Association of State Share of Nonphysician Practitioners With Diagnostic Imaging Ordering Among Emergency Department Visits for Medicare Beneficiaries

Multisystem factors contributing to redundant intracranial vascular imaging in the ED

PURPOSE

To evaluate the multisystem factors contributing to redundant neurovascular orders in the ED.

METHODS

This was an IRB-approved, retrospective study, performed at a single institution examining a 5-year history of redundant CTA/MRA head and neck (HN) exams performed in the ED for patients with no documented clinical change in mental status/neurological exam necessitating additional imaging. Factors contributing to redundant ordering including provider experience, synchronous order placement, and radiologist recommendations were examined. Additionally, the impact of duplicative imaging in terms of medical cost and ED length of stay was evaluated.

RESULTS

250 patients met inclusion criteria with both CTA/MRA of the HN performed during a single ED encounter (total 500 exams). 190 (76%) redundant exams were not recommended by a radiologist and contributed to an added ED length of stay of 3.6 h on average. Provider experience was not a significant contributing factor. 60 (24%) of redundant exams were recommended by a radiologist and were most frequently CTAs needed to clarify an area of artifact/high-grade stenosis/occlusion on a primary MRA exam.

CONCLUSION

Evaluation of contributing factors to redundant CTA/MRA HN exams ordering has highlighted multiple associated factors including provider experience, recommendations by radiologists for clarification of MRA findings, as well as systems processes related to synchronous CTA/MRA order placement.

Effect of Provider Type on Overutilization of CT Angiograms of the Head and Neck for Patients Presenting to the Emergency Department with Nonfocal Neurologic Symptoms

PURPOSE

Overutilization of neuroimaging in the emergency department (ED), especially CT angiogram of the head and neck (CTAHN) examinations, contributes to rising health care expenditures, exposes patients to radiation, and may result in delays in care. We evaluated the rate of CTAHN overutilization for patients with nonfocal neurologic complaints in the ED and its potential association with patient clinical data, demographic data, and ED provider type.

METHODS

This study was retrospective, was approved by an institutional review board, and was performed at a single institution, spanning a 6-year period. ED patients with nonfocal neurologic complaints who had a CTAHN examination with no history of trauma, recent surgery, or intracranial malignancy were included. Each CTAHN examination was categorized into one of four groups (0 = negative, 1 = chronic findings not related to presentation, 2 = nonacute and/or nonemergent findings or findings that may account for the presentation, and 3 = acute and/or emergent findings that may account for the presentation). Basic demographic data including patient age, patient sex, ordering ED provider type (attending, resident, nonphysician practitioner [(NPP]) were collected and analyzed using a multiple logistic regression analysis.

RESULTS

A total of 960 CTAHN examinations were reviewed. The mean age of patients was 50 years (SD = 18 years), with 63% female patients and 37% male patients. Headache was the most frequent presentation (76%). A total of 75% of cases were negative, and 7% had chronic imaging findings not related to their ED presentation. A total of 12.5% of cases had nonacute and/or nonemergent findings possibly related to the presentation, and only 5.5% had acute and/or emergent findings related to ED presentation. A significantly greater proportion of CTAHN examinations ordered by NPPs, followed by the proportion ordered by ED residents, were negative or had no findings related to the patient presentation, and these patients were ultimately discharged to home.

DISCUSSION

A total of 82% of ED CTAHN examinations performed for patients with nonfocal neurologic complaints had no actionable findings. These examinations are significantly more likely to be ordered by NPPs and ED residents.

Short-Term Strategies for Augmenting the National Radiologist Workforce

The current radiology landscape has an imbalance between the rising demand for radiology services and the national radiologist workforce available. More vacant radiology positions exist than graduating radiology trainees. The origins of this problem are complex and require long-term solutions. Rather than working longer and/or faster, radiologists can work smarter. In this article, we present multiple short-term strategies to increase the effective radiologist workforce and/or increase workforce efficiency, to alleviate the current workload challenges. These strategies are derived from an analysis of possible practice-level changes in personnel, process, and physical plant. The impacts of the potential changes are estimated. No single change addresses the mismatch between supply and demand for radiology services. By creating an inventory of potential solutions, practices can choose the potential mechanism(s) to address the workforce shortage that best fit their needs and local environment.

The Role of Advanced Practice Providers in Pediatric Emergency Care Across Nine Emergency Departments

OBJECTIVES

Advance practice providers (APPs) have been increasingly incorporated into emergency department (ED) staffing. The objective of this study was to describe patient factors that predict when pediatric patient care is provided by APPs and/or physicians. We hypothesized that APPs care for a significant proportion of pediatric patients and are more likely to care for lower acuity patients.

METHODS

We performed a retrospective chart review of encounters in patients aged younger than 18 years across 9 EDs from January 2018 to December 2019. Data on age, acuity level, International Classification of Diseases, Tenth Revision code, procedures performed, disposition, provider type, and length of stay were extracted from the electronic health record.

RESULTS

Of 159,035 patient encounters, 37% were cared for by an APP (30% APP independently, 7% physician + APP) and 63% by physicians independently. Advance practice providers were more likely to care for lower acuity patients (60.8% vs 4.4%, P < 0.05) and those in EDs with less pediatric emergency medicine (PEM) coverage (33.4% vs 6.8%, P < 0.05). In an adjusted multinomic regression model, APPs were less likely than physicians to care for high-acuity patients (odds ratio [OR], 0.03; 95% confidence interval [CI], 0.01-0.09), admitted patients (OR, 0.31; CI, 0.28-0.35) and patients in EDs with more PEM coverage (OR, 0.09; CI, 0.09-0.09).

CONCLUSIONS

Advance practice providers cared for more than one third of pediatric patients and tended to care for lower acuity patients and for patients in EDs with less PEM coverage. These data highlight the importance of integrating APPs into initiatives aiming to improve pediatric emergency care.

Prevalence of "One-Off Events" in Radiology: Implications for Radiology in Episode-Based Alternative Payment Models

OBJECTIVE

As reimbursement mechanisms become more value-based, there are questions about the applicability of these mechanisms for nonepisodic care, particularly care provided by nonpatient-facing specialists, for example, radiologists. Accordingly, this study examined the prevalence of nonepisodic care-one-off events-in diagnostic radiology.

METHODS

We conducted a multiyear (2015-2019) retrospective study of diagnostic imaging using a large commercial payer database including commercial insurance and Medicare Advantage. Using a 12-month evaluation period starting with the day of the initial imaging study/studies, we categorized imaging studies as one-off events if there were no additional studies (beyond the first day of the evaluation period) for the next 12 months in the same body region. We also evaluated an alternative, more stringent definition of a one-off event: the only imaging study during the 12-month evaluation period. We computed the percentage of one-off events overall and by body region.

RESULTS

We found that one-off events comprised 33.2%-45.8% of imaging studies depending on whether one-off events are defined as the only study in the evaluation period or imaging only on the first day of the evaluation period, respectively. This share varied widely by body region: highest for cardiac (80.9%-87.7%) and lower for chest (26.8%-35.2%). By place-of-service, the proportion was lowest for the inpatient (12.9%-29.1%) and long-term care settings (18.6%-30%).

DISCUSSION

Given the sizeable share of imaging studies categorized as one-off events, much of radiologists' workload falls outside of the framework of episodic measurement tools and value-based payment models.

Principles for the Physician-Led Patient-Centered Medical Home and Other Approaches to Team-Based Care: A Position Paper From the American College of Physicians

Team-based care models such as the Patient-Centered Medical Home are associated with improved patient health outcomes, better team coordination and collaboration, and increased well-being among health care professionals. Despite these attributes, hindrances to wider adoption remain. In addition, some health care professionals have sought to practice independent of the physician-led health care team, potentially undermining patient access to physicians who have the skills and training to deliver whole-person, comprehensive, and longitudinal care. In this paper, the American College of Physicians reaffirms the importance of the physician-led health care team and offers policy recommendations on professionalism, payment models, training, licensure, and research to support the expansion of dynamic clinical care teams.

Medicaid Insurance is Associated With Decreased MRI Use for Ankle Sprains Compared With Private Insurance: A Retrospective Database Analysis

BACKGROUND

Advanced imaging modalities are expensive, and access to advanced imaging services may vary by socioeconomic factors, creating the potential for unwarranted variations in care. Ankle sprains are a common injury for which variations in MRI use can occur, both via underuse of indicated MRIs (appropriate use) and overuse of nonindicated MRIs (inappropriate use). High-value, equitable healthcare would decrease inappropriate use and increase appropriate use of MRI for this common injury. It is unknown whether socioeconomic factors are associated with underuse of indicated MRIs and overuse of nonindicated MRIs for ankle sprains.

QUESTIONS/PURPOSES

Using ankle sprains as a paradigm injury, given their high population incidence, we asked: (1) Does MRI use for ankle sprains vary by insurance type? (2) After controlling for relevant confounding variables, did patients who received an MRI have higher odds of undergoing ankle surgery?

METHODS

Between 2011 and 2019, a total of 6,710,223 patients were entered into the PearlDiver Mariner Patient Records Database with a diagnosis of ankle sprain. We considered patients with continuous enrollment in the database for at least 1 year before and 2 years after the diagnosis as potentially eligible. Based on that, 68% (4,567,106) were eligible; a further 20% (1,372,478) were excluded because of age younger than 18 years, age at least 65 years with Medicaid insurance, or age < 65 years with Medicare insurance. Another 0.1% (9169) had incomplete data, leaving 47% (3,185,459) for analysis here. Patients with Medicaid insurance differed from patients with Medicare Advantage or private insurance with respect to age, gender, region, and comorbidity burden. The primary outcome was ankle MRI occurring within 12 months after diagnosis. The use of ankle surgery after MRI in each cohort was measured as a secondary outcome. We used multivariable logistic regression models to evaluate the association between insurance type and MRI use while adjusting for age, gender, region, and comorbidity burden. Separate multivariable regression models were created to evaluate the association between receiving an MRI and subsequent ankle surgery for each insurance type, adjusting for age, gender, region, and comorbidity burden. Within 12 months of an ankle sprain diagnosis, 1% (3522 of 339,457) of patients with Medicaid, 2% (44,793 of 2,627,288) of patients with private insurance, and 1% (1660 of 218,714) of patients with Medicare Advantage received an MRI.

RESULTS

After controlling for age, gender, region, and comorbidity burden, patients with Medicaid had lower odds of receiving an MRI within 12 months after ankle sprain diagnosis than patients with private insurance (odds ratio 0.60 [95% confidence interval 0.57 to 0.62]; p < 0.001). Patients with Medicaid who received an MRI had higher adjusted odds of undergoing subsequent ankle surgery (OR 23 [95% CI 21 to 26]; p < 0.001) than patients with private insurance (OR 12.7 [95% CI 12 to 13]; p < 0.001).

CONCLUSION

Although absolute MRI use was generally low, there was substantial relative variation by insurance type. Given the high incidence of ankle sprains in the general population, these relative differences can translate to tens of thousands of MRIs. Further studies are needed to evaluate the reasons for decreased appropriate MRI use in patients with Medicaid and overuse of MRI in patients with private insurance. The establishment of clinical practice guidelines by orthopaedic professional societies and more stringent gatekeeping for MRI use by health insurers could reduce unwarranted variations in MRI use.

LEVEL OF EVIDENCE

Level III, prognostic study.

Population Health Management in Radiology: Economic Considerations

There is a growing emphasis on population health management (PHM) in the United States, in part because it has the worst health outcomes indices among high-income countries despite spending by far the most on health care. Successful PHM is expected to lead to a healthier population with reduced health care utilization and cost. The role of radiology in PHM is increasingly being recognized, including efforts in care coordination, secondary prevention, and appropriate imaging utilization, among others. To further discuss economic considerations for PHM, we must understand the evolving health care payer environment, which combines fee-for-service and increasingly, an alternative payment model framework developed by the Health Care Payment Learning and Action Network. In considering the term "value-based care," perceived value needs to accrue to those who ultimately pay for care, which is more commonly employers and the government. This perspective drives the design of alternative payment models and thus should be taken into consideration to ensure sustainable practice models.

Private equity in ophthalmology: taking the long view

PURPOSE OF REVIEW

Private equity's momentum in eye care remains controversial, even as investment continues to hasten the consolidation of ophthalmology and optometry practices. In this review, we discuss the growing implications of private equity activity in ophthalmology, drawing on updated empirical findings from the literature. We also examine recent legal and policy efforts to address private equity investment in healthcare, with implications for ophthalmologists considering sales to private equity.

RECENT FINDINGS

Concerns about private equity centres around evidence that some investment entities are not just valuable sources of capital or business expertise, but that they take outright ownership and control of acquired practices in order to drive high returns on investment. Although practices may receive considerable benefits from private equity investment, empirical evidence suggests that private equity's most consistent effect on acquired practices is to increase spending and utilization without commensurate benefits on patient health. Although data on workforce effects are limited, an early study on workforce composition changes in private equity-acquired practices demonstrates that physicians were more likely to enter and exit a given practice than their counterparts in nonacquired practices, suggesting some degree of workforce flux. State and federal oversight of private equity's impact on healthcare may be ramping up in response to these demonstrated changes.

SUMMARY

Private equity will continue to broaden their footprint in eye care, necessitating ophthalmologists to take the long view of private equity's net effects. For practices considering a private equity sale, recent policy developments highlight the importance of identifying and vetting a well aligned investment partner, with safeguards to preserve clinical decision-making and physician autonomy.

Trends in Diagnostic Imaging by Nonphysician Practitioners and Associations With Urbanicity and Scope-of-Practice Authority

OBJECTIVE

We aimed to assess the changing share of diagnostic imaging billed by NPPs and how such changes differ by urbanicity within the context of scope-of-practice (SOP) regulations and legislation.

METHODS

This retrospective cohort study used patient claims for diagnostic imaging studies spanning 2016-2020 from Optum Clinformatics Datamart datasets. Multivariable modeling determined the odds of patients receiving NPP-interpreted vs physician-interpreted imaging. Imaging rates and trends in proportions of NPP-billed claims were assessed by urbanicity and relative to other factors including SOP, imaging modality, and place of service.

RESULTS

Of all identified imaging claims, 3,348,881 (3.0%) were attributed to NPPs, with the highest rates of NPP interpretations per 10,000 images occurring in rural and small-town areas. From 2016 to 2020, the rate of NPP-billed imaging increased from 257 to 331 claims per 10,000 beneficiaries (P = 0.004), observed across both metropolitan (240 to 315, P = 0.001) and micropolitan (367 to 436, P = 0.020) settings. Although rates in rural and small-town areas rose, the increase was not significant (330 to 392, P = 0.363). Rises in NPP imaging in metropolitan settings occurred in states with moderately restrictive (307 to 358, P = 0.008) and least restrictive (289 to 419, P = 0.004) SOP legislation.

DISCUSSION

Rates of diagnostic imaging interpretation by NPPs are rising. Growth in recent years appears driven by metropolitan areas in states with less restrictive SOP regulations. Future work is necessary to assess the quality of and downstream costs related to increasing NPP-interpreted imaging.

Summary of the 2022 ACR Intersociety Meeting

The ACR Intersociety Committee meeting of 2022 (ISC-2022) was convened around the theme of "Recovering From The Great Resignation, Moral Injury and Other Stressors: Rebuilding Radiology for a Robust Future." Representatives from 29 radiology organizations, including all radiology subspecialties, radiation oncology, and medical physics, as well as academic and private practice radiologists, met for 3 days in early August in Park City, Utah, to search for solutions to the most pressing problems facing the specialty of radiology in 2022. Of these, the mismatch between the clinical workload and the available radiologist workforce was foremost-as many other identifiable problems flowed downstream from this, including high job turnover, lack of time for teaching and research, radiologist burnout, and moral injury.