Faculty Bibliography

Episodic care forms a payment methodology of increasing relevance to neurointerventional specialists and other providers. Episodic care payment models are currently recognized in both payment paths described by the Medicare Access and Children's Health Insurance Program (CHIP) Reauthorization Act (MACRA): the Merit-Based Incentive Payment System and Advanced Alternative Payment Models. Understanding the cost of care, as well as how such costs are shaped in the context of episodic care, will be critical to success in both of these paths.

PURPOSE: To use patient-generated data to assess the changing role of emergency department (ED) imaging for a spectrum of clinical indications. METHODS: The Household Component Emergency Room Visits File was obtained from 1996 through 2014 for the Medical Expenditure Panel Survey, a nationally representative survey of US households. Percentage of visits associated with various imaging modalities was computed annually, stratified by respondents' self-reported primary condition during the visit. Modality characteristics were assessed for conditions most frequently imaged in 1996 or 2014. RESULTS: For most conditions, use of advanced imaging (defined by Medical Expenditure Panel Survey as CT or MRI) in the ED increased significantly (P < .001). The largest growth occurred for urinary calculus (from 0% to 48.5%) and headache (from 17.5% to 33.3%), which were the most commonly imaged conditions by CT or MRI in 2014. For ultrasound, the most commonly imaged condition was pregnancy in 1996 (32.9%) and 2014 (44.5%). No other condition was associated with ultrasound in >20% of visits. For radiography, the most commonly imaged conditions were extremity wounds and fractures in 1996 (range 84.5%-90.2%) and 2014 (range 93.4%-93.9%). Use of radiography decreased for urinary calculus from 67.4% to 24.2% (P < .001). CONCLUSION: For many conditions, ED utilization of advanced imaging increased significantly, though growth was variable across conditions. In certain scenarios, advanced ED imaging is adding to, rather than replacing, other modalities. Ultrasound and radiography utilization was overall unchanged. That national patient survey data mirror traditional claims-based studies suggests an expanded role for patient-generated data in identifying areas of imaging utilization that may benefit from targeted optimization efforts.

OBJECTIVE: The objective of our study was to assess the utility of CT features in the diagnosis of cecal volvulus. MATERIALS AND METHODS: Forty-three patients undergoing CT for cecal volvulus and with surgical or clinical follow-up were included. Two radiologists (11 years and 1 year of experience) evaluated CT examinations for the following: whirl sign, abnormal cecal position, "bird beak" sign, severe cecal distention, mesenteric engorgement, a newly described "central appendix" sign (defined as abnormal appendix position near midline), and overall impression for cecal volvulus. Univariable and multivariable assessments were performed. Patients with CT examinations in which the appendix was not visible were excluded from calculations involving the central appendix sign. RESULTS: Fifty-one percent (n = 22) of patients had cecal volvulus. All CT findings were significantly more common in patients with cecal volvulus (p < 0.01) other than mesenteric engorgement for reader 1 (p = 0.332). Readers 1 and 2 identified the central appendix sign in 92.9% and 92.3% of patients with volvulus versus in 37.5 and 31.1% of patients without volvulus. The whirl sign exhibited a sensitivity for cecal volvulus of 90.9% for reader 1 and 95.5% for reader 2, and a specificity of 61.9% for both readers. Abnormal cecal position exhibited a sensitivity of 90.0% for reader 1 and 100.0% for reader 2 and a specificity of 66.7% and 38.1%. The bird beak sign exhibited a sensitivity of 86.4% for reader 1 and 100.0% for reader 2 and a specificity of 85.7% and 71.4%. Severe cecal distention exhibited a sensitivity of 100.0% for both readers and a specificity of 81.0% and 61.9%. Mesenteric engorgement exhibited a sensitivity of 40.9% for reader 1 and 100.0% for reader 2 and a specificity of 76.2% and 71.4%. The central appendix sign exhibited a sensitivity of 92.9% for reader 1 and 92.3% for reader 2 and a specificity of 62.5% and 68.8%. Overall impression exhibited a sensitivity of 100.0% for both readers and a specificity of 76.2% and 57.1%. At multivariable analysis, the AUC for cecal volvulus ranged from 0.787 to 0.931, and the whirl sign was an independent predictor of volvulus for both readers (p