Faculty Bibliography

RATIONALE AND OBJECTIVES/OBJECTIVE:This study aimed to characterize articles in popular general radiology journals that go uncited for a decade after publication. METHODS:Using the Web of Science database, we identified annual citation counts for 13,459 articles published in Radiology, American Journal of Roentgenology, and Academic Radiology between 1997 and 2006. From this article cohort, we then identified all original research articles that accrued zero citations within a decade of publication. A concurrent equal-sized cohort of most cited articles was created. Numerous characteristics of the uncited and most cited articles were identified and compared. RESULTS:Only 47 uncited articles went uncited for a decade after publication. When compared to the 47 most cited articles over that same window, the uncited articles were significantly (P < .05) less likely to have a clinical focus, include a nonradiologist author and authors from multiple institutions and multiple nations, report research funding support and statistically significant findings, and include punctuation marks in their titles. Compared to the most cited articles, uncited articles also had significantly (P < .05) fewer authors, abstract words, manuscript words, references, tables, figure parts, and pages, as well as smaller subject sample sizes. CONCLUSION/CONCLUSIONS:Of articles published in popular general radiology journals, only a very small number of original research investigations remained uncited a decade after publication. Given that citations reflect the impact of radiology research, this observation suggests that journals are appropriately selecting meaningful work. Investigators seeking to avoid futile publication might consider their research initiatives in light of these characteristics.

PURPOSE/OBJECTIVE:To investigate the national coverage landscape for prostate MRI services, assessing the presence of updated and accurate coverage requirements by private payers. METHODS:The database Policy Reporter was used to evaluate private payer coverage related to prostate MRI for 81 plans covering 149 million people in the United States. Both the indications and requirements for prostate MRI coverage were recorded in a variety of clinical scenarios, including initial diagnosis, staging, active surveillance, and suspected recurrence. RESULTS:Overall, 11.1% of payers cover prostate MRI in biopsy-naïve patients with suspected prostate cancer, with the remaining 88.9% requiring a prior negative biopsy. Nearly all payers also require either a rising prostate-specific antigen (PSA) or abnormal digital rectal examination (DRE). Rarely, a planned future MRI-targeted biopsy serves as a basis for MRI coverage. Initial staging is covered by most payers, although typically with stringent indications (eg, PSA ≥ 20 ng/mL, Gleason score ≥7 or 8, stage T3 or T4, or ≥20% risk of nodal metastases). Only 10 payers discuss active surveillance, with 8 of these requiring a repeat biopsy before MRI. Coverage for detection of post-treatment recurrence often requires a rising PSA or abnormal DRE, and occasionally only if a CT is first performed; only 10 of 81 payers address coverage after androgen deprivation treatment. CONCLUSION/CONCLUSIONS:Prostate MRI coverage varies widely among private payers, fails to recognize major clinical scenarios, is overly restrictive, and is often not reflective of current clinical practice. This creates challenges for patients and referring physicians seeking to obtain ready access to prostate MRI services.

CONTEXT/BACKGROUND:- In Gleason score GS (7) prostate cancers, the quantity of Gleason pattern 4 (GP 4) is an important prognostic factor and influences treatment decisions. Magnetic resonance imaging (MRI)-targeted biopsy has been increasingly used in clinical practice. OBJECTIVE:- To investigate whether MRI-targeted biopsy may detect GS 7 prostate cancer with greater GP 4 quantity, and whether it improves biopsy/radical prostatectomy GS concordance. DESIGN/METHODS:- A total of 243 paired standard and MRI-targeted biopsies with cancer in either standard or targeted or both were studied, 65 of which had subsequent radical prostatectomy. The biopsy findings, including GS and tumor volume, were correlated with the radical prostatectomy findings. RESULTS:- More prostate cancers detected by MRI-targeted biopsy were GS 7 or higher. Mean GP 4 percentage in GS 7 cancers was 31.0% ± 29.3% by MRI-targeted biopsy versus 25.1% ± 29.5% by standard biopsy. A total of 122 of 218 (56.0%) and 96 of 217 (44.2%) prostate cancers diagnosed on targeted biopsy and standard biopsy, respectively, had a GP 4 of 10% or greater ( P = .01). Gleason upgrading was seen in 12 of 59 cases (20.3%) from MRI-targeted biopsy and in 24 of 57 cases (42.1%) from standard biopsy ( P = .01). Gleason upgrading correlated with the biopsy cancer volume inversely and GP 4 of 30% or less in standard biopsy. Such correlation was not found in MRI-targeted biopsy. CONCLUSIONS:- Magnetic resonance imaging-targeted biopsy may detect more aggressive prostate cancers and reduce the risk of Gleason upgrading in radical prostatectomy. This study supports a potential role for MRI-targeted biopsy in the workup of prostate cancer and inclusion of percentage of GP 4 in the prostate biopsy reports.

The Medicare and CHIP Reauthorization Act of 2015 remains the payment policy law of the land. 2017 was the first year in which performance reporting will tangibly impact future physician payments. The Centers for Medicare & Medicaid Services (CMS) considers 2017 and 2018 transitional years before full implementation in 2019. As such, 2018 increases the reporting requirements over 2017 in the form of a gradual phase-in while introducing several key changes and new elements. Indeed, it is the nature of the transition itself that led to the somewhat unique title of this manuscript, i.e., MACRA 2.5. Stakeholder feedback to the CMS regarding the program has ranged widely from the elimination of core components to expanding reporting to non-government payers. This article explores the potential impact on neurointerventional physicians.

OBJECTIVE:The purpose of this study is to assess downstream costs associated with pancreatic cysts incidentally detected at MRI. MATERIALS AND METHODS/METHODS:Two hundred patients with an incidental pancreatic cyst detected at MRI were identified. Downstream events (imaging, office visits, endoscopic ultrasound-guided fine-needle aspiration, or chemotherapy) were identified from the electronic medical record. Radiologists' recommendations and ordering physician management were classified relative to the American College of Radiology (ACR) incidental findings committee recommendations. Costs for the downstream events were estimated using national Medicare rates and a 3% annual discount rate. Mean costs were computed. RESULTS:Estimated downstream costs averaged $460 per cyst ($872 per cyst with any follow-up testing). Nine patients had a clinically relevant outcome during follow-up (increase in cyst size, development of new cyst, or development of pancreatic cancer). Downstream cost per cyst with a clinically relevant outcome was $1364. Costs were greater when ordering physicians overmanaged ($842) versus when they were adherent ($631) or undermanaged ($252) relative to radiologist recommendation. Although costs were $252 when ordering physicians undermanaged relative to ACR incidental findings committee recommendations, costs were similar when ordering physicians were adherent ($811) or overmanaged ($845) relative to ACR incidental findings committee recommendations. Costs did not vary significantly according to whether radiologists recommended follow-up testing ($317-$491) or whether radiologist recommendations were adherent, undermanaged, or overmanaged relative to ACR incidental findings committee recommendations ($344-$528). CONCLUSION/CONCLUSIONS:The findings suggest a role for targeted educational efforts, collaborative partnerships, and other initiatives to foster greater adherence to radiologist recommendations, including critical test results notification systems, automated reminders within electronic health systems, and stronger language within radiology reports when no follow-up testing is recommended.

Electronic brachytherapy (EBT) garnered interest among dermatologists as a non-invasive treatment for keratinocyte carcinomas. While the magnitude of use and cost burden had not yet been quantified, this interest prompted an official statement from the American Academy of Dermatology supporting its use as secondary option in special circumstances, and led to changes to billing and coding for the procedure. Using provider level Medicare claims, this study demonstrates increased use of EBT between 2012-2015. We also showed that very few dermatologists utilized EBT, with only 39 dermatologists billing for EBT in 2015. This study documents that large scale policy changes were implemented in response to the practice behaviors of a small number of dermatologists, and provides information regarding the cost of EBT for consideration on how to best optimize its use in clinical practice.

OBJECTIVE:The objective of our study was to study patterns of services rendered by U.S. physicians who self-identify as nuclear medicine (NM) specialists. MATERIALS AND METHODS/METHODS:Recent Medicare physician claims and demographic files were obtained and linked. NM specialists were defined as physicians self-identifying NM as their primary specialty on claims or as any of their specialties during enrollment. Using other self-identified specialties, we classified physicians as nuclear radiologists, nuclear cardiologists, exclusively NM physicians, or Others. Our primary outcome measure was the percentage of NM effort (in work relative value units [WRVUs]) per physician per specialty group. Secondary outcome measures included physician sociodemographic parameters and most common uniquely rendered services. RESULTS:Nationally, 1583 physicians self-identified as NM specialists during the calendar years 2012 through 2015. The distribution of WRVUs attributed to NM varied widely by specialty group; most nuclear radiologists and nuclear cardiologists devoted 10% or less of their effort to NM services whereas most NM physicians devoted 90% or more of their effort to NM services. NM specialists were most commonly nuclear radiologists (52.2%) and men (80.3%) and practiced in urban (98.4%) and nonacademic settings (62.9%). NM physicians interpreted more general NM studies, nuclear radiologists interpreted more cross-sectional imaging studies, and nuclear cardiologists interpreted mostly nuclear cardiology studies, with a majority of their overall work attributed to clinical evaluation and management (E/M). E/M services accounted for less than 2% of WRVUs for both nuclear radiologists and NM physicians. CONCLUSION/CONCLUSIONS:The work patterns of U.S. NM specialists is highly variable. Most NM physicians practice 90% or more NM, whereas most nuclear radiologists and nuclear cardiologists practice 10% or less NM. Commonly performed services vary considerably by specialty group.

PURPOSE/OBJECTIVE:The purpose of the study is to characterize current practice patterns of abdominal radiologists based on work descriptions within job postings on numerous national radiology specialty websites. METHODS:Job postings for either "abdominal" or "body" radiologists were searched weekly on five society websites (SAR, SCBT-MR, ARRS, ACR, RSNA) over a 1-year period. Postings were reviewed for various characteristics. RESULTS:Nine hundred and sixteen total ads for 341 unique abdominal radiologist positions were reviewed (34.6% academic, 64.2% private practice, 1.2% other). Postings occurred most commonly in March (12.3%) and least commonly in November (4.8%). States with most positions were Florida (27), California (26), and New York (24). Of postings delineating expectations of specific abdominal modalities, 67.4% mentioned MRI, 58.5% ultrasound, 41.1% fluoroscopy, 14.3% PET, and 54.0% interventions. Additional non-abdominal expectations included general radiology (28.7%), breast imaging (21.1%), and general nuclear medicine (9.7%). Additional skills included prostate MRI (7.0%), OBGYN ultrasound (5.0%), and CT colonoscopy (2.6%). 79.2% required an abdominal imaging fellowship (specifically a body MRI fellowship in 4.1%). CONCLUSION/CONCLUSIONS:By using job postings for abdominal radiologists, we have taken a practical approach to characterizing the current status of this subspecialty, reflecting recent job expectations and requirements. The large majority of positions required a body fellowship, and the positions commonly entailed a variety of skills beyond non-invasive diagnostic abdominal imaging. Of note, expectations of considerable minorities of positions included abdominal interventions, general radiology, and breast imaging. These insights may guide the development of abdominal radiology fellowships and mini-fellowships, as well as assist radiologists entering or returning to the job market.

PURPOSE/OBJECTIVE:While MRI-Ultrasound Fusion-targeted biopsy (MRF-TB) allows for improved detection of clinically significant prostate cancer (csPCa), concerning numbers of clinically significant disease are still missed. We hypothesize that a number of these are due to the learning curve associated with MRF-TB. We report results of repeat MRF-TB in men with continued suspicion for cancer and the institutional learning curve in detection of csPCa over time. MATERIALS AND METHODS/METHODS:Analysis of 1813 prostate biopsies in a prospectively acquired cohort of men presenting for prostate biopsy over a 4-year period. All men were offered pre-biopsy MRI and assigned a maximum Prostate Imaging - Reporting and Data System version 2 (PI-RADS) score. Biopsy outcomes of men with suspicious region of interest (ROI) were compared. The relationship between time and csPCa detection was analyzed. RESULTS:csPCa detection rate increased 26% over time in men with PI-RADS 4 and 5 (4/5) ROI. On repeat MRF-TB in men with continued suspicion for cancer, 53% of men with PI-RADS 4/5 ROI demonstrated clinically significant discordance from initial MRF-TB, compared to only 23% of men with PI-RADS 1/2 ROI. Significantly less csPCa were missed or under-graded in the most recent biopsies as compared to the earliest biopsies. CONCLUSION/CONCLUSIONS:High upgrade rates on repeat MRF-TB and increasing cancer detection rate over time demonstrate the significant learning curve associated with MRF-TB. Men with low risk or negative biopsies with persistent concerning ROI should be promptly re-biopsied. Improved targeting accuracy with operator experience can help decrease the number of missed csPCa.