Faculty Bibliography

PURPOSE/OBJECTIVE:The aims of this study were to compare the number of unique Medicare fee-for-service beneficiaries served by radiologists and other physicians and to identify characteristics of radiologists serving the most number of unique patients. METHODS:Medicare Physician and Other Supplier Public Use Files were used to identify all physicians who provided services to Medicare fee-for-service beneficiaries for the entirety of 2013. The average number of unique beneficiaries served was computed per specialty. The number of unique beneficiaries served was further stratified among radiologists in terms of physician and practice characteristics. RESULTS:Among 56 unique physician specialties, diagnostic radiologists on average served the most unique beneficiaries (3,150 ± 2,344). Among radiologists, the number of unique beneficiaries varied in association with numerous characteristics and was larger for male (3,214) versus female (2,521) radiologists, rural (3,551) versus urban (3,092) radiologists, nonacademic (3,427) versus academic (1,932) radiologists, generalist (3,866) versus subspecialist (1,981) radiologists, and radiologists in the South (3,716) versus other geographic regions (range, 2,432-3,217). The number of unique beneficiaries served increased significantly with smaller group practice size (2,218 for ≥100 group members versus 3,669 for ≤9 members). Among subspecialists, the number of unique beneficiaries was largest for breast imagers (2,594). CONCLUSIONS:The large number of unique beneficiaries served by radiologists highlights their important role in orchestrating patient care and their immense opportunities to expand the face of the specialty. An understanding of which radiologists serve the largest numbers of unique patients may help radiology practices target patient engagement and other Imaging 3.0™ efforts.

Imaging is critically important for the diagnosis, staging, and management of men with high-risk prostate cancer. Conventional imaging modalities, including computed tomography and radionuclide bone scan have been employed for local and metastatic staging, but their performance has generally been poor. Sodium fluoride positron emission tomography is recommended when there is high suspicion for bone metastases despite a negative or indeterminate bone scan. Magnetic resonance imaging has advantages in local staging but its value depends on the extent of disease. Whole body positron emission tomography/magnetic resonance imaging could provide both local and distant staging although the technology is not yet widely disseminated. None of the existing positron emission tomography agents are recommended in practice guidelines, however, among them, prostate specific membrane antigen-based tracers seem to hold the most promise based on sensitivity and specificity.

OBJECTIVE:The purpose of this study is to assess the utility of texture analysis of multiple MRI sequences for the differentiation of uterine leiomyomas and leiomyosarcomas. MATERIALS AND METHODS/METHODS:Seventeen leiomyosarcomas and 51 leiomyomas undergoing MRI before resection were included. Whole-lesion volumes of interest were placed on T2-weighted images, contrast-enhanced T1-weighted images, and apparent diffusion coefficient (ADC) maps. The diagnostic performance of histogram metrics was assessed. RESULTS:achieved sensitivity of 82.4% and specificity of 74.5%. CONCLUSION/CONCLUSIONS:For whole-lesion histogram metrics obtained on various MRI sequences, T2-weighted images provided the highest, and ADC maps the lowest, performance for differentiating uterine leiomyomas and leiomyosarcomas. Metrics reflecting percentiles from the bottom half of the histogram distribution outperformed the standard mean. Models combining the T2-weighted imaging whole-lesion metrics and patient age achieved particularly high diagnostic performance. Although these findings require validation in larger studies, they have implications for facilitating improved treatment selection for these two entities.

PURPOSE/OBJECTIVE:In March 2017, the ACGME relaxed resident duty-hour restrictions to allow first-year residents to work 24-hour shifts, affecting the internship experience of incoming radiology residents. The aim of this study was to assess the media response to this duty-hour change, comparing news articles with favorable and unfavorable views. METHODS:Google News was used to identify 36 relevant unique news articles published over a 4-week period after the announcement. Articles' stance was categorized as favorable, unfavorable, or neutral. Additional article characteristics were explored. RESULTS:Article sources were 58% national, 22% local, and 20% medical news. Article stance was most commonly unfavorable for national news sources (48%), compared with neutral for local (62%) and medical (72%) news sources. Most common reasons for unfavorable stance were sleep deprivation (n = 11), medical errors (n = 11), residents' health (n = 9), risk for car accidents (n = 9), a patriarchal hazing system (n = 6), and work-life balance (n = 5). Most common reasons for favorable stance were impact on resident education (n = 7) and continuity of care (n = 7). Supporting data were cited by 38% of unfavorable and 100% of favorable articles. Unfavorable articles most commonly quoted physicians affiliated with resident advocacy groups; favorable articles most commonly quoted physicians affiliated with the ACGME. CONCLUSIONS:The relaxed duty-hour restrictions received an overall unfavorable media response, particularly in nonmedical news sources, driven by concerns regarding sleep-deprived doctors. Favorable articles ubiquitously cited data supporting the safety of relaxed duty hour restrictions. Further research is warranted to better understand the impact of relaxed resident duty-hour limits on sleep deprivation, residents' health and education, and the quality of patient care.

OBJECTIVE:The purpose of this study is to identify the specialty characteristics of providers referring musculoskeletal (MSK) extremity imaging examinations to radiologists, so as to better understand the drivers of MSK imaging utilization and potentially improve the appropriateness of such imaging examinations. MATERIALS AND METHODS/METHODS:Data on provider referral for MSK extremity imaging services were extracted from the 2014 Medicare Referring Provider Utilization for Procedures public use file, which aggregates data on diagnostic procedures according to referring provider identities and service codes. MSK extremity imaging services were identified using Neiman Institute Types of Service codes. The referring provider specialty was identified from cross-linked Medicare provider characteristics files. RESULTS:For 4,275,647 MSK extremity imaging examinations ordered, the most common specialties of the referring providers were orthopedic surgery (37.6% of ordered examinations), internal medicine (20.2%), family practice (14.8%), emergency medicine (7.9%), and rheumatology (5.7%). Orthopedic surgery was the referring specialty that most commonly ordered MSK extremity CT (33,465 ordered examinations; for all other specialties, < 2000 examinations), MRI (325,485 examinations; for all other specialities, < 20,000 examinations), and radiography (1,249,748 examinations; for all other specialities, < 850,000 examinations), whereas internal medicine was the referring specialty that most commonly ordered MSK extremity ultrasound examinations (8052 ordered examinations; for all other specialties, < 6000 examinations). Among the select specialties most relevant to MSK imaging, the most frequent referrers after orthopedic surgeons were rheumatologists, for radiography (236,057 ordered examinations) and ultrasound (2034 examinations), and podiatrists, for CT (1201 examinations) and MRI (19,159 examinations). The most commonly ordered individual MSK extremity imaging services were knee radiography, with 190,354 examinations ordered by orthopedic surgeons; hand radiography, with 66,167 examinations ordered by rheumatologists; foot radiography, with 137,042 examinations ordered by podiatrists; shoulder radiography, with 11,299 examinations ordered by sports medicine specialists; and hip radiography, with 9838 examinations ordered by physiatrists. CONCLUSION/CONCLUSIONS:Referral patterns for MSK imaging vary considerably by provider specialty. Referral pattern insights may guide targeted efforts by radiologists to ensure the appropriateness of such examinations.

PURPOSE/OBJECTIVE:To study opioid prescribing behavior of US interventional radiologists (IRs). METHODS:Using Medicare Physician and Other Supplier Public Use File claims, we identified 2,133 radiologists whose practice in 2015 comprised predominantly interventional radiology. Cross-linking the Medicare Part D Prescriber File, their opioid prescription writing behavior was characterized. RESULTS:Most (52.2%) IRs wrote 10 or fewer prescriptions total for Medicare beneficiaries. Of the 47.8% who wrote >10 prescriptions, 87.4% prescribed an opioid, most commonly hydrocodone with acetaminophen, at least once (71.3%, 1-10 opioid prescriptions; 27.4%, 11-100; 1.3%, ≥101). Overall, 23.0% of all prescriptions by those IRs writing >10 were for opioids, with an average 8.0-day prescription. Average opioid prescriptions per IR were significantly (P ≤ .015) independently associated with their providing clinical evaluation and management (E&M) services (9.7 opioid prescriptions per IR with demonstrable E&M encounters versus 2.2 if not), practice size (12.6 for practices with ≤ 10 members versus 3.7-4.8 for larger groups), and geography (8.3 in the South versus 3.6-4.0 elsewhere). Rates were highest in Georgia (39.5) and lowest in Delaware (2.0). Higher opioid prescribing rates showed additional univariable associations with more years in practice and nonacademic practices. CONCLUSION/CONCLUSIONS:Most IRs write few, if any, prescriptions for Medicare beneficiaries. Of those who do, the large majority writes for opioids, at rates higher than national physician benchmarks. IRs' opioid prescribing varies significantly based on physician and practice characteristics and particularly whether the IR provides clinical E&M services. In light of the nation's opioid epidemic, these observations may guide education, practice improvement, and policy efforts to optimize opioid prescribing.

PURPOSE/OBJECTIVE:The aim of this study was to characterize out-of-pocket patient costs for advanced imaging across the US private insurance marketplace. METHODS:Using the 2017 CMS Health Insurance Marketplace Benefits and Cost Sharing Public Use File, which details coverage policies for qualified health plans on federally facilitated marketplaces, measures of out-of-pocket costs for advanced imaging and other essential health benefits were analyzed for all 18,429 plans. RESULTS:Independent of deductibles, 48.0% of plans required coinsurance (percentage fees) for advanced imaging, 9.7% required copayments (flat fees), and 8.0% required both; 34.3% required neither. For out-of-network services, 91.5% required coinsurance, 0.1% copayments, and 1.0% both; only 7.4% required neither. In the presence of deductibles, patient coinsurance burdens for advanced imaging in and out of network were 27.7% and 47.7%, respectively, and average in- and out-of-network copayments were $319 and $630, respectively. In the presence of deductibles, patients' average coinsurance ranged from 10.0% to 40.9% in network and from 29.1% to 75.0% out of network by state; these tended to be higher in lower income states (r = -0.332). For no-deductible policies, patients' average out-of-network coinsurance burden for advanced imaging was 99.9%. Among assessed benefits, advanced imaging had the highest in-network and second highest out-of-network copayments. CONCLUSIONS:In the US private insurance marketplace, patients very commonly pay coinsurance when undergoing advanced imaging, both in and out of network. But out-of-network services usually involve drastically higher patient financial responsibilities (potentially 100% of examination cost). To more effectively engage patients in shared decision making and mitigate the hardships of surprise balance billing, radiologists should facilitate transparent communication of advanced imaging costs with patients.

Purpose: To characterize Medicare services billed by current SSR members. Materials and Methods: With SSR Executive Committee permission, national provider identifiers (NPIs) were manually identified for all SSR members (who had all attested to >50% of one's practice in musculoskeletal [MSK] radiology). NPIs permitted member cross-linking to the 2015 CMS Physician and Other Supplier Public Use File to then identify all services each billed Medicare. Service codes were mapped to seven mapping-validated subspecialties (MSK, abdominal, breast, cardiothoracic, neuroradiology, nuclear medicine, and vascular-interventional radiology [VIR]) using the Neiman Imaging Types of Service classification system. Radiologists' percentages of work RVUs (wRVU) in each subspecialty were computed. Various subgroup analyses were performed. Results: Of 1,014 SSR members, 49.5% performed >=50% of their wRVUs in MSK. In terms of billed wRVUs, 53.4% of these radiologists mapped to a secondary subspecialty of neuroradiology in terms of billed wRVUs, 16.3% to abdominal, 11.8% to cardiothoracic, and 5.2% to VIR. Of all SSR members, 45.6% were generalists (i.e., no subspecialty crossed the majority wRVU threshold), but 37.4% of them performed a plurality of work in MSK. No other subspecialty accounted for greater than 2% of SSR members. A higher percentage of MSK wRVUs was significantly associated (p<0.001) with an academic affiliation (66.8% vs. 44.5%) as well as two different markers of greater SSR engagement: 1) attending the 2014 SSR meeting (63.5% vs. 49.9%) and 2) serving as an SSR committee member (75.7% vs. 51.6%). Of all other 27,618Medicare-participating radiologists nationally meeting inclusion criteria, 3.2% (879) had >=50% of their wRVUs in MSK but are not SSR members. Conclusion: Medicare claims-based practice classification provides unique insight into SSR membership. This information may help better understand current membership needs, plan future meeting content, and guide further society growth