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Mehan WA, Shin D, Buch K. Multisystem factors contributing to redundant intracranial vascular imaging in the ED. Emerg Radiol 2024; 31:447-453. [PMID: 38769220 DOI: 10.1007/s10140-024-02240-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 05/02/2024] [Indexed: 05/22/2024]
Abstract
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.
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Affiliation(s)
- William A Mehan
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Donghoon Shin
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Karen Buch
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA.
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Burley T, Cahanin RL, Brody LT, Boissonnault WG, Ross MD. Reliability of a Musculoskeletal Imaging Competency Examination for Physical Therapists. JOURNAL, PHYSICAL THERAPY EDUCATION 2024; 38:133-140. [PMID: 38758177 DOI: 10.1097/jte.0000000000000328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 10/27/2023] [Indexed: 05/18/2024]
Abstract
INTRODUCTION The Burley Readiness Examination (BRE) for Musculoskeletal (MSK) Imaging Competency assesses physical therapists' baseline MSK imaging competency. Establishing its reliability is essential to its value in determining MSK imaging competency. The purpose of this study was to test the reliability of the BRE for MSK Imaging Competency among physical therapists (PTs) with varying levels of training and education. REVIEW OF LITERATURE Previous literature supports PTs' utility concerning diagnostic imaging; however, no studies directly measure their competency. With PTs expanding their practice scope and professional PT education programs, increasing their MSK imaging instruction, assessing competency becomes strategic in determining the future of MSK education and training. SUBJECTS One hundred twenty-three United States licensed PTs completed the BRE. METHODS Physical therapists completed the BRE through an online survey platform. Point biserial correlation (rpb) was calculated for each examination question. Final analyses were based on 140 examination questions. Examination scores were compared using independent sample t-test and one-way analysis of variance. Chi-square tests and odds ratios (ORs) assessed the relationship of a passing examination score (≥75%) and the type of training. Reliability of the BRE was assessed using Cronbach's alpha (α). RESULTS Mean overall examination score was 75.89 ± 8.56%. Seventy PTs (56.9%) obtained a passing score. Physical therapists with additional MSK imaging training, board certification, and residency or fellowship training scored significantly higher (P < .001) compared with those with only entry-level PT program education. Physical therapists with additional MSK imaging training scored significantly higher (x̄ = 81.07% ± 8.93%) and were almost 5 times (OR = 4.74, 95% CI [1.95-11.50]) as likely to achieve a passing score than those without. The BRE demonstrated strong internal consistency (Cronbach's α = 0.874). DISCUSSION AND CONCLUSIONS The BRE was reliable, consistently identifying higher examination scores among those with increased MSK imaging training. Training in MSK imaging influenced competency more than other factors. The BRE may be of analytical value to PT professional and postprofessional programs.
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Affiliation(s)
- Troy Burley
- Troy Burley is an assistant professor at the University of South Alabama, 5721 USA Drive North, Mobile, AL, 36688 . Please address all correspondence to Troy Burley
- Richard L. Cahanin is an assistant professor at the University of South Alabama
- Lori T. Brody is a professor at Rocky Mountain University of Health Professions
- William G. Boissonnault is professor emeritus, University of Wisconsin-Madison, Department of Orthopedics and Rehabilitation
- Michael D. Ross is an associate professor in the Physical Therapy Department at Daemen University
| | - Richard L Cahanin
- Troy Burley is an assistant professor at the University of South Alabama, 5721 USA Drive North, Mobile, AL, 36688 . Please address all correspondence to Troy Burley
- Richard L. Cahanin is an assistant professor at the University of South Alabama
- Lori T. Brody is a professor at Rocky Mountain University of Health Professions
- William G. Boissonnault is professor emeritus, University of Wisconsin-Madison, Department of Orthopedics and Rehabilitation
- Michael D. Ross is an associate professor in the Physical Therapy Department at Daemen University
| | - Lori T Brody
- Troy Burley is an assistant professor at the University of South Alabama, 5721 USA Drive North, Mobile, AL, 36688 . Please address all correspondence to Troy Burley
- Richard L. Cahanin is an assistant professor at the University of South Alabama
- Lori T. Brody is a professor at Rocky Mountain University of Health Professions
- William G. Boissonnault is professor emeritus, University of Wisconsin-Madison, Department of Orthopedics and Rehabilitation
- Michael D. Ross is an associate professor in the Physical Therapy Department at Daemen University
| | - William G Boissonnault
- Troy Burley is an assistant professor at the University of South Alabama, 5721 USA Drive North, Mobile, AL, 36688 . Please address all correspondence to Troy Burley
- Richard L. Cahanin is an assistant professor at the University of South Alabama
- Lori T. Brody is a professor at Rocky Mountain University of Health Professions
- William G. Boissonnault is professor emeritus, University of Wisconsin-Madison, Department of Orthopedics and Rehabilitation
- Michael D. Ross is an associate professor in the Physical Therapy Department at Daemen University
| | - Michael D Ross
- Troy Burley is an assistant professor at the University of South Alabama, 5721 USA Drive North, Mobile, AL, 36688 . Please address all correspondence to Troy Burley
- Richard L. Cahanin is an assistant professor at the University of South Alabama
- Lori T. Brody is a professor at Rocky Mountain University of Health Professions
- William G. Boissonnault is professor emeritus, University of Wisconsin-Madison, Department of Orthopedics and Rehabilitation
- Michael D. Ross is an associate professor in the Physical Therapy Department at Daemen University
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Abu Awwad D, Ekpo E. Imaging of the adjacent upper limb: Outcomes and diagnostic yield. Radiography (Lond) 2024; 30:753-758. [PMID: 38432174 DOI: 10.1016/j.radi.2024.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 02/02/2024] [Accepted: 02/19/2024] [Indexed: 03/05/2024]
Abstract
INTRODUCTION Injuries to extremities are a common presentation to emergency departments and may be associated with multiple abnormalities. Patients may be referred for X-ray imaging of multiple adjacent regions, but the diagnostic outcomes of these X-ray examinations have not been fully explored. The aim of this study was to assess the diagnostic efficacy of X-ray examinations of adjacent body regions in the upper limb. METHODS Upper limb X-rays examinations performed over six months were collected from two hospitals, and all patients who had adjacent regions X-rayed were included. Using the radiology reports as a reference standard, the diagnostic yield of these additional adjacent X-ray examinations was assessed. Descriptive statistics and Pearson's Chi Square were used for data analysis. RESULTS 591 patients had 1455 X-ray examinations, ranging from two to six X-ray requests. More than 80% of X-ray examinations were due to an injury, but less than 60% had symptoms mentioned in the clinical history. Overall, 39.1% of initial examinations reported a new finding but only 1.5% of all subsequent imaging had a new abnormality detected. Examinations with symptoms specified in the clinical history were more likely to detect new findings (p=<0.001). CONCLUSION Imaging is an essential diagnostic tool in medical settings, but all radiographic tests should be justified, and adjacent imaging has a low diagnostic yield, hence, all limbs should be carefully assessed individually to assess the need for imaging. Every request should be justified based on presentation and symptoms, particularly when multiple areas may be impacted. IMPLICATIONS FOR PRACTICE Radiographic imaging is easily accessible but adherence to guidelines and assessing the diagnostic yield of common examinations is important to ensure benefits to patients.
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Affiliation(s)
- D Abu Awwad
- Discipline of Medical Imaging Sciences, The University of Sydney, Susan Wakil Health Building, Camperdown, Sydney, Australia.
| | - E Ekpo
- Discipline of Medical Imaging Sciences, The University of Sydney, Susan Wakil Health Building, Camperdown, Sydney, Australia.
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Mišić M, Lee N, Zidda F, Sohn K, Usai K, Löffler M, Uddin MN, Farooqi A, Schifitto G, Zhang Z, Nees F, Geha P, Flor H. Brain white matter pathways of resilience to chronic back pain: a multisite validation. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.01.30.578024. [PMID: 38352359 PMCID: PMC10862888 DOI: 10.1101/2024.01.30.578024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
Chronic back pain (CBP) is a global health concern with significant societal and economic burden. While various predictors of back pain chronicity have been proposed, including demographic and psychosocial factors, neuroimaging studies have shown that brain characteristics can serve as robust predictors of CBP. However, large-scale, multisite validation of these predictors is currently lacking. In two independent longitudinal studies, we examined white matter diffusion imaging data and pain characteristics in patients with subacute back pain (SBP) over six- and 12-month periods. Diffusion data from individuals with CBP and healthy controls (HC) were analyzed for comparison. Whole-brain tract-based spatial statistics analyses revealed that a cluster in the right superior longitudinal fasciculus (SLF) tract had larger fractional anisotropy (FA) values in patients who recovered (SBPr) compared to those with persistent pain (SBPp), and predicted changes in pain severity. The SLF FA values accurately classified patients at baseline and follow-up in a third publicly available dataset (Area under the Receiver Operating Curve ~ 0.70). Notably, patients who recovered had FA values larger than those of HC suggesting a potential role of SLF integrity in resilience to CBP. Structural connectivity-based models also classified SBPp and SBPr patients from the three data sets (validation accuracy 67%). Our results validate the right SLF as a robust predictor of CBP development, with potential for clinical translation. Cognitive and behavioral processes dependent on the right SLF, such as proprioception and visuospatial attention, should be analyzed in subacute stages as they could prove important for back pain chronicity.
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Affiliation(s)
- Mina Mišić
- Institute of Cognitive and Clinical Neuroscience, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, 68159 Mannheim, Germany
| | - Noah Lee
- Department of Psychiatry, University of Rochester Medical Center, 14642 Rochester, NY, USA
| | - Francesca Zidda
- Institute of Cognitive and Clinical Neuroscience, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, 68159 Mannheim, Germany
| | - Kyungjin Sohn
- Department of Statistics and Operations Research, University of North Carolina, 27599 Chapel Hill, NC, USA
| | - Katrin Usai
- Institute of Cognitive and Clinical Neuroscience, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, 68159 Mannheim, Germany
| | - Martin Löffler
- Institute of Cognitive and Clinical Neuroscience, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, 68159 Mannheim, Germany
- Department of Experimental Psychology, Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany
| | - Md Nasir Uddin
- Department of Neurology, University of Rochester Medical Center, 14642 Rochester, NY, USA
| | - Arsalan Farooqi
- Department of Psychiatry, University of Rochester Medical Center, 14642 Rochester, NY, USA
| | - Giovanni Schifitto
- Department of Neurology, University of Rochester Medical Center, 14642 Rochester, NY, USA
| | - Zhengwu Zhang
- Department of Statistics and Operations Research, University of North Carolina, 27599 Chapel Hill, NC, USA
| | - Frauke Nees
- Institute of Cognitive and Clinical Neuroscience, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, 68159 Mannheim, Germany
- Institute of Medical Psychology and Medical Sociology, University Medical Center Schleswig Holstein, Kiel University, 24105 Kiel, Germany
| | - Paul Geha
- Department of Psychiatry, University of Rochester Medical Center, 14642 Rochester, NY, USA
| | - Herta Flor
- Institute of Cognitive and Clinical Neuroscience, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, 68159 Mannheim, Germany
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Banashefski B, Ji R, Dhruva SS, Neuhaus J, Redberg RF. Cardiac coronary tomography angiography (CCTA) use across geographical regions in the USA and the UK: a cross-sectional study. BMJ SURGERY, INTERVENTIONS, & HEALTH TECHNOLOGIES 2023; 5:e000201. [PMID: 38020493 PMCID: PMC10660629 DOI: 10.1136/bmjsit-2023-000201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 10/16/2023] [Indexed: 12/01/2023] Open
Abstract
Objective Increased use of CT imaging has been identified as a key component of unsustainable rising healthcare costs in the USA and globally. Understanding evidence and its relation to imaging coverage policies can help identify patterns of variation to better inform high value care initiatives. This cross-sectional study evaluates regional differences in US utilisation of cardiac coronary tomography angiography (CCTA) and compares use in the USA and England. Design We determined differences in CCTA order rates by US Medicare region and compared order rates in the US and England, compared CT scanner prevalence in the USA and UK, and reviewed the CCTA coverage policies for each region. Setting The US and the UK. Participants Medicare Coverage Database; Medicare 2018 Part B data; National Health Services 2018 data. Interventions CCTA orders, CT scanner prevalence. Main outcome measures CCTA orders per beneficiary, CT scanner prevalence, CCTA policy variation. Results We found that CCTA coverage policies are more permissive in the UK compared with the USA. However, CT scanner prevalence per beneficiary is four times greater in the USA than the UK. There was significant variation in number of CCTA ordered per 100 000 beneficiaries between regions in England and the USA, ranging from 74 to 313 in the US and 57-317 in England. Conclusions There is significant geographical variation in use of CCTA in both the USA and England, although overall use does not differ significantly between both countries. Similarities in order rates, despite a much higher CT scanner density in the USA, may be related to more permissive guidelines around use of CCTA in the UK. Variation in both countries may also reflect the lack of high-quality clinical outcomes data for use of CCTA, underscoring opportunities for more evidence and evidence-based policy to promote appropriate use of CCTA imaging.
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Affiliation(s)
| | - Robin Ji
- Department of Medicine, University of California School of Medicine, San Francisco, California, USA
| | - Sanket S. Dhruva
- Department of Medicine, University of California School of Medicine, San Francisco, California, USA
- San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
| | - John Neuhaus
- Department of Epidemiology & Biostatistics, University of California School of Medicine, San Francisco, California, USA
| | - Rita F Redberg
- Department of Medicine, University of California School of Medicine, San Francisco, California, USA
- University of California, San Francisco, California, USA
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Werenski HE, Nguyen CJ, Johansson ED, Bunch PM, Randle RW. Value of Old Imaging for Patients Undergoing Parathyroidectomy for Primary Hyperparathyroidism. J Surg Res 2023; 282:147-154. [PMID: 36274449 DOI: 10.1016/j.jss.2022.09.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 08/04/2022] [Accepted: 09/15/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Although imaging plays no role in diagnosing primary hyperparathyroidism (PHPT), preoperative localization is essential for a focused parathyroidectomy. We hypothesized that reviewing imaging obtained prior to PHPT diagnosis can identify enlarged parathyroid glands and provide information that might potentially impact the preoperative evaluation and intraoperative course of patients undergoing parathyroidectomy. METHODS We included adult patients with PHPT who underwent parathyroidectomy between October 2015 and October 2020 and had contrast-enhanced computed tomography (CT) imaging of the lower neck and upper chest obtained prior to diagnosis for unrelated indications. A radiologist reviewed the prediagnosis CTs blinded to subsequent parathyroid localization imaging and operative findings. A surgeon assessed the radiologist's findings in the context of each case to determine the potential impact of information from old imaging on surgical decision-making. RESULTS We identified at least one enlarged parathyroid gland on prior contrast-enhanced CT in 30 (75%) of 40 included patients. Despite old imaging enabling correct localization, 60% of these 30 underwent dedicated parathyroid imaging prior to parathyroidectomy. Knowledge of the enlarged parathyroid(s) on prior imaging might have allowed a more focused approach in 10.0% and prompted a more thorough exploration in 13.3%. In the total cohort, reviewing prior imaging could have provided information capable of changing the preoperative evaluation in 52.5% and the operative course in 17.5%. CONCLUSIONS The identification of enlarged parathyroid glands on contrast-enhanced CT imaging that predates a diagnosis of PHPT is possible. Prospective studies might verify the impact of these findings on the preoperative evaluation and operative course of patients undergoing parathyroidectomy.
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Affiliation(s)
- Hope E Werenski
- Department of Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina
| | - Christopher J Nguyen
- Department of Radiology, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina
| | - Erik D Johansson
- Department of Radiology, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina
| | - Paul M Bunch
- Department of Radiology, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina
| | - Reese W Randle
- Department of Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina.
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Linet MS, Applegate KE, McCollough CH, Bailey JE, Bright C, Bushberg JT, Chanock SJ, Coleman J, Dalal NH, Dauer LT, Davis PB, Eagar RY, Frija G, Held KD, Kachnic LA, Kiess AP, Klein LW, Kosti O, Miller CW, Miller-Thomas MM, Straus C, Vapiwala N, Wieder JS, Yoo DC, Brink JA, Dalrymple JL. A Multimedia Strategy to Integrate Introductory Broad-Based Radiation Science Education in US Medical Schools. J Am Coll Radiol 2023; 20:251-264. [PMID: 36130692 PMCID: PMC10578400 DOI: 10.1016/j.jacr.2022.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 08/01/2022] [Accepted: 08/04/2022] [Indexed: 12/27/2022]
Abstract
US physicians in multiple specialties who order or conduct radiological procedures lack formal radiation science education and thus sometimes order procedures of limited benefit or fail to order what is necessary. To this end, a multidisciplinary expert group proposed an introductory broad-based radiation science educational program for US medical schools. Suggested preclinical elements of the curriculum include foundational education on ionizing and nonionizing radiation (eg, definitions, dose metrics, and risk measures) and short- and long-term radiation-related health effects as well as introduction to radiology, radiation therapy, and radiation protection concepts. Recommended clinical elements of the curriculum would impart knowledge and practical experience in radiology, fluoroscopically guided procedures, nuclear medicine, radiation oncology, and identification of patient subgroups requiring special considerations when selecting specific ionizing or nonionizing diagnostic or therapeutic radiation procedures. Critical components of the clinical program would also include educational material and direct experience with patient-centered communication on benefits of, risks of, and shared decision making about ionizing and nonionizing radiation procedures and on health effects and safety requirements for environmental and occupational exposure to ionizing and nonionizing radiation. Overarching is the introduction to evidence-based guidelines for procedures that maximize clinical benefit while limiting unnecessary risk. The content would be further developed, directed, and integrated within the curriculum by local faculties and would address multiple standard elements of the Liaison Committee on Medical Education and Core Entrustable Professional Activities for Entering Residency of the Association of American Medical Colleges.
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Affiliation(s)
- Martha S Linet
- Chief and Senior Investigator, Radiation Epidemiology Branch (retired) and currently NIH Scientist Emerita, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland.
| | - Kimberly E Applegate
- Division Chief and Professor of Pediatric Radiology (retired), University of Kentucky Children's Hospital, University of Kentucky, Lexington, Kentucky, and currently Chair of Committee 3 of the International Commission on Radiological Protection, Ottawa, Canada
| | - Cynthia H McCollough
- Brooks-Hollern Professor of Medical Physics and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota
| | - Janet E Bailey
- Professor of Radiology and Associate Chair for Education in Radiology, University of Michigan Health System, Ann Arbor, Michigan
| | - Cedric Bright
- Associate Dean for Admissions and Clinical Professor, Department of Internal Medicine, East Carolina's Brody School of Medicine, Greenville, North Carolina
| | - Jerrold T Bushberg
- Clinical Professor of Radiology and Radiation Oncology, University of California Davis School of Medicine, Sacramento, California, and Vice President, National Council of Radiation Protection and Measurements, Bethesda, Maryland
| | - Stephen J Chanock
- Director and Chief of the Cancer Genomics Research Laboratory, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Jenna Coleman
- Executive Director of the Medical Educational Council of Pensacola, Pensacola, Florida
| | - Nicole H Dalal
- Resident, Department of Internal Medicine, University of California San Francisco School of Medicine, San Francisco, California
| | - Lawrence T Dauer
- Attending Physicist, Departments of Medical Physics and Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Pamela B Davis
- Dean School of Medicine (emerita) and Arline H. and Curtis F. Garvin Research Professor, Center for Community Health Integration, and Professor of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Robert Y Eagar
- Diagnostic Radiology Resident, Department of Radiology, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Guy Frija
- Professor of Radiology (Emeritus), Université de Paris, Paris, France
| | - Kathryn D Held
- President of the National Council on Radiation Protection and Measurements, Bethesda, Maryland, and Associate Radiation Biologist, Department of Radiation Oncology, Massachusetts General Hospital and Associate Professor of Radiation Oncology, Harvard Medical School, Boston, Massachusetts
| | - Lisa A Kachnic
- Chair, Department of Radiation Oncology, Columbia University Medical Center and the Herbert Irving Comprehensive Cancer Center, New York, New York
| | - Ana P Kiess
- Assistant Professor of Radiation Oncology and Molecular Radiation Sciences and Director of the Residency Program, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Lloyd W Klein
- Clinical Professor of Medicine, University of California San Francisco School of Medicine, San Francisco, California
| | - Ourania Kosti
- Senior Program Officer at the Nuclear and Radiation Studies Board of the National Academies of Sciences, Engineering, and Medicine, Washington, DC
| | - Charles W Miller
- Chief (retired) Radiation Studies Branch, Division of Environmental Hazards and Health Effects, Centers for Disease Control and Prevention, Atlanta, Georgia, and currently a Consultant in Nuclear and Radiological Environmental Health, Atlanta, Georgia
| | - Michelle M Miller-Thomas
- Associate Professor of Radiology and Director of Medical Student Education at Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Missouri
| | - Christopher Straus
- Associate Professor of Radiology and Director of Medical Student Education, University of Chicago School of Medicine, Chicago, Illinois
| | - Neha Vapiwala
- Professor and Vice Chair of Education, Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jessica S Wieder
- Director of the Center for Radiation Information and Outreach, US Environmental Protection Agency, Washington, DC
| | - Don C Yoo
- Director of Nuclear Medicine, Miriam Hospital and Professor of Diagnostic Imaging and Clinical Educator, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - James A Brink
- Chair, Department of Radiology, Brigham and Women's Hospital and Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - John L Dalrymple
- Professor of Obstetrics, Gynecology and Reproductive Biology and Associate Dean for Medical Education Quality Improvement, Harvard Medical School, Boston, Massachusetts, and Associate Chair and Vice Chair for Faculty Development and Faculty Affairs and Gynecologic Oncology Fellowship Program Director, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Wangaryattawanich P, Rutman AM, Petcharunpaisan S, Mossa-Basha M. Incidental findings on brain magnetic resonance imaging (MRI) in adults: a review of imaging spectrum, clinical significance, and management. Br J Radiol 2023; 96:20220108. [PMID: 35522780 PMCID: PMC9975529 DOI: 10.1259/bjr.20220108] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 04/19/2022] [Accepted: 04/29/2022] [Indexed: 01/27/2023] Open
Abstract
Utilization of brain MRI has dramatically increased in recent decades due to rapid advancement in imaging technology and improving accessibility. As a result, radiologists increasingly encounter findings incidentally discovered on brain MRIs which are performed for unrelated indications. Some of these findings are clinically significant, necessitating further investigation or treatment and resulting in increased costs to healthcare systems as well as increased patient anxiety. Moreover, management of these incidental findings poses a significant challenge for referring physicians. Therefore, it is important for interpreting radiologists to know the prevalence, clinical consequences, and appropriate management of these findings. There is a wide spectrum of incidental findings on brain MRI such as asymptomatic brain infarct, age-related white matter changes, microhemorrhages, intracranial tumors, intracranial cystic lesions, and anatomic variants. This article provides a narrative review of important incidental findings encountered on brain MRI in adults with a focus on prevalence, clinical implications, and recommendations on management of these findings based on current available data.
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Affiliation(s)
| | | | | | - Mahmud Mossa-Basha
- Department of Radiology, University of North Carolina, Chapel Hill, NC, United States
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9
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The LIMIT-NI clinical decision instrument reduces neuroimaging compared to unstructured clinician judgement in recurrent seizure patients. Am J Emerg Med 2022; 62:14-18. [DOI: 10.1016/j.ajem.2022.09.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 09/19/2022] [Accepted: 09/23/2022] [Indexed: 11/19/2022] Open
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10
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Frush DP. An Ounce of Prevention Is Worth a Pound of Cur(ie). J Am Coll Radiol 2022; 19:677-679. [PMID: 35339457 DOI: 10.1016/j.jacr.2022.02.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 02/22/2022] [Indexed: 11/19/2022]
Affiliation(s)
- Donald P Frush
- Department of Radiology, Duke University Medical Center, Durham, North Carolina.
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Lynch P, Mitton T, Killeen DE, Kutz JW, Newcomer M. Diagnosing Pulsatile Tinnitus: A Review of 251 Patients. Otol Neurotol 2022; 43:128-136. [PMID: 34629443 DOI: 10.1097/mao.0000000000003370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To analyze the underlying etiologies, presenting characteristics, and diagnostic workup of patients with pulsatile tinnitus (PT). STUDY DESIGN Retrospective review. SETTING Tertiary referral center. PATIENTS All patients who received a diagnostic workup for PT from January 01, 2015 and May 31, 2020. MAIN OUTCOME MEASURE Diagnostic rate of imaging studies. RESULTS Among 251 patients with PT, the most common etiologies included neoplasms (16%), arteriopathies (14%), venopathies (8.5%), middle/inner ear pathology (9.0%), or idiopathic (50%). Patients with identifiable etiologies of PT more often had hypertension, obesity, vision changes, ipsilateral asymmetric hearing loss, or an abnormal otologic examination. Only 18.5% of patients without those characteristics had an identifiable etiology of PT. The most commonly ordered diagnostic studies were magnetic resonance imaging with contrast (n = 146), MR angiography (MRA) (n = 105), CT angiography (CTA) (n = 84), computed tomography (CT) without contrast (n = 76), and MR Venogram (MRV) (n = 62). Magnetic resonance imaging with contrast and CT without contrast preferentially identified patients with nonvascular etiologies of PT, while MRA and CTA identified patients with vascular etiologies of PT. MRV did not demonstrate high diagnostic rate for either type of PT. No difference in diagnostic rate was found between MR-based or CT-based imaging. CONCLUSIONS Patients who lack a history of hypertension, obesity, vision changes, ipsilateral asymmetric hearing loss, or an abnormal otologic examination are less likely to have an identifiable cause for PT. In cases where a specific etiology was identified, MR-based imaging (MRI with contrast and MRA) or CT-based imaging (CT without contrast and CTA) were equally efficacious in identifying that etiology. MR-based imaging is preferred for neoplasms, while CT-based imaging is preferred for semicircular canal dehiscence.
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Affiliation(s)
- Patrick Lynch
- Department of Otolaryngology, UT Southwestern Medical Center, Dallas, Texas
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12
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The Incidence and Management of Osgood-Schlatter Disease in General Practice. Br J Gen Pract 2021; 72:e301-e306. [PMID: 34990396 PMCID: PMC8869186 DOI: 10.3399/bjgp.2021.0386] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 11/22/2021] [Indexed: 11/22/2022] Open
Abstract
Background Osgood–Schlatter disease (OSD) is a non-traumatic knee problem that is primarily observed in sports-active children and adolescents aged 8–15 years. Aim To determine the incidence of OSD and to gain an insight into the management of children and adolescents with OSD in general practice. Design and setting A retrospective cohort study was conducted using a healthcare database containing full electronic health records of over 200 000 patients in general practice in and around the Dutch city of Rotterdam. Method Patients with a new diagnosis of OSD from 1 January 2012 to 31 December 2017 were extracted using a search algorithm based on International Classification of Primary Health Care coding and search terms in free text. Data on the management of OSD were manually interpreted. Results The mean incidence over the study period was 3.8 (95% confidence interval [CI] = 3.5 to 4.2) per 1000 person–years in those aged 8–18 years. Boys had a higher incidence rate of 4.9 (95% CI = 4.3 to 5.5) compared with girls (2.7, 95% CI = 2.3 to 3.2). Peak incidence was at 12 years of age for boys and 11 years for girls. Advice was the most commonly applied strategy (55.1%), followed by rest (21.0%), referral for imaging (19.5%), and physiotherapy (13.4%). Conclusion To the authors’ knowledge, for the first time the incidence of OSD has been calculated using GP electronic medical files. There is a discrepancy, especially for imaging and referral to a medical specialist, between the current Dutch general practice guidelines and how GPs actually manage the condition in clinical practice.
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Tu LH, Venkatesh AK, Malhotra A, Taylor RA, Sheth KN, Forman HP, Yaesoubi R. Scenarios to improve CT head utilization in the emergency department delineated by critical results reporting. Emerg Radiol 2021; 29:81-88. [PMID: 34617133 DOI: 10.1007/s10140-021-01947-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 05/18/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Increasing use of advanced imaging in the emergency department (ED) has resulted in higher cost without better outcomes. Our goal was to evaluate the yield of CT head exams by scenario to guide efforts at improving patient selection. METHODS We performed a retrospective study at an academic medical center over 4 years (1/1/2014-12/31/2017). The chief complaint, imaging order, and exam result text were obtained for all adult ED encounters. For the 50 most common chief complaints leading to CT head exams, the ratio of exams to total encounters and ratio of critical results to imaging studies were calculated. Significant difference in "yield" was assessed via binomial test. RESULTS Over 708,145 adult ED encounters, 58,783 CT head exams were ordered, with an overall critical result yield of 8.0%. The three most common chief complaints had higher yield (p < 0.05): altered mental status (9.8%), fall (9.7%), and new headache (10.1%). Lower yield (p < 0.05) was found for 19 chief complaints: dizziness (6.2%), falls in patients > 65 years old (7.1%), syncope (5.3%), seizure with known epilepsy (4.8%), chest pain (3.7%), head injury (4.9%), headache re-evaluation (7.0%), alcohol intoxication (2.5%), fatigue (6.5%), headache-recurrent or in the setting of known migraines (5.2%), hypertension (4.4%), lethargy (5.8%), loss of consciousness (5.3%), migraine (3.2%), psychiatric evaluation (2.9%), near syncope (4.6%), drug problem (3.1%), symptomatically decreased blood sugar (3.2%), and suicidal (1.7%). CONCLUSION Our study provides a priority list of low yield scenarios of CT head use for improvement of patient selection.
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Affiliation(s)
- Long H Tu
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, USA.
| | - Arjun K Venkatesh
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, USA
| | - Richard A Taylor
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Kevin N Sheth
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Howard P Forman
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, USA
| | - Reza Yaesoubi
- Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
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Itoga NK, Martinez-Singh K, Lee JT, John Harris E, Baker LC, Garcia-Toca M. Analysis of Medicare Payments and Patient Outcomes With Pre-Operative Imaging for Carotid Endarterectomy. Ann Vasc Surg 2021; 76:179-184. [PMID: 34153493 DOI: 10.1016/j.avsg.2021.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 05/18/2021] [Accepted: 06/06/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The use of radiographic evaluation of carotid disease may vary, and current guidelines do not strongly recommend the use of cross-sectional imaging (CSI) prior to surgical intervention. We sought to describe the trends in preoperative carotid imaging and evaluate the associated clinical outcomes and Medicare payments for patients undergoing carotid endarterectomy (CEA) for asymptomatic carotid disease. METHODS We used a 20% Medicare sample from 2006 to 2014 identifying patients undergoing CEA for asymptomatic disease. We evaluated preoperative carotid ultrasound and CSI use: CT or MRI of the neck prior to CEA. We calculated average payments of each study from the carrier file and revenue center file. Imaging payments included both the professional component (PC) and the technical component (TC). Claims with a reimbursement of $0 and studies where payment for both the TC and PC could not be identified were excluded from the overall calculation to determine average payment per study. Inpatient reimbursements according to DRG 37-39 were calculated. We compared hospital length of stay (LOS), in hospital stroke, carotid re-exploration, and mortality according to CSI use. RESULTS A total of 58,993 CEAs were identified with pre-operative carotid imaging. The average age was 74.8 ± 7.5 years, and 56.0% were men. A total of 19,678 (33%) patients had ultrasound alone with an average of (2.4 ± 1.9) exams prior to CEA. A total of 39,315 patients underwent CSI prior to CEA with 2.5 ± 2.1 ultrasounds, 0.95 ± 0.86 neck CTs and 0.47 ± 0.7 MRIs per patient. The average payment for ultrasound was $140 ± 40, $282 ± 94 for CT and $410 ± 146 for MRI. The average inpatient reimbursements were $7,413 ± 4,215 for patients without CSI compared with $7,792 ± 3,921 for patients with CSI, P < 0.001. The average LOS during CEA admission was 2.5 ± 3.7days. Patients with CSI had a slightly lower percentage of patients being discharged by postoperative day 2 compared with ultrasound alone (88.9% vs. 91.5%, respectively, P < 0.001). The overall in-hospital stroke rate was 0.38% and carotid re-exploration rate was 1.0% and there was no statistical significant difference between groups. Median follow-up was 3.9 years, and mortality at 8 years was 50% and did not statistically differ between groups. CONCLUSIONS Our analysis found preoperative imaging to include CSI in nearly two-thirds of patients prior to CEA for asymptomatic disease. As imaging and inpatient payments were higher with patients with CSI further work is needed to understand when CSI is appropriate prior to surgical intervention to appropriately allocate healthcare resources.
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Affiliation(s)
- Nathan K Itoga
- Division of Vascular Surgery, Department of Surgery, Stanford University, Stanford, CA; Department of Health Research and Policy, Stanford University, Stanford, CA; Department of Surgery, University of Hawaii, Honolulu, Hawaii.
| | | | - Jason T Lee
- Division of Vascular Surgery, Department of Surgery, Stanford University, Stanford, CA
| | - Edmund John Harris
- Division of Vascular Surgery, Department of Surgery, Stanford University, Stanford, CA
| | - Laurence C Baker
- Department of Health Research and Policy, Stanford University, Stanford, CA
| | - Manuel Garcia-Toca
- Division of Vascular Surgery, Department of Surgery, Stanford University, Stanford, CA
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Head and Neck CTA Utilization: Analysis of Ordering Frequency and Nonroutine Results Communication, With Focus on the Fifty Most Common Emergency Department Clinical Presentations. AJR Am J Roentgenol 2021; 218:544-551. [PMID: 34585611 DOI: 10.2214/ajr.21.26543] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: Utilization of head and neck CTA in the emergency department (ED) has grown disproportionately to other neuroimaging examinations. Objective: To characterize utilization of head and neck CTA in the ED, comparing utilization and frequency of nonroutine results communication among patients' chief concerns. Methods: All adult ED visits for a single healthcare system from January 2014 to December 2017 were retrospectively reviewed. Variables recorded included chief concerns, whether head and neck CTA was performed, and, if so, whether the report documented nonroutine results communication. The fifty chief concerns resulting in the highest number of head and neck CTA examinations were identified. Frequencies of head and neck CTA ordering and of nonroutine results communication were calculated. A subset of reports documenting nonroutine communication were manually reviewed. Results: Head and neck CTA was ordered in 2.5% (17,903) of 708,145 ED visits in 236,476 patients (mean age 48.9±20.5 years; 110,952 male, 125,521 female, 3 unknown sex). Head and neck CTA was ordered for 833 distinct chief concerns. Nonroutine results communication was documented for 17.6% (31,55/17,903) of examinations. Among the fifty chief concerns associated with the highest number of examinations, frequency of ordering head and neck CTA ranged from <0.5% (five concerns) to 55.2% (stroke code), and frequency of nonroutine communication ranged from 5.6% (transient ischemic attack) to 67.5% (unresponsive). Chief concerns not among the fifty most common accounted for 50.0% (8956/17903) of examinations; these exhibited a collective frequency of nonroutine communication of 4.8% (429/8956). Manual review of 11.1% (350/3155) of reports with a nonroutine communication indicated an acute finding related to the indication in 51.1%, non-emergent but potentially explanatory finding in 28.0%, incidental finding in 28.0%, and communication of negative results in 6.9%. Conclusion: Head and neck CTA is ordered in 2.5% of ED visits for a wide range of chief concerns. Frequencies of ordering and of nonroutine results communication are highly variable among chief concerns. Acute indication-related findings account for half of nonroutine radiologist communications. Clinical Impact: Insight into patterns regarding head and neck CTA ordering and nonroutine results may help optimize patient selection and radiologist communications in the ED setting.
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Young JL, Snodgrass SJ, Cleland JA, Rhon DI. The relationship between knee radiographs and the timing of physical therapy in individuals with patellofemoral pain. PM R 2021; 14:496-503. [PMID: 34288533 DOI: 10.1002/pmrj.12678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 07/07/2021] [Accepted: 07/09/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Routine knee radiographs are discouraged for individuals with non-traumatic knee pain, but they are often still ordered despite limited evidence for their value in guiding treatment choices. Radiograph utilization may delay the use of physical therapy, which has been associated with improved outcomes and lower long-term costs. OBJECTIVE To examine the relationship between obtaining knee radiographs for patients with patellofemoral pain (PFP) and the timing of physical therapy, and the association between ordering radiographs for patients who use physical therapy and the likelihood of knee pain recurrence. STUDY DESIGN Retrospective cohort. SETTING United States Military Health System civilian and military clinics. PATIENTS 23,332 individuals aged 18 to 50 diagnosed with PFP between 2010 and 2011 in the United States Military Health System who received physical therapy. INTERVENTIONS Physical therapy provided to individuals who did or did not receive an initial radiograph. MAIN OUTCOME MEASURES Timing of physical therapy and recurrence of knee pain were compared between groups (with and without initial radiographs). RESULTS If radiographs were used, the odds of initiating physical therapy (aOR = 0.78; 95% CI 0.64 to 0.94) within 30 days of the initial diagnosis were significantly lower. The mean days from diagnosis to initiating physical therapy was 12.1 (95% CI 9.1 to 16.1) if patients had radiographs versus 6.9 (95% CI 5.2 to 9.1) without. The odds of knee pain recurrence were no greater if radiographs were used (aOR = 1.01; 95% CI 0.83 to 1.22). CONCLUSIONS Receiving knee radiographs as part of initial care for PFP was associated with delayed initiation of physical therapy, but there was no association between early knee radiographs and recurrence of knee pain. Routine use of radiographs for PFP is not warranted, and can potentially delay appropriate treatment. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Jodi L Young
- Doctor of Science in Physical Therapy, Bellin College, 3201 Eaton Rd., Green Bay, WI, USA.,Discipline of Physiotherapy, School of Health Sciences, The University of Newcastle, University Dr., Callaghan, NSW, Australia
| | - Suzanne J Snodgrass
- Discipline of Physiotherapy, School of Health Sciences, The University of Newcastle, University Dr., Callaghan, NSW, Australia
| | - Joshua A Cleland
- Doctor of Physical Therapy Program, Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Daniel I Rhon
- Discipline of Physiotherapy, School of Health Sciences, The University of Newcastle, University Dr., Callaghan, NSW, Australia.,TX, USA.,Physical Therapy Department, Baylor University, Stanley, TX, USA
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Linet MS, Davis PB, Brink JA. The Need for a Broad-based Introduction to Radiation Science within U.S. Medical Schools' Educational Curriculum. Radiology 2021; 301:35-40. [PMID: 34282969 DOI: 10.1148/radiol.2021210665] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Martha S Linet
- From the Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, 9609 Medical Center Dr, NCI Shady Grove Room 7E536, Bethesda, MD 20892-9778 (M.S.L.); Department of Pediatrics, School of Medicine, Case Western Reserve University, Cleveland, Ohio (P.B.D.); and Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (J.A.B.)
| | - Pamela B Davis
- From the Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, 9609 Medical Center Dr, NCI Shady Grove Room 7E536, Bethesda, MD 20892-9778 (M.S.L.); Department of Pediatrics, School of Medicine, Case Western Reserve University, Cleveland, Ohio (P.B.D.); and Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (J.A.B.)
| | - James A Brink
- From the Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, 9609 Medical Center Dr, NCI Shady Grove Room 7E536, Bethesda, MD 20892-9778 (M.S.L.); Department of Pediatrics, School of Medicine, Case Western Reserve University, Cleveland, Ohio (P.B.D.); and Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (J.A.B.)
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Appropriateness of Computed Tomography Scanning in the Diagnosis of Craniosynostosis. J Craniofac Surg 2021; 33:222-225. [PMID: 34267136 DOI: 10.1097/scs.0000000000007928] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Although physicians from a variety of specialties encounter infants with possible craniosynostosis, judicious use of computed tomography (CT) imaging is important to avoid unnecessary radiation exposure and healthcare expense. The present study seeks to determine whether differences in specialty of ordering physician affects frequency of resulting diagnostic confirmations requiring operative intervention. METHODS Radiology databases from 2 institutions were queried for CT reports or indications that included "craniosynostosis" or "plagiocephaly." Patient demographics, specialty of ordering physician, confirmed diagnosis, and operative interventions were recorded. Cost analysis was performed using the fixed unit cost for a head CT to calculate the expense before 1 study led to operative intervention. RESULTS Three hundred eighty-two patients were included. 184 (48.2%) CT scans were ordered by craniofacial surgeons, 71 (18.6%) were ordered by neurosurgeons, and 127 (33.3%) were ordered by pediatricians. One hundred four (27.2%) patients received a diagnosis of craniosynostosis requiring operative intervention. Craniofacial surgeons and neurosurgeons were more likely than pediatricians to order CT scans that resulted in a diagnosis of craniosynostosis requiring operative intervention (P < 0.001), with no difference between craniofacial surgeons and neurosurgeons (P = 1.0). The estimated cost of obtaining an impact CT scan when ordered by neurosurgeons or craniofacial surgeons as compared to pediatricians was $2369.69 versus $13,493.75. CONCLUSIONS Clinicians who more frequently encounter craniosynostosis (craniofacial and neurosurgeons) had a higher likelihood of ordering CT images that resulted in a diagnosis of craniosynostosis requiring operative intervention. This study should prompt multi-disciplinary interventions aimed at improving evaluation of pretest probability before CT imaging.
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Tambe J, Onana Y, Dongmo S, Nguefack-Tsague G, Ongolo-Zogo P. Health Insurance Ownership and Quality of Computed Tomography Requests: Experience from a Peripheral Referral Hospital in Cameroon. Radiol Res Pract 2021; 2021:9959114. [PMID: 34239730 PMCID: PMC8241523 DOI: 10.1155/2021/9959114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 06/09/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Health insurance ownership facilitates access and minimizes financial hardship after utilization of healthcare services such as computed tomography (CT). Understanding the rational utilization of CT by people with health insurance can help optimize the scheme and provide baseline information for a national universal health coverage program. OBJECTIVE To assess the relationship between health insurance ownership and the appropriateness of requests for CT in a peripheral referral hospital in Cameroon. METHODS A survey of CT users was conducted during which information on health insurance ownership was collected and the request forms for CT assessed for appropriateness using the American College of Radiologists (ACR) Appropriateness Criteria®. RESULTS We consecutively enrolled 372 participants of which 167 (45%) were females. The median age (range) was 52 (18-92) years. Thirty-eight out of 370 participants reported having health insurance (10.3%; 95% confidence interval (CI): 7.2%-13.4%). Twenty-nine out of 352 CT scan requests (8.2%; 95% CI: 5.3-11.0) were judged to be "inappropriate." The proportion of inappropriate scan requests was higher amongst people with health insurance compared to those without health insurance (18.4% vs. 7.0%; χ 2 = 5.8; p=0.02). In the logistic regression analysis, health insurance ownership was associated to the appropriateness of CT requests in the univariate analysis only (OR = 0.33; 95% CI: 0.13-0.84; p=0.020). CONCLUSIONS Inappropriate requests for CT were low but nevertheless associated to health insurance ownership. The continuous sensitization and training of physicians would help minimize potential wasteful utilization of resources.
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Affiliation(s)
- Joshua Tambe
- Division of Radiology, Department of Internal Medicine and Pediatrics, University of Buea, Buea, Cameroon
- Department of Public Health, Centre for Research and Training in Graduate Studies in Life, Health and Environmental Sciences, The University of Yaoundé I, Yaoundé, Cameroon
| | - Yannick Onana
- Department of Clinical Sciences, University of Ngaoundéré, Ngaoundéré, Cameroon
| | - Sylviane Dongmo
- Division of Radiology, Department of Internal Medicine and Pediatrics, University of Buea, Buea, Cameroon
| | - Georges Nguefack-Tsague
- Biostatistics Unit, Department of Public Health, The University of Yaoundé I, Yaoundé, Cameroon
| | - Pierre Ongolo-Zogo
- Department of Public Health, Centre for Research and Training in Graduate Studies in Life, Health and Environmental Sciences, The University of Yaoundé I, Yaoundé, Cameroon
- Department of Radiology and Radiation Oncology, The University of Yaoundé I, Yaoundé, Cameroon
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Are chest X-rays valuable for patients presenting to emergency departments with acute abdominal pain? Australas Emerg Care 2021; 25:84-87. [PMID: 33879427 DOI: 10.1016/j.auec.2021.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 03/23/2021] [Accepted: 03/23/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Emergency department patients presenting with acute abdominal pain are often prescribed a chest X-ray; however, the value of chest X-rays in acute abdominal pain is poorly understood. The aim of this study was to assess the value of chest X-rays in acute abdominal pain. METHODS A retrospective analysis of 944 chest X-rays performed for acute abdominal pain was conducted. Patient clinical information, radiology reports, and findings of other diagnostic investigations were also collected. MedCal® software was used to calculate diagnostic performance of chest X-rays. A Chi-Square test was used to assess the association between positive chest X-ray findings and both age and gender. RESULTS Of the 944 chest X-rays identified as satisfying inclusion factors, only 10 cases (approximately 1%) demonstrated pathology that was likely to be the cause of the abdominal pain. Further analysis demonstrated the following performance metrics at 95%CI: sensitivity (12.8; 8.78-17.72); specificity (100; 98.4-100); positive predictive value (100%); negative predictive value (52.76; 51.54-53.98); accuracy (55.82; 51.17-60.40). CONCLUSION Chest X-ray has limited sensitivity and diagnostic value in patients presenting to the emergency department with abdominal pain and does not appear to be a useful diagnostic investigation for abdominal pain.
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Abstract
It may seem unlikely that the field of radiology perpetuates disparities in health care, as most radiologists never interact directly with patients, and racial bias is not an obvious factor when interpreting images. However, a closer look reveals that imaging plays an important role in the propagation of disparities. For example, many advanced and resource-intensive imaging modalities, such as MRI and PET/CT, are generally less available in the hospitals frequented by people of color, and when they are available, access is impeded due to longer travel and wait times. Furthermore, their images may be of lower quality, and their interpretations may be more error prone. The aggregate effect of these imaging acquisition and interpretation disparities in conjunction with social factors is insufficiently recognized as part of the wide variation in disease outcomes seen between races in America. Understanding the nature of disparities in radiology is important to effectively deploy the resources and expertise necessary to mitigate disparities through diversity and inclusion efforts, research, and advocacy. In this article, the authors discuss disparities in access to imaging, examine their causes, and propose solutions aimed at addressing these disparities.
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Affiliation(s)
- Stephen Waite
- From the Department of Radiology, SUNY Downstate Medical Center, 450 Clarkson Ave, Brooklyn, NY 11203 (S.W., J.M.S.); and Department of Psychiatry, Weill Cornell Medical College, New York, NY (D.C.)
| | - Jinel Scott
- From the Department of Radiology, SUNY Downstate Medical Center, 450 Clarkson Ave, Brooklyn, NY 11203 (S.W., J.M.S.); and Department of Psychiatry, Weill Cornell Medical College, New York, NY (D.C.)
| | - Daria Colombo
- From the Department of Radiology, SUNY Downstate Medical Center, 450 Clarkson Ave, Brooklyn, NY 11203 (S.W., J.M.S.); and Department of Psychiatry, Weill Cornell Medical College, New York, NY (D.C.)
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Burley T, Brody LT, Boissonnault WG, Ross MD. Development of a Musculoskeletal Imaging Competency Examination for Physical Therapists. Phys Ther 2020; 100:2254-2265. [PMID: 32885236 DOI: 10.1093/ptj/pzaa154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/21/2020] [Indexed: 02/09/2023]
Abstract
OBJECTIVE The number of physical therapists with imaging ordering privileges is increasing; however, a known level of competency and knowledge is generally lacking within the profession, as is a method to determine practitioner competency. The purpose of this study was to develop a valid musculoskeletal (MSK) imaging competency examination for physical therapists. METHODS This 3-round Delphi method study utilized experts to reach consensus on examination content and development. Round 1 was completed by 37 experts. The last 2 rounds were completed by 35 experts. Experts rated questions on a 5-point Likert rating scale of importance (1 = not at all important, 5 = very important). Consensus was achieved with an a priori decision of (1) >75% agreement of the expert panel rating and ≥4 on the Likert scale, and (2) ≥.90 on Cronbach alpha and intraclass correlation coefficients. Experts recommended a passing score of 75%. The examination was subsequently reviewed by a panel of 5 radiologists. RESULTS The Delphi method and radiologist panel review resulted in the 151-question Burley Readiness Examination (BRE) for MSK Imaging Competency. Interrater agreement and internal consistency of the Delphi panel were excellent, with an average intraclass correlation coefficient and Cronbach alpha of .928 and .950, respectively. CONCLUSIONS The BRE is a tool that has the potential to demonstrate practitioners' level of baseline competency with MSK imaging. Additional testing among physical therapists will provide further validation and reliability of the examination. IMPACT The use and application of diagnostic imaging is becoming more widespread in physical therapist practice throughout the United States. The BRE could potentially have broader implications for health care utilization and cost in the area of MSK imaging.
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Affiliation(s)
- Troy Burley
- Rocky Mountain University of Health Professions, Provo, Utah
| | - Lori T Brody
- Sports and Spine Physical Therapy, University of Wisconsin, Mt. Horeb, Wisconsin
| | | | - Michael D Ross
- Department of Physical Therapy, Daemen College, 4380 Main Street, Amherst, NY 14426 (USA)
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Tambe J, Mbuagbaw L, Ongolo-Zogo P, Nguefack-Tsague G, Edjua A, Mbome-Njie V, Ze Minkande J. Assessing and coping with the financial burden of computed tomography utilization in Limbe, Cameroon: a sequential explanatory mixed-methods study. BMC Health Serv Res 2020; 20:981. [PMID: 33109154 PMCID: PMC7590681 DOI: 10.1186/s12913-020-05830-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 10/19/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There has been a significant increase in computed tomography (CT) utilization over the past two decades with the major challenges being a high exposure to ionizing radiation and rising cost. In this study we assess the risk of financial hardship after CT utilization and elaborate on how users adapt and cope in a sub-Saharan context with user fee for services and no national health insurance policy. METHODS We carried out a sequential explanatory mixed methods study with a quantitative hospital-based survey of CT users followed by in-depth interviews of some purposively selected participants who reported risk of financial hardship after CT utilization. Data was summarized using frequencies, percentages and 95% confidence intervals. Logistic regression was used in multivariable analysis to determine predictors of risk of financial hardship. Identified themes from in-depth interviews were categorized. Quantitative and qualitative findings were integrated. RESULTS A total of 372 participants were surveyed with a male to female sex ratio of 1:1.2. The mean age (standard deviation) was 52(17) years. CT scans of the head and facial bones accounted for 63% (95%CI: 59-68%) and the top three indications were suspected stroke (27% [95%CI: 22-32%]), trauma (14% [95%CI: 10-18%]) and persistent headaches (14% [95%CI: 10-18%]). Seventy-two percent (95%CI: 67-76%) of the respondents reported being at risk of financial hardship after CT utilization and predictors in the multivariable analysis were a low socioeconomic status (aOR: 0.19 [95%CI: 0.10-0.38]; p < 0.001), being unemployed or retired (aOR: 11.75 [95%CI: 2.59-53.18]; p = 0.001) and not having any form of health insurance (aOR: 3.59 [95%CI: 1.31-9.85]; p = 0.013). Coping strategies included getting financial support from family and friends, borrowing money and obtaining discounts from the hospital administration and staff. CONCLUSION No health insurance ownership, being unemployed or retired and a low socioeconomic status are associated with financial hardship after CT utilization. Diverse coping strategies are utilized to lessen the financial burden, some with negative consequences. Minimizing out-of-pocket payments and/or the direct cost of CT can reduce this financial burden and improve CT access.
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Affiliation(s)
- Joshua Tambe
- Post-Graduate School for Life Sciences, Health and Environment, The University of Yaoundé I, Yaoundé, Cameroon.
- Division of Radiology, University of Buea, Buea, Cameroon.
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
- Biostatistics Unit, Father Sean O'Sullivan Research Centre, St Joseph's Healthcare, Hamilton, Canada
| | - Pierre Ongolo-Zogo
- Post-Graduate School for Life Sciences, Health and Environment, The University of Yaoundé I, Yaoundé, Cameroon
| | - Georges Nguefack-Tsague
- Department of Public Health, Biostatistics unit, Faculty of Medicine and Biomedical Sciences, The University of Yaoundé I, Yaoundé, Cameroon
| | - Andrew Edjua
- Higher Technical Teacher's Training College Kumba, University of Buea, Buea, Cameroon
| | | | - Jacqueline Ze Minkande
- Post-Graduate School for Life Sciences, Health and Environment, The University of Yaoundé I, Yaoundé, Cameroon
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Duran A, Donelan C, Bowman Peterson J, Gladding SP, Weissmann P, Roth CS. Communicating value to patients-a high-value care communication skills curriculum. Postgrad Med 2020; 133:231-236. [PMID: 32762590 DOI: 10.1080/00325481.2020.1807728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION With rising health care costs in the United States, trainees will be increasingly challenged in discussing testing stewardship with patients. OBJECTIVE We piloted a high-value care (HVC) communication skills curriculum utilizing the Four Habits Model for communication. We hoped residents would 1) learn to apply the Four Habits communication model to HVC discussions with standardized patients (SP) and 2) improve value-based communication skills through training in a high-intensity curriculum with feedback from trained faculty facilitators and peers. METHODS Thirty interns at the University of Minnesota were randomized to a standard HVC communication SP encounter (n = 15) or a high-intensity HVC communication skills curriculum (n = 15). The high-intensity curriculum included video and audio-recorded SP encounters followed by facilitated small group discussions/feedback. Experiences were reported in a post-intervention survey; communication skills were assessed with the CARE empathy scale. RESULTS 70% (21/30) of interns (57% high intensity, 43% standard) responded to the survey. In total, 88% of high intensity v. 44% of standard interns agreed/strongly agreed that the curriculum was valuable for their communication skills. High-intensity interns were more likely to report that feedback was valuable with subsequent incorporation of feedback into future patient encounters. High-intensity participants also reported higher levels of interest in future HVC curricula (55% vs 22%). CONCLUSION There was no difference in overall performance on the CARE empathy scale. Our HVC high-intensity skills curriculum was well received by interns and provided opportunities to practice structured conversations and debrief around testing stewardship.
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Affiliation(s)
- Alisa Duran
- Section of Women's Health and General Internal Medicine, Minneapolis VA Health Care System, University of Minnesota, Minneapolis, MN, USA
| | - Crystal Donelan
- Department of Emergency Medicine, George Washington University, Washington D.C., USA
| | - Jill Bowman Peterson
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA.,Minneapolis VA Health Care System, Minneapolis, MN, USA
| | - Sophia P Gladding
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Peter Weissmann
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA.,Minneapolis VA Health Care System, Minneapolis, MN, USA
| | - Craig S Roth
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA.,Minneapolis VA Health Care System, Minneapolis, MN, USA
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Elzinga JL, Dunne CL, Vorobeichik A, Keto-Lambert D, Grigat D, Lang E, Dowling S. A Systematic Review Protocol to Determine the Most Effective Strategies to Reduce Computed Tomography Usage in the Emergency Department. Cureus 2020; 12:e9509. [PMID: 32884867 PMCID: PMC7461135 DOI: 10.7759/cureus.9509] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 08/01/2020] [Indexed: 12/28/2022] Open
Abstract
This study describes the protocol for a systematic review and meta-analysis. The primary objective of the review is to identify experimental studies assessing the effectiveness of interventions that aim to reduce the proportion of computed tomography (CT) in emergency departments (EDs). Data permitting, our secondary objectives will be to assess the impact of reduction in CT utilization on the length of stay, admission to hospital, and uptake/satisfaction with the intervention. When available, balancing measures such as readmission to hospital or ED revisit rates will be included. Pre-defined subgroup analyses include patient populations (adult or pediatric), type of ED, and the nature of the intervention. Through this review, the research team aims to inform knowledge translation initiatives aimed at lowering CT usage in the ED by identifying the most effective interventions to safely improve CT resource stewardship.
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Affiliation(s)
| | - Cody L Dunne
- Emergency Medicine, University of Calgary, Calgary, CAN
| | | | - Diana Keto-Lambert
- Pediatrics, University of Alberta Evidence-Based Practice Center, Edmonton, CAN
| | - Daniel Grigat
- Emergency Medicine, Strategic Clinical Network, Alberta Health Services, Calgary, CAN
| | - Eddy Lang
- Emergency Medicine, University of Calgary, Calgary, CAN
| | - Shawn Dowling
- Emergency Medicine, Alberta Health Services, Calgary, CAN
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Morris M, Destian S, Chu Y, Klumpp M, Zohrabian VM. Investigation of Whole Spine MRI in the Emergency Department at Two Large Tertiary Care Academic Medical Centers in the United States. Curr Probl Diagn Radiol 2020; 50:637-645. [PMID: 32839068 DOI: 10.1067/j.cpradiol.2020.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 07/09/2020] [Accepted: 07/20/2020] [Indexed: 11/22/2022]
Abstract
RATIONALE AND OBJECTIVES The impact of emergent whole spine magnetic resonance imaging (WS-MRI) on patient management has not been extensively studied to date. Here, we explore indications, results, and outcomes associated with WS-MRI performed through the emergency departments (EDs) of 2 large tertiary care, academic medical centers in the Northeastern United States. We hypothesize that given a relatively low barrier to entry, coupled with lack of appropriateness guidelines, a sizeable proportion of WS-MRI studies performed emergently do not result in spine findings necessitating inpatient admission for immediate treatment. MATERIALS AND METHODS We retrospectively studied 335 adult patients (≥18 years) who underwent WS-MRI through the ED between 2016 and 2019. The demographic data collected included, age, sex, chief complaint, history of spine disease, and date and type of last spine imaging prior to ED presentation. Data compiled from the time of ED visit included WS-MRI result and patient disposition, including reason for hospital admission, by which patients were categorized into groups to allow for ease of comparisons. Hypergeometric tests were used to determine statistically significant associations between random discrete variables. RESULTS Trauma was the most frequent chief complaint, comprising 35% (n = 117) of all presentations, followed by pain (25%, n = 84), motor deficit (16%, n = 55), sensory disturbance (12%, n = 41), bowel, and/or bladder dysfunction (9%, n = 30), and subjective or objective fevers with suspicion for spine infection (2%, n = 8). The largest proportion of WS-MRI studies revealed degenerative disc disease (DDD) as the principal result (41%, n = 139). 52% of all patients were either discharged directly from the ED (41%) or admitted for a non-spine issue after WS-MRI (11%); of these numbers, 61% underwent WS-MRI and no other imaging study in the ED. In patients who presented with a chief complaint of pain, DDD was often the principal WS-MRI finding (54%), albeit this association was not statistically significant. DDD, nonetheless, was positively associated with a discharge from the ED (P <0.001). Trauma was positively associated with fracture or ligamentous/soft tissue injury (P <0.001) on WS-MRI and hospital admission for a spine issue (P <0.01). CONCLUSION That just under half of patients in our study were admitted for spine-related pathology suggests that WS-MRI is valuable in the emergent setting. At the same time, however, that over half of patients were not subsequently admitted for a spine-related issue points to the possibility of further refining which patients would benefit most from WS-MRI. WS-MRI may be less helpful in patients presenting with pain, though may be higher-yield in those with trauma, motor deficits, and bowel/bladder complaints. Although MRI is highly sensitive in ruling out emergent central nervous system pathology, given the resource-intensive nature of the test, it is prudent to carefully select which patients should undergo emergent WS-MRI, especially in instances when more cost-effective, alternative diagnostic approaches, including detailed neurological exam, computed tomography, or localized/targeted MRI, are possible.
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Affiliation(s)
- Montana Morris
- Yale School of Medicine, Department of Radiology & Biomedical Imaging, New Haven, CT
| | - Sylvie Destian
- SUNY Upstate Medical University, Department of Radiology, Syracuse, NY
| | - Youngmin Chu
- SUNY Upstate Medical University, Department of Radiology, Syracuse, NY
| | - Matthew Klumpp
- SUNY Upstate Medical University, Department of Radiology, Syracuse, NY
| | - Vahe M Zohrabian
- Yale School of Medicine, Department of Radiology & Biomedical Imaging, New Haven, CT.
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Powers WJ, Kam CH, Ritter VS, Fine JP. Diagnostic accuracy of acute infarcts in multiple cerebral circulations for cardioembolic stroke: Literature review and meta-analysis. J Stroke Cerebrovasc Dis 2020; 29:104849. [PMID: 32402721 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 03/12/2020] [Accepted: 03/25/2020] [Indexed: 10/24/2022] Open
Abstract
OBJECTIVE To determine the diagnostic value of acute infarcts in multiple cerebral circulations (AIMCC) on MRI diffusion-weighted imaging (DWI) for cardioembolism (CE) stroke subtype in adult patients hospitalized with acute ischemic stroke, we conducted a systematic literature review and meta-analysis. METHODS MEDLINE was searched via PubMed for articles reporting patients hospitalized with acute ischemic stroke with MRI DWI categorized as AIMCC vs other and use of Trial of Org 10172 in Acute Stroke Treatment (TOAST) Criteria for cardioembolism subtype. Measures of diagnostic accuracy were calculated from the retrieved studies. RESULTS Seven eligible articles comprised 5813 patients. Bivariate random effects models estimated sensitivity 0.19 (95% CI, 0.13 to 0.27), specificity 0.89 (0.86 to 0.91), positive predictive value 0.37 (0.30 to 0.45), negative predictive value 0.76 (0.7 to 0.82), positive likelihood ratio 1.70 (1.13 to 2.57) and negative likelihood ratio 0.91 (0.83 to 1). INTERPRETATION The pattern of AIMCC on DWI is of limited diagnostic value. It is not sufficiently accurate to exclude cardiac pathology by a negative test nor does a positive test indicate a major increase in the probability of identifying a potential cardioembolic source.
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Affiliation(s)
- William J Powers
- Department of Neurology, University of North Carolina School of Medicine, Chapel Hill, NC, United States.
| | - Candice H Kam
- Department of Neurology, University of North Carolina School of Medicine, Chapel Hill, NC, United States.
| | - Victor S Ritter
- Department of Biostatistics, UNC Gillings School of Global Public Health, Chapel Hill, NC, United States.
| | - Jason P Fine
- Department of Biostatistics, UNC Gillings School of Global Public Health, Chapel Hill, NC, United States.
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Wintermark M, Willis MH, Hom J, Franceschi AM, Fotos JS, Mosher T, Cruciata G, Reuss T, Horton R, Fredericks N, Burleson J, Haines B, Bruno M. Everything Every Radiologist Always Wanted (and Needs) to Know About Clinical Decision Support. J Am Coll Radiol 2020; 17:568-573. [DOI: 10.1016/j.jacr.2020.03.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 12/26/2019] [Accepted: 03/19/2020] [Indexed: 12/18/2022]
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Adenaw N, Wen J, Pahwa AK, Sheth S, Johnson PT. Decreasing Duplicative Imaging: Inpatient and Emergency Medicine Abdominal Ultrasound Within 72 Hours of Abdominal CT. J Am Coll Radiol 2020; 17:590-596. [PMID: 32247697 DOI: 10.1016/j.jacr.2020.03.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 03/10/2020] [Accepted: 03/13/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE The aim of this project was to reduce abdominal ultrasound examinations in patients who had undergone abdominal CT within 72 hours previously. METHODS A best practice advisory (BPA) was created in the electronic medical record to advise against the use of abdominal ultrasound in adult inpatients and emergency department patients who had undergone abdominal CT within the preceding 72 hours. Acceptable acknowledgment reasons to proceed with the order were made available if providers chose to override. Frequency of BPA firing and subsequent ordering behavior were evaluated 6 months after integration of the BPA into the electronic medical record. Chart review was conducted for 100 patients whose orders were placed through an override of the alert to determine if the ultrasound study added value and for all patients whose ultrasound studies were canceled to confirm that patient care was not compromised by omitting the ultrasound study. RESULTS In the first 6 months, a total of 614 inpatient and emergency department abdominal ultrasound orders triggered the BPA. A total of 16% of orders (n = 96) were canceled by the provider after the BPA, reflecting 518 overrides. The majority of retained orders were to evaluate the gallbladder (44% [227 of 518]). Chart review confirmed utility for gallbladder imaging and that the canceled ultrasound examinations would not have contributed value to patients' care. CONCLUSIONS A recently performed abdominal CT scan may obviate the need for inpatient and emergency department abdominal ultrasound, particularly in the setting of hospital-acquired acute kidney injury. A BPA resulted in only 16% of orders' being canceled, whereas chart review revealed a much larger opportunity to avoid duplicative imaging.
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Affiliation(s)
- Nebiyu Adenaw
- The Russell H. Morgan Department of Radiology and Radiologic Science, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jessica Wen
- The Russell H. Morgan Department of Radiology and Radiologic Science, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Amit K Pahwa
- The Russell H. Morgan Department of Radiology and Radiologic Science, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sheila Sheth
- The Russell H. Morgan Department of Radiology and Radiologic Science, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Pamela T Johnson
- The Russell H. Morgan Department of Radiology and Radiologic Science, Johns Hopkins University School of Medicine, Baltimore, Maryland.
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National Trends in Imaging Rates for Eye-Related Emergency Department Visits in the United States. Am J Ophthalmol 2020; 211:114-122. [PMID: 31730840 DOI: 10.1016/j.ajo.2019.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 10/29/2019] [Accepted: 11/04/2019] [Indexed: 11/20/2022]
Abstract
PURPOSE To identify nationwide trends and factors associated with advanced imaging (computed tomography [CT] and magnetic resonance imaging [MRI]) use for eye-related emergency department (ED) visits. DESIGN Retrospective, trend study. METHODS Setting: National Hospital Ambulatory Medical Care Survey 2007-2015. PATIENT POPULATION Eye-related ED patients who underwent CT or MRI. MAIN OUTCOME MEASURE(S) Population-based CT/MR imaging rates and independent factors associated with imaging. RESULTS An estimated 7 million eye-related ED visits occurred between 2007 and 2015. Adjusted for annual eye-related ED visits, the rate of imaging use rose 94%, from 121.7 per 1,000 eye-related ED visits in 2007 to 236.0 per 1,000 eye-related ED visits in 2015. Visual disturbances, contusion of the eye and/or adnexa, open globes and open wounds of ocular adnexa, diplopia, superficial corneal and/or conjunctival injuries, and orbital fractures accounted for 73.2% of all visits where imaging was performed. On multivariable analysis, older patients (odds ratio [OR] = 1.02, 95% confidence interval [CI] 1.01-1.03) and females (OR=2.07, 95% CI 1.18-3.63) were more likely to undergo imaging than younger patients and males. Imaging was also more likely to be performed for Medicare beneficiaries (OR=2.12, 95% CI 1.08-4.15) than for privately insured patients. Patients who were admitted to the hospital were 6 times more likely (OR=6.39, 95% CI 2.04-20.0) to undergo imaging than those who were not admitted. CONCLUSIONS Advanced imaging for eye-related ED visits has escalated at a higher rate than ED visits for eye complaints. Future studies to develop evidence-based algorithms for use of CT/MR imaging for eye complaints that can help balance benefits against financial costs and health risk are warranted.
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Munera F, Infante JC. Deep Learning for Chest Radiography in the Emergency Department. Radiology 2019; 293:581-582. [DOI: 10.1148/radiol.2019192079] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Felipe Munera
- From the Department of Radiology, University of Miami Miller School of Medicine, Jackson Memorial Hospital/Ryder Trauma Center, 1611 NW 12th Ave, WW-279, Miami, FL 3316
| | - Juan C. Infante
- From the Department of Radiology, University of Miami Miller School of Medicine, Jackson Memorial Hospital/Ryder Trauma Center, 1611 NW 12th Ave, WW-279, Miami, FL 3316
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Ostby SA, Evans JG, Smith HJ, Boitano TKL, Toboni MD, Heimann MA, Booth JS, Thomas JJ, Michael Straughn J. Reducing emergency department (ED) computed tomography (CT) utilization in women treated for gynecologic cancers. Gynecol Oncol 2019; 156:288-292. [PMID: 31767189 DOI: 10.1016/j.ygyno.2019.11.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 11/13/2019] [Accepted: 11/17/2019] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The objective of this quality improvement (QI) project was to decrease the rate of low-value computed tomography (CT) imaging in established gynecologic oncology patients presenting to the emergency department (ED). METHODS This was a cohort study with a before and after design that evaluated implementation of a QI project designed to decrease CT utilization in established gynecologic oncology patients in the ED. The pre-intervention cohort included patients admitted through the ED from 4/1/17 to 5/31/18, while the post-intervention cohort was from 6/1/18 to 5/31/19. The intervention included gynecologic oncology consultation before CT on patients who had imaging within the prior 3 weeks. Details regarding CT, ED length of stay (LOS), and oncologic history were abstracted. The value of CT was determined by consensus from 2 reviewers. Prospective data monitoring evaluated for patient safety. RESULTS Prior to intervention, there were 129 unique ED encounters in gynecologic oncology patients leading to admission. CT scans were performed in 101 (78.3%) encounters, 57.7% of which were deemed to be of low-value. Following implementation, the CT utilization rate decreased significantly from median monthly rate of 75.2% to 49.1% (p < 0.00001), and the ED LOS decreased from 8.1 to 6.9 h (p = 0.0102). The number of CT scans deemed to be low-value in the post-intervention group decreased to 2 (3.8%). CONCLUSIONS Implementation of an early consultation policy and imaging guidelines led to a significant decrease in unnecessary CT utilization and shorter ED LOS in gynecologic oncology patients presenting to the ED.
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Affiliation(s)
- Stuart A Ostby
- University of Alabama at Birmingham Department of Obstetrics & Gynecology, United States of America.
| | - Joel G Evans
- University of Alabama at Birmingham Division of Emergency Medicine, United States of America
| | - Haller J Smith
- University of Alabama at Birmingham Division of Gynecologic Oncology, United States of America
| | - Teresa K L Boitano
- University of Alabama at Birmingham Department of Obstetrics & Gynecology, United States of America
| | - Michael D Toboni
- University of Alabama at Birmingham Department of Obstetrics & Gynecology, United States of America
| | - Matthew A Heimann
- University of Alabama at Birmingham Division of Emergency Medicine, United States of America
| | - J Stu Booth
- University of Alabama at Birmingham Division of Emergency Medicine, United States of America
| | - Jarred J Thomas
- University of Alabama at Birmingham Division of Emergency Medicine, United States of America
| | - J Michael Straughn
- University of Alabama at Birmingham Division of Gynecologic Oncology, United States of America
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Atsina KB, Rozenberg A, Selvarajan SK. The utility of whole spine survey MRI in blunt trauma patients sustaining single level or contiguous spinal fractures. Emerg Radiol 2019; 26:493-500. [DOI: 10.1007/s10140-019-01693-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 04/23/2019] [Indexed: 10/26/2022]
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Increasing Utilization of Chest Imaging in US Emergency Departments From 1994 to 2015. J Am Coll Radiol 2019; 16:674-682. [DOI: 10.1016/j.jacr.2018.11.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 11/05/2018] [Accepted: 11/09/2018] [Indexed: 11/17/2022]
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