Faculty Bibliography

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).

RATIONALE AND OBJECTIVES: To characterize online news coverage relating to mammography, including articles' stance toward screening mammography. MATERIALS AND METHODS: Google News was used to search U.S. news sites over a 9-year period (2006-2015) based on the search terms "mammography" and "mammogram." The top 100 search results were recorded. Identified articles were manually reviewed. RESULTS: The top 100 news articles were from the following sources: local news outlet (50%), national news outlet (24%), nonimaging medical source (13%), entertainment or culture news outlet (6%), business news outlet (4%), peer-reviewed journal (1%), and radiology news outlet (1%). Most common major themes were the screening mammography controversy (29%), description of a new breast imaging technology (23%), dense breasts (11%), and promotion of a public screening initiative (11%). For the most recent year, article stance toward screening mammography was 59%, favorable; 16%, unfavorable; and 25%, neutral. After 2010, there was an abrupt shift in articles' stances from neutral to both favorable and unfavorable. CONCLUSIONS: A wide range of online news sources addressed a range of issues related to mammography. National, rather than local, news sites were more likely to focus on the screening controversy and more likely to take an unfavorable view. The controversial United States Preventive Services Task Force guidelines may have influenced articles to take a stance on screening mammography. As such online news may impact public perception of the topic and thus potentially impact guideline adherence, radiologists are encouraged to maintain awareness of this online coverage and to support the online dissemination of reliable and accurate information.

PURPOSE: The aim of this study was to assess both existing Medicare provider code assignments and a new claims-based system for subspecialty classification of private practice radiologists. METHODS: Websites of the 100 largest US radiology private practices were used to identify 1,476 radiologists self-identified with a single subspecialty ([1] abdominal, [2] breast, [3] cardiothoracic, or [4] musculoskeletal imaging; [5] nuclear medicine; [6] interventional radiology; [7] neuroradiology). Concordance of existing Medicare radiology subspecialty provider codes (present only for nuclear medicine and interventional radiology) was first assessed. Next, using a classification approach based on Neiman Imaging Types of Service (NITOS) piloted among academic practices, the percentage of subspecialty work relative value units (wRVUs) from 2012 to 2014 Medicare claims were used to assign each radiologist a unique subspecialty. RESULTS: Existing Medicare provider codes matched only 8.0% of nuclear medicine physicians and 10.7% of interventional radiologists to their self-reported subspecialties. The NITOS-based system mapped a median 51.9% of private practice radiologists' wRVUs to self-identified subspecialties (range, 23.3% [nuclear medicine] to 73.6% [neuroradiology]). The 50% NITOS-based wRVU threshold previously established for academic radiologists correctly assigned subspecialties to 48.8% of private practice radiologists but incorrectly categorized 2.9%. Practice patterns of the remaining 48.3% were sufficiently varied such that no single subspecialty assignment was possible. CONCLUSIONS: Existing Medicare provider codes poorly mirror subspecialty radiologists' own practice website-designated subspecialties. Actual payer claims data permit far more granular and accurate subspecialty identification for many radiologists. As new payment models increasingly focus on subspecialty-specific performance measures, claims-based identification methodologies show promise for reproducibly and transparently matching radiologists to practice-relevant metrics.

PURPOSE: To evaluate the impact of questionnaires completed by patients at the time of abdominopelvic CT performed for abdominal pain on the completeness of clinical information and the identification of potential causes of pain, compared with order requisitions alone. METHODS: 100 outpatient CT examinations performed for the evaluation of abdominal pain were retrospectively reviewed. The specificity of the location of pain was compared between the order requisition and patient questionnaire. An abdominal imaging fellow (Reader 1) and abdominal radiologist (Reader 2) reviewed the examinations independently in two sessions 6 weeks apart (one with only the order requisition and one also with the questionnaire). Readers recorded identified causes of pain and rated their confidence in interpretation (1-5 scale; least to greatest confidence). RESULTS: In 30% of patients, the questionnaire provided a more specific location for pain. Among these, the pain was localized to a specific quadrant in 40%. With having access to the questionnaire, both readers identified additional causes for pain not identified in session 1 (Reader 1, 8.6% [7/81]; Reader 2 5.3% [4/75]). Additional identified causes of pain included diverticulitis, cystitis, peritoneal implants, epiploic appendagitis, osseous metastatic disease, umbilical hernia, gastritis, and SMA syndrome. Confidence in interpretation was significantly greater using the questionnaire for both readers (Reader 1: 4.8 +/- 0.6 vs. 4.0 +/- 0.5; Reader 2: 4.9 +/- 0.3 vs. 4.7 +/- 0.5, p < 0.001). CONCLUSION: Patient questionnaires provide additional relevant clinical history, increased diagnostic yield, and improve radiologists' confidence. Radiology practices are encouraged to implement questionnaires and make these readily available to radiologists at the time of interpretation.

OBJECTIVE: The purpose of this study was to determine the outcomes of hyperechoic renal lesions measuring 1 cm or less at ultrasound examination. MATERIALS AND METHODS: This retrospective study included 161 hyperechoic renal lesions measuring 1 cm or less at ultrasound that were evaluated with follow-up ultrasound, CT, or MRI. Follow-up imaging examinations were reviewed to assess for definitive lesion characterization or size stability. RESULTS: Follow-up included 11 unenhanced CT, 39 contrast-enhanced CT, 52 unenhanced and contrast-enhanced CT, two unenhanced MRI, 50 unenhanced and contrast-enhanced MRI, and 87 ultrasound examinations. At CT or MRI 58.4% of lesions were confirmed to be angiomyolipomas. At CT, one lesion represented a stone, and one a hyperdense cyst. At CT or MRI 11.8% of the lesions had no correlate; 3.1% were not visualized at follow-up ultrasound. An additional 23.6% were stable at 2-year follow-up imaging or beyond. Two lesions were evaluated with only contrast-enhanced CT less than 1 month after ultrasound, and the CT images did not show macroscopic fat or calcification or meet the criteria for a simple cyst. These lesions were considered indeterminate. One lesion in a 65-year-old man was imaged with unenhanced and contrast-enhanced CT 23 months after ultrasound, and the CT showed an increase in size, solid enhancement, and no macroscopic fat. This lesion was presumed to represent renal cell carcinoma. Overall, the one lesion presumed malignant and the two indeterminate lesions constituted 1.9% of the cohort. The other 98.1% of lesions were considered clinically insignificant. CONCLUSION: Most hyperechoic renal lesions measuring 1 cm or smaller were clinically insignificant, suggesting that such lesions may not require additional imaging. Patient demographics, symptoms and risk factors for malignancy may help inform the decision to forgo follow-up imaging of such lesions.

As societal stakeholders call for increased evidence-based health policy, considerable attention has focused on Medicare, the country's largest payer. Concurrently, medical imaging has come under considerable scrutiny as a contributor to rising health care expenditures. Accordingly, many recent studies have focused on multiple factors related to the utilization of imaging among Medicare beneficiaries. This article summarizes several national Medicare fee-for-service data sources relevant to supporting ongoing investigations. Aggregated 100% data sets include the Physician/Supplier Procedure Summary Master Files and the Medicare Provider Utilization and Payment Data: Physician and Other Supplier Public Use File. The former focuses on services, specialties, and sites of service; the latter focuses on providers. Both permit high-level national assessments of imaging utilization and spending. Individual 5% random-sample claims-level data sources include the Carrier Standard Analytical File Limited Data Set and the Research Identifiable File, which contain greater beneficiary-level information. Both facilitate more robust patient- and encounter-level analyses and some assessment of downstream outcomes but involve greater costs and require greater privacy oversight. More recently, Medicare data are being merged with registry data (eg, Surveillance, Epidemiology, and End Results-Medicare Linked Database files), creating opportunities for even more robust analyses given richer clinical information. Understanding these data sets and trade-offs in their use will aid policy-focused imaging health services researchers in most effectively conducting their investigations.

PURPOSE: Prior studies have shown higher screening mammography rates for beneficiaries in capitated managed care Medicare Advantage (MA) plans compared with traditional fee-for-service Medicare. The aim of this study was to explore variation in screening mammography rates at the level of MA managed care plans. METHODS: Using the 2016 MA Healthcare Effectiveness Data and Information Set Public Use File, screening mammography rates were identified for all 385 reporting MA plans. Associations were explored with a range of plan characteristics from this file, as well as from the CMS Part C and Part D Medicare Star Ratings Data File, Medicare Advantage Plan Directory, and Medicare Monthly Enrollment by Plan File. RESULTS: Overall MA plan screening rates were high (mean, 72.6 +/- 9.4%) but varied substantially among plans (range, 14.3%-91.8%). Screening rates were higher in nonprofit versus for-profit plans (77.3% versus 71.8%, P < .001), as well as in health maintenance organization or local preferred provider organization plans versus private fee-for-service or regional preferred provider organization plans (71.9%-73.2% versus 65.5%-66.8%, P = .001). Among parent organizations with five or more plans, screening rates were highest for Kaiser Foundation (median, 88.4%) and lowest for Molina Healthcare (median, 65.3%). Screening rates showed small but significant associations with plans' contract lengths, enrolled populations, and counties served. Screening rates showed strong associations (r = 0.796-0.798) with colorectal cancer screening and annual flu vaccine rates and showed moderate associations (r = 0.283-0.365) with ambulatory and preventive care visits, osteoporosis screenings, body mass index assessments, and nonrecommended prostate-specific antigen screenings after age 70. CONCLUSIONS: Screening mammography rates vary considerably among MA plans. With increased federal interest in promoting the MA program, enhanced transparency will be necessary to ensure appropriate Medicare beneficiary participation decision making.