding differences between charges versus patient costs; 20% had disclaimers regarding professional fees. 20% of hospitals provided out-of-pocket costs for uninsured patients or tools allowing out-of-pocket cost determination. Median (range) MR exam charges were: brain with and without contrast: $5375 ($834-$13,857), noncontrast knee: $3402 (4530-$6924); noncontrast lumbar spine: $ 3449 ($473-$7367). Median (range) CT exam charges were: noncontrast head: $1923 ($165-$4974), noncontrast chest: $1947 ($282-$2991); contrast abdomen/pelvis: $4307 ($486-$11,726). CONCLUSION/CONCLUSIONS:While all top-ranked hospitals had publicly available chargemasters, they rarely provided transparent information to allow patients to determine out-of-pocket costs for advanced diagnostic imaging services.

PURPOSE/OBJECTIVE:Provide evidence- and expert-based recommendations for optimal use of imaging in advanced prostate cancer. Due to increases in research and utilization of novel imaging for advanced prostate cancer, this guideline is intended to outline techniques available and provide recommendations on appropriate use of imaging for specified patient subgroups. METHODS:An Expert Panel was convened with members from ASCO and the Society of Abdominal Radiology, American College of Radiology, Society of Nuclear Medicine and Molecular Imaging, American Urological Association, American Society for Radiation Oncology, and Society of Urologic Oncology to conduct a systematic review of the literature and develop an evidence-based guideline on the optimal use of imaging for advanced prostate cancer. Representative index cases of various prostate cancer disease states are presented, including suspected high-risk disease, newly diagnosed treatment-naïve metastatic disease, suspected recurrent disease after local treatment, and progressive disease while undergoing systemic treatment. A systematic review of the literature from 2013 to August 2018 identified fully published English-language systematic reviews with or without meta-analyses, reports of rigorously conducted phase III randomized controlled trials that compared ≥ 2 imaging modalities, and noncomparative studies that reported on the efficacy of a single imaging modality. RESULTS:A total of 35 studies met inclusion criteria and form the evidence base, including 17 systematic reviews with or without meta-analysis and 18 primary research articles. RECOMMENDATIONS/CONCLUSIONS:One or more of these imaging modalities should be used for patients with advanced prostate cancer: conventional imaging (defined as computed tomography [CT], bone scan, and/or prostate magnetic resonance imaging [MRI]) and/or next-generation imaging (NGI), positron emission tomography [PET], PET/CT, PET/MRI, or whole-body MRI) according to the clinical scenario.

PURPOSE/OBJECTIVE:CMS implemented Merit-Based Incentive Payment System (MIPS) policies to cap points and remove "topped out" quality measures having extremely high national performance. We assess such policies' impact on quality measure reporting, focusing on diagnostic radiology. METHODS:Data regarding MIPS 2019 quality measures were extracted from the CMS Quality Benchmarks File and the Quality Payment Program Explore Measures search tool and summarized by collection type and specialty. RESULTS:Among 348 MIPS measure-and-collection-type combinations, 40.5% were topped out (56.6% of those with a benchmark) and 23.3% were capped. Among measures with a benchmark, the percent topped out varied (P < .001) by collection type: claims 82.7%, qualified registry 60.4%, electronic health record 11.6%. The percent capped was also greatest for claims measures (52.3%). Among 699 Qualified Clinical Data Registry (QCDR) measures, 63 had a benchmark, of which 44.4% were topped out. The percent of measures topped out also varied significantly (P < .001) by specialty, ranging from 0.0% (electrophysiology) to 95.0% (diagnostic radiology). Among 20 unique measure-and-collection-type combinations for diagnostic radiology, only one was not topped out, and 30.0% were capped. Among 20 radiology QCDR measures, 5 had a benchmark, of which 3 were topped out. CONCLUSION/CONCLUSIONS:CMS topped out measure scoring and removal policies disproportionately impact radiology, which has the highest topped out percentage among all specialties and only a single non-topped out measure. This asymmetry disproportionately impairs radiologists' MIPS flexibility and is anticipated to progress in ensuing years. Current CMS policies create a looming crisis for radiologists in MIPS. The high risk of an insufficient number of available quality measures creates an urgent need for new radiology measure development.

PURPOSE/OBJECTIVE:The aim of this study was to assess recent trends in the generalist versus subspecialist composition of the national radiologist workforce. METHODS:Practicing radiologists were identified using 2012 to 2017 CMS Physician and Other Supplier Public Use Files. Work relative value units associated with radiologists' billed claims were mapped to subspecialties using the Neiman Imaging Types of Service to classify radiologists as subspecialists when exceeding a 50% work effort in a given subspecialty and as generalists otherwise. Additional practice characteristics were obtained from CMS Physician Compare. Chi-square statistics were computed. RESULTS:The percentage of radiologists practicing as subspecialists increased from 37.1% in 2012 and 2013 to 38.8% in 2014, 41.0% in 2015, 43.9% in 2016, and 44.6% in 2017. By subspecialty, 2012 to 2017 workforce changes were as follows: breast, +3.7%; abdominal, +2.4%; neuroradiology, +1.8%; musculoskeletal, +0.8%; cardiothoracic, +0.2%; nuclear, -0.2%; and interventional, -1.2%. Increased subspecialization overall was consistently observed (P < .05) across cohorts defined by gender, years in practice, practice size, and academic status. The degree of increasing subspecialization was greatest for female (+12.1%) and earlier career (+10.2% for those in practice <10 years) radiologists and those in larger groups (+7.2% for ≥100 members). Subspecialization increased in 45 states, and state-level increased subspecialization correlated weakly with population density (r = +0.248). CONCLUSIONS:In recent years, the national radiologist workforce has become increasingly subspecialized, particularly related to shifts toward breast imaging, abdominal imaging, and neuroradiology. Although growing subspecialization may advance more sophisticated imaging care, a diminishing supply of generalists could affect patient access and potentially separate radiologists across workforce sectors.