Faculty Bibliography

PURPOSE: To identify factors associated with list price variation for radiologists' services. METHODS: The 2014 Medicare Physician and Other Supplier Public Use File was used to identify submitted charges ("list prices") and payments for radiologists' services (ie, not hospital service charges). Charge-to-payment ratios were computed for individual radiologists as a measure of excess charges. Numerous radiologist-level factors identifiable using publicly available data sets were explored. RESULTS: Among 26,715 radiologists nationally, the mean charge-to-payment ratio was 4.2 +/- 2.0. A greater charge-to-payment ratio was most strongly predicted for those serving higher-complexity patients (ratio ranging from 3.8 +/- 1.8 to 4.1 +/- 1.6 for radiologists in the first through third quartiles in terms of patient complexity, compared with a ratio of 4.8 +/- 2.8 for radiologists in the highest quartile in terms of patient complexity). A higher charge-to-payment ratio was also observed among those with, rather than without, a teaching institutional affiliation (4.7 +/- 2.8 versus 4.0 +/- 1.8, respectively) and among subspecialists rather than generalists (4.4 +/- 2.5 versus 3.9 +/- 1.5, respectively). Among subspecialties, charge-to-payment ratios ranged from 3.3 +/- 1.3 (breast imaging) to 5.7 +/- 4.1 (interventional radiology). Charge-to-payment ratios showed weak inverse correlations with total service volume (r = -0.13) and total payments (r = -0.11). CONCLUSION: Distinct from hospital prices and historically considered arbitrary, higher charges for radiologists' services demonstrate consistent patterns of variation and are most strongly seen for those serving higher complexity patients. As price transparency initiatives expand, radiologists should be aware of how and why their list prices compare with local and national benchmarks.

Active surveillance (AS) has emerged as a beneficial strategy for management of low risk prostate cancer (PCa) and prevention of overtreatment of indolent disease. However, selection of patients for AS using traditional 12-core transrectal prostate biopsy is prone to sampling error and presents a challenge for accurate risk stratification. In fact, around a third of men are upgraded on repeat biopsy which disqualifies them as appropriate AS candidates. This uncertainty affects adoption of AS among patients and physicians, leading to current AS protocols involving repetitive prostate biopsies and unclear triggers for progression to definitive treatment. Prostate magnetic resonance imaging (MRI) has the potential to overcome some of these limitations through localization of significant tumors in the prostate. In conjunction with MRI-targeted prostate biopsy, improved sampling and detection of clinically significant PCa can help streamline the process of selecting suitable men for AS and early exclusion of men who require definitive treatment. MRI can also help minimize the invasive nature of monitoring for disease progression while on AS. Men with stable MRI findings have high negative predictive value for Gleason upgrade on subsequently biopsy, suggesting that men may potentially be monitored by serial MRI examinations with biopsy reserved for significant changes on imaging. Targeted biopsy on AS also allows for specific sampling of concerning lesions, although further data is necessary to evaluate the relative contribution of systematic and targeted biopsy in detecting the 25-30% of men who progress on AS. Further research is also warranted to better understand the nature of clinically significant cancers that are missed on MRI and why certain men have progression of disease that is not visible on prostate MRI. Consensus is also needed over what constitutes progression on MRI, when prostate biopsy can be safely avoided, and how to best utilize this additional information in current AS protocols. Despite these challenges, prostate MRI, either alone or in conjunction with MRI-targeted prostate biopsy, has the potential to significantly improve our current AS paradigm and rates of AS adoption among patients moving forward.

Advancements in magnetic resonance imaging (MRI) and MRI-ultrasound (US)-fusion targeted biopsy have resulted in a paradigm shift in the diagnosis of prostate cancer by overcoming the limitations of systematic biopsy. Prebiopsy MRI and MRI-US-fusion biopsy results in an increased detection of clinically significant disease, reduction in the detection of indolent disease, and allows for tumor localization during targeted biopsy. With these advantages, we have adopted a prebiopsy MRI and MRI-US-fusion biopsy diagnostic care pathway for all men at risk for prostate cancer and have performed more than 1900 biopsies to date. Herein we present our institutional development of MRI-US-fusion biopsy and highlight our results in those men who have had a previous negative biopsy, no prior biopsy, and those with a prior cancer diagnosis who may be candidate for active surveillance. Risk stratification with biomarkers and nomograms may allow for further counseling on the need for biopsy and the risk of harboring clinically significant disease.

OBJECTIVE: The purpose of this study is to assess informal consultations between radiologists and referring physicians as identified through an electronic medical record (EMR) search. MATERIALS AND METHODS: The EMR was searched for physician notes containing either the term "radiologist" or "radiology" in combination with any of the following: "second opinion," "second-opinion," "2nd opinion," "2nd-opinion," "rereview," "re-review," "reread," "re-read," "overread," "over-read," "spoke with," "discussed with," or "reviewed with." A sample of 300 notes describing a consultation by a referring physician with a diagnostic radiologist was identified. RESULTS: Of the consultations, 73.3% were related to a specific previously interpreted imaging study, and 26.7% were related to other general management issues, including patient safety. Only 18.7% of the physicians' notes indicated the name of the consulted radiologist; a fraction of these consultations were with a radiologist other than the one who originally interpreted the study or with a radiologist at an outside institution. Of consultations with a local radiologist regarding a specific prior examination, 33.9% resulted in a new finding, a change in severity of a previously detected finding, or a change in management recommendation. Of consultations with a change from the initial report, 24.6% were documented by the radiologist via an addendum; 92.9% of these addenda agreed with the referring physicians' notes. CONCLUSION: Radiologists may be unaware of how their consultations are captured within physician notes that may be incomplete or misrepresent the communication. Radiology practices should consider developing policies requiring radiologists to document informal consultations potentially affecting patient management, while developing solutions to facilitate such documentation when it is not readily achieved through report addenda (e.g., through direct documentation by the radiologist in the EMR).