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Anderson T, Hopper C, MacCraith E, McCabe A, Shortt CP. Assessment of clinically significant urolithiasis positivity rate using CT KUB for suspected renal colic. Ir J Med Sci 2024; 193:1009-1013. [PMID: 37542633 DOI: 10.1007/s11845-023-03477-5] [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: 05/24/2023] [Accepted: 07/24/2023] [Indexed: 08/07/2023]
Abstract
BACKGROUND Unenhanced low-dose computed tomography of the kidneys, ureter and bladder (CT KUB) is the gold standard diagnostic imaging modality in the assessment of suspected renal colic. As the radiation dose is not negligible, it is important to monitor the diagnostic yield of CT KUBs. The aim of this study is to evaluate the diagnostic yield of CT KUB studies performed for suspected renal colic in patients presenting to the emergency department. METHODS A retrospective review was performed of 500 patients who underwent CT KUB for suspected renal colic over a seven month period from June 2019 to January 2020. Clinical information and imaging was reviewed for each patient. Statistical analysis was performed using GraphPad Prism 8 (GraphPad Software, San Diego, CA, USA). RESULTS Forty-nine percent of patients in the series were female (248/500) and the mean age was 45. The positivity rate for obstructing ureteral calculus was 34% (169/500). Concerningly, there was a significantly lower positivity rate in females compared to males (19% versus 48%; p < 0.0001) which raises the issue of unnecessary radiation exposure to this cohort. In the 200 female patients who were negative for obstructing urolithiasis, the mean age was 43. Females also had a significantly higher rate of negative CT KUB (62% versus 37%; p < 0.0001) where no underlying alternative pathology was diagnosed. CONCLUSIONS Women are less likely than men to have obstructing urolithiasis on CT KUB for suspected renal colic. This difference is not accounted for by a higher rate of alternative diagnoses among female patients. The findings of this study should prompt clinicians to exercise caution when considering this imaging modality in this patient cohort.
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Dekker HM, Stroomberg GJ, Van der Molen AJ, Prokop M. Review of strategies to reduce the contamination of the water environment by gadolinium-based contrast agents. Insights Imaging 2024; 15:62. [PMID: 38411847 PMCID: PMC10899148 DOI: 10.1186/s13244-024-01626-7] [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: 09/14/2023] [Accepted: 01/19/2024] [Indexed: 02/28/2024] Open
Abstract
Gadolinium-based contrast agents (GBCA) are essential for diagnostic MRI examinations. GBCA are only used in small quantities on a per-patient basis; however, the acquisition of contrast-enhanced MRI examinations worldwide results in the use of many thousands of litres of GBCA per year. Data shows that these GBCA are present in sewage water, surface water, and drinking water in many regions of the world. Therefore, there is growing concern regarding the environmental impact of GBCA because of their ubiquitous presence in the aquatic environment. To address the problem of GBCA in the water system as a whole, collaboration is necessary between all stakeholders, including the producers of GBCA, medical professionals and importantly, the consumers of drinking water, i.e. the patients. This paper aims to make healthcare professionals aware of the opportunity to take the lead in making informed decisions about the use of GBCA and provides an overview of the different options for action.In this paper, we first provide a summary on the metabolism and clinical use of GBCA, then the environmental fate and observations of GBCA, followed by measures to reduce the use of GBCA. The environmental impact of GBCA can be reduced by (1) measures focusing on the application of GBCA by means of weight-based contrast volume reduction, GBCA with higher relaxivity per mmol of Gd, contrast-enhancing sequences, and post-processing; and (2) measures that reduce the waste of GBCA, including the use of bulk packaging and collecting residues of GBCA at the point of application.Critical relevance statement This review aims to make healthcare professionals aware of the environmental impact of GBCA and the opportunity for them to take the lead in making informed decisions about GBCA use and the different options to reduce its environmental burden.Key points• Gadolinium-based contrast agents are found in sources of drinking water and constitute an environmental risk.• Radiologists have a wide spectrum of options to reduce GBCA use without compromising diagnostic quality.• Radiology can become more sustainable by adopting such measures in clinical practice.
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Affiliation(s)
- Helena M Dekker
- Department of Medical Imaging, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands.
| | - Gerard J Stroomberg
- RIWA-Rijn - Association of River Water Works, Groenendael 6, 3439 LV, Nieuwegein, The Netherlands
| | - Aart J Van der Molen
- Department of Radiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Mathias Prokop
- Department of Medical Imaging, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
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Walther F, Eberlein-Gonska M, Hoffmann RT, Schmitt J, Blum SFU. Measuring appropriateness of diagnostic imaging: a scoping review. Insights Imaging 2023; 14:62. [PMID: 37052758 PMCID: PMC10102275 DOI: 10.1186/s13244-023-01409-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 03/18/2023] [Indexed: 04/14/2023] Open
Abstract
In radiology, the justification of diagnostic imaging is a key performance indicator. To date, specific recommendations on the measurement of appropriateness in diagnostic imaging are missing. To map the study literature concerning the definition, measures, methods and data used for analyses of appropriateness in research of diagnostic imaging. We conducted a scoping review in Medline, EMBASE, Scopus and the Cochrane Central Register of Controlled Trials. Two independent reviewers undertook screening and data extraction. After screening 6021 records, we included 50 studies. National guidelines (n = 22/50) or American College of Radiology Appropriateness Criteria (n = 23/50) were used to define and rate appropriateness. 22/50 studies did not provide methodological details about the appropriateness assessment. The included studies varied concerning modality, amount of reviewed examinations (88-13,941) and body regions. Computed tomography (27 studies, 27,168 examinations) was the most frequently analyzed modality, followed by magnetic resonance imaging (17 studies, 6559 examinations) and radiography (10 studies, 7095 examinations). Heterogeneous appropriateness rates throughout single studies (0-100%), modalities, and body regions (17-95%) were found. Research on pediatric and outpatient imaging was sparse. Multicentric, methodologically robust and indication-oriented studies would strengthen appropriateness research in diagnostic imaging and help to develop reliable key performance indicators.
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Affiliation(s)
- Felix Walther
- Center for Evidence-Based Healthcare, University Hospital Carl Gustav Carus and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany.
- Quality and Medical Risk Management, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
| | - Maria Eberlein-Gonska
- Quality and Medical Risk Management, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Ralf-Thorsten Hoffmann
- Institute and Polyclinic for Diagnostic and Interventional Radiology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Jochen Schmitt
- Center for Evidence-Based Healthcare, University Hospital Carl Gustav Carus and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Sophia F U Blum
- Quality and Medical Risk Management, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Institute and Polyclinic for Diagnostic and Interventional Radiology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
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Alanazi AH, Cradock A, Toomey R, Galligan M, Ryan J, Stowe J, Rainford L. Agreement Between International Radiologists on the Appropriateness and Urgency in Lumbar Spine MRI Referrals. Int J Gen Med 2022; 15:6315-6324. [PMID: 35924176 PMCID: PMC9342870 DOI: 10.2147/ijgm.s366653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 06/13/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose To determine how radiologists across health-care jurisdictions internationally assess the appropriateness and urgency levels of lumbar spine Magnetic Resonance Imaging MRI referrals. Patients and Methods Clinical information was extracted from 203 lumbar spine MRI referrals. Texts were divided into 10 datasets and embedded into a software to facilitate the classification process. Participant radiologists were recruited at the Image Perception Lab, at the Radiological Society of North America Congress, 2019 and through the institution radiology network. Radiologists were asked if they use referral guidelines in their practices. Radiologists assigned appropriateness and urgency levels based on the referral text. Appropriateness level descriptors were: indicated, indicated but needs more information or not indicated. Urgency levels were categorized: urgent, semi-urgent, or not urgent. All cases containing neurological symptoms with/without red flags were extracted and exact agreement between radiologists’ responses on the indication status was calculated. Results Seventy radiologists from 25 countries participated; 42% of participants indicated non-use of referral guidelines. Poor-moderate radiology agreements were recorded for appropriateness and referral urgency level decisions. 79.6% of responses indicated that cases containing neurological symptoms with/without red flags were indicated for scanning. Conclusion Despite referral guidelines promotion, nearly half of participants stated non-usage. Subsequently, a varied agreement levels were found in assigning the appropriateness of the referrals. Appropriateness of referrals with neurological symptoms (with/without red flags) recorded good agreement.
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Affiliation(s)
- Ali Hasayan Alanazi
- Radiography and Diagnostic Imaging, University College Dublin, Dublin, Ireland
- Correspondence: Ali Hasayan Alanazi, South Central Buildings, APT 29, Sandyford, Dublin, Air Code D18 RW02, Ireland, Tel +35 3833782878, Email
| | - Andrea Cradock
- Radiography and Diagnostic Imaging, University College Dublin, Dublin, Ireland
| | - Rachel Toomey
- Radiography and Diagnostic Imaging, University College Dublin, Dublin, Ireland
| | - Marie Galligan
- School of Medicine, University College Dublin, Dublin, Ireland
| | | | - John Stowe
- Radiography and Diagnostic Imaging, University College Dublin, Dublin, Ireland
| | - Louise Rainford
- Radiography and Diagnostic Imaging, University College Dublin, Dublin, Ireland
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An investigation of lumbar spine magnetic resonance referrals in two Irish university teaching centres: Radiology clinical judgement versus iRefer guideline compliance. Radiography (Lond) 2022; 28:460-465. [PMID: 35027270 DOI: 10.1016/j.radi.2021.12.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 11/30/2021] [Accepted: 12/20/2021] [Indexed: 11/22/2022]
Abstract
INTRODUCTION With the annual increase in medical imaging demand, the appropriateness of the lumbar spine magnetic resonance imaging LSMRI referrals is worldwide gaining attention. This study aims to determine the appropriateness of LSMRI referrals and compare radiology clinical decisions to iRefer compliance based solely on referral text content. METHODS Referral text was extracted from 1021 LSMRI referrals. Two review panels were recruited: three expert radiologists and three MRI radiographers. Radiologists classified cases as indicated or not indicated for scanning based on their clinical judgement. The radiographers classified based solely on iRefer guidelines. Majority voting for each case was applied to both review panels and reviewer agreement was tested using Kappa analysis. Logistic regression models were developed to identify medical disciplines associated with high rates of indicated referrals. RESULTS 21.7% and 11.9% of the cases were found not indicated for MRI for radiologists and radiographers, respectively. Radiology review identified 18% of the GPs referrals as not indicated and 17% in the radiographers' review. Panel agreement was fair: Kappa values of 0.23 and0.26 for the radiologists and radiographers respectively. Neurosurgery was associated with the highest rate of indicated referrals across both review panels: oncology referrals raised the highest number of open comments. CONCLUSION The study identified a lower number of not indicated referrals compared to previous research. Findings indicate the importance of both guidelines compliance and clinical judgement to optimise practice. IMPLICATIONS FOR PRACTICE Findings in this study found that even when strict instructions were given to the MR radiographers to vet referrals using the iRefer guidelines, ambiguity within the guidelines resulted in variations in decision-making. This suggests that detailed protocols are required to support radiographers in the vetting process to ensure a standardised approach.
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Herd P, Moynihan D. Health care administrative burdens: Centering patient experiences. Health Serv Res 2021; 56:751-754. [PMID: 34515996 PMCID: PMC8522557 DOI: 10.1111/1475-6773.13858] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 08/02/2021] [Indexed: 11/27/2022] Open
Affiliation(s)
- Pamela Herd
- McCourt School of Public PolicyGeorgetown UniversityWashingtonDistrict of ColumbiaUSA
| | - Donald Moynihan
- McCourt School of Public PolicyGeorgetown UniversityWashingtonDistrict of ColumbiaUSA
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Bottari G, Stellacci G, Ferorelli D, Dell’Erba A, Aricò M, Benevento M, Palladino G, Solarino B. Imaging Appropriateness in Pediatric Radiology during COVID-19 Pandemic: A Retrospective Comparison with No COVID-19 Period. CHILDREN-BASEL 2021; 8:children8060463. [PMID: 34205841 PMCID: PMC8227712 DOI: 10.3390/children8060463] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 05/28/2021] [Accepted: 05/30/2021] [Indexed: 12/15/2022]
Abstract
During the COVID-19 pandemic, the number of accesses to the Pediatric Emergency Department (pED) in Italy sharply decreased by 30%. The purpose of this study is to evaluate how this novel setting impacted on management of children with trauma, and the use and appropriateness of imaging studies in such patients at the pED. All imaging studies performed in patients with trauma at the pED of a tertiary children's Hospital during the first wave of the COVID-19 pandemic (between March and May 2020) were reviewed, in comparison with a control time interval (March to May 2019). In the pre-COVID control era, 669 imaging studies documented bone fractures in 145/568 children (25.5%). In the COVID-era, 79/177 (44.6%) pediatric patients showed bone fractures on 193 imaging studies. Comparative analysis shows a 71% decrease in imaging studies, and the proportion of negative imaging studies (with no evidence of bone fractures) dropped in 2020 by 19% compared to the 2019 control era (p < 0.001). The sharp decrease of negative studies suggests that the rate of appropriateness was higher during COVID-era, suggesting some attitude toward defensive medicine in the previous control year, as a result of some degree of imaging inappropriateness. The impact of a pandemic on emergency medicine may offer a unique opportunity to revisit diagnostic and therapeutic protocols in pediatrics.
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Affiliation(s)
- Giampiero Bottari
- Department of Interdisciplinary Medicine (DIM), Institute of Legal Medicine, University of Bari, Piazza G. Cesare 11, 70124 Bari, Italy; (D.F.); (A.D.); (M.B.); (B.S.)
- Correspondence:
| | - Giandomenico Stellacci
- Department of Pediatric Radiology, Giovanni XXIII Pediatric Hospital, Via G. Amendola 207, 70126 Bari, Italy; (G.S.); (G.P.)
| | - Davide Ferorelli
- Department of Interdisciplinary Medicine (DIM), Institute of Legal Medicine, University of Bari, Piazza G. Cesare 11, 70124 Bari, Italy; (D.F.); (A.D.); (M.B.); (B.S.)
| | - Alessandro Dell’Erba
- Department of Interdisciplinary Medicine (DIM), Institute of Legal Medicine, University of Bari, Piazza G. Cesare 11, 70124 Bari, Italy; (D.F.); (A.D.); (M.B.); (B.S.)
| | - Maurizio Aricò
- COVID-19 Management Crisis Unit, Giovanni XXIII Pediatric Hospital, Via G. Amendola 207, 70126 Bari, Italy;
| | - Marcello Benevento
- Department of Interdisciplinary Medicine (DIM), Institute of Legal Medicine, University of Bari, Piazza G. Cesare 11, 70124 Bari, Italy; (D.F.); (A.D.); (M.B.); (B.S.)
| | - Giuseppe Palladino
- Department of Pediatric Radiology, Giovanni XXIII Pediatric Hospital, Via G. Amendola 207, 70126 Bari, Italy; (G.S.); (G.P.)
| | - Biagio Solarino
- Department of Interdisciplinary Medicine (DIM), Institute of Legal Medicine, University of Bari, Piazza G. Cesare 11, 70124 Bari, Italy; (D.F.); (A.D.); (M.B.); (B.S.)
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Ebdon-Jackson S, Frija G. Improving justification of medical exposures using ionising radiation: considerations and approaches from the European Society of Radiology. Insights Imaging 2021; 12:2. [PMID: 33409611 PMCID: PMC7788115 DOI: 10.1186/s13244-020-00940-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 11/03/2020] [Indexed: 02/24/2023] Open
Abstract
This discussion paper has been produced within the context of the European Society of Radiology EuroSafe Imaging initiative and considers primarily the issues and challenges associated with justification of medical exposures using ionising radiation for individual patient diagnostic imaging procedures. It addresses both regulatory requirements and practical considerations and discusses approaches that are intended to improve justification.
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Affiliation(s)
- Steve Ebdon-Jackson
- Medical Exposure Regulatory Infrastructure Team, CRCE, Public Health England, Chilton, Didcot, UK
| | - Guy Frija
- Descartes University Paris, Paris, France.
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Mar PL, Chen G, Gandhi G, Tang ZZ, Leiserowitz A, Tripuraneni A, Kreps E, Botting L, Lakkireddy D, Granato JE, Gopinathannair R. Cost-effectiveness analysis of magnetic resonance imaging–conditional pacemaker implantation: Insights from a multicenter study and implications in the current era. Heart Rhythm 2018; 15:1690-1697. [DOI: 10.1016/j.hrthm.2018.05.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Indexed: 10/16/2022]
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Fine B, Schultz SE, White L, Henry D. Impact of restricting diagnostic imaging reimbursement for uncomplicated low back pain in Ontario: a population-based interrupted time series analysis. CMAJ Open 2017; 5:E760-E767. [PMID: 29042408 PMCID: PMC5741429 DOI: 10.9778/cmajo.20160151] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND In 2012, the Ontario government withdrew public insurance coverage of imaging tests for uncomplicated low back pain. We studied the impact of this restriction on test ordering by physicians. METHODS We compared the numbers of lumbar spine radiography, computed tomography (CT) and single-segment magnetic resonance imaging (MRI) studies ordered by physicians in the 3 years before and after the policy change. We linked claims data from the Ontario Health Insurance Program with physician details to calculate rates per test-ordering physician. We compared changes in rates of monthly test ordering by family physicians and specialists before and after the policy change using segmented regression analysis of interrupted time series data. RESULTS The number of lumbar spine radiography and spine CT studies ordered by family physicians decreased by 98 597 (28.7%) and 17 499 (28.7%), respectively, in the year after the policy change; there was little change in ordering by specialists. The number of lumbar spine radiography studies ordered per family physician by month decreased by 0.81 tests (p < 0.001) after the intervention, followed by a smaller rebound increase that remained below baseline. Monthly ordering of spine CT per family physician declined by 0.1 tests (p < 0.001), and that of limited spine MRI rose before the intervention, decreased by 0.18 tests (p < 0.001) after the intervention, then started to rise again. Monthly ordering of limited spine MRI by specialists, which had been stable before the policy change, decreased by 0.1 tests per specialist (p < 0.001) afterward, then rose to preintervention levels. INTERPRETATION The restriction in coverage of imaging tests caused a larger decrease in test ordering by family physicians than by specialists and a larger, more sustained reduction in the use of lumbar spine radiography and spine CT than of spine MRI.
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Affiliation(s)
- Benjamin Fine
- Affiliations: Department of Medical Imaging (Fine, White), University of Toronto; Institute for Clinical Evaluative Sciences (Schultz, Henry); Joint Department of Medical Imaging (Fine, White), University Health Network/Mount Sinai Hospital/Women's College Hospital; Dalla Lana School of Public Health (Henry) and Institute of Health Policy Management and Evaluation (Henry), University of Toronto, Toronto, Ont.; Centre for Research in Evidence-Based Practice (Henry), Bond University, Gold Coast, Australia; Department of Diagnostic Imaging (Fine), Trillium Health Partners, Mississauga, Ont
| | - Susan E Schultz
- Affiliations: Department of Medical Imaging (Fine, White), University of Toronto; Institute for Clinical Evaluative Sciences (Schultz, Henry); Joint Department of Medical Imaging (Fine, White), University Health Network/Mount Sinai Hospital/Women's College Hospital; Dalla Lana School of Public Health (Henry) and Institute of Health Policy Management and Evaluation (Henry), University of Toronto, Toronto, Ont.; Centre for Research in Evidence-Based Practice (Henry), Bond University, Gold Coast, Australia; Department of Diagnostic Imaging (Fine), Trillium Health Partners, Mississauga, Ont
| | - Lawrence White
- Affiliations: Department of Medical Imaging (Fine, White), University of Toronto; Institute for Clinical Evaluative Sciences (Schultz, Henry); Joint Department of Medical Imaging (Fine, White), University Health Network/Mount Sinai Hospital/Women's College Hospital; Dalla Lana School of Public Health (Henry) and Institute of Health Policy Management and Evaluation (Henry), University of Toronto, Toronto, Ont.; Centre for Research in Evidence-Based Practice (Henry), Bond University, Gold Coast, Australia; Department of Diagnostic Imaging (Fine), Trillium Health Partners, Mississauga, Ont
| | - David Henry
- Affiliations: Department of Medical Imaging (Fine, White), University of Toronto; Institute for Clinical Evaluative Sciences (Schultz, Henry); Joint Department of Medical Imaging (Fine, White), University Health Network/Mount Sinai Hospital/Women's College Hospital; Dalla Lana School of Public Health (Henry) and Institute of Health Policy Management and Evaluation (Henry), University of Toronto, Toronto, Ont.; Centre for Research in Evidence-Based Practice (Henry), Bond University, Gold Coast, Australia; Department of Diagnostic Imaging (Fine), Trillium Health Partners, Mississauga, Ont
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Min A, Chan VW, Aristizabal R, Peramaki ER, Agulnik DB, Strydom N, Ramsey D, Forster BB. Clinical Decision Support Decreases Volume of Imaging for Low Back Pain in an Urban Emergency Department. J Am Coll Radiol 2017; 14:889-899. [DOI: 10.1016/j.jacr.2017.03.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 03/04/2017] [Accepted: 03/08/2017] [Indexed: 10/19/2022]
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Quarterly Reporting of Computed Tomography Ordering History Reduces the Use of Imaging in an Emergency Department. J Emerg Med 2016; 52:684-689. [PMID: 27955985 DOI: 10.1016/j.jemermed.2016.11.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Revised: 10/21/2016] [Accepted: 11/01/2016] [Indexed: 01/12/2023]
Abstract
BACKGROUND Computed tomography (CT) is a useful and necessary part of many emergency department (ED) assessments. However, the costs of imaging and the health risks associated with radiation exposure have sparked national efforts to reduce CT ordering in EDs. STUDY OBJECTIVE We analyzed CT ordering habits prior to and following implementation of a feedback tool at a community hospital. METHODS In this intervention study, we identified the CT-ordering habits of physicians and mid-level care providers (physician assistants and nurse practitioners) at baseline and after implementation of a system that sent quarterly feedback reports comparing their ordering habits with those of their peers. Variability in ordering and subgroup analyses by body region were included in these reports. RESULTS We examined the records of 104,454 patients seen between October 1, 2013 and December 31, 2014. There were 5552 or 21.0% of patients seen during the baseline period that underwent CT imaging. We observed an absolute reduction in imaging of 2.3% (95% confidence interval 1.7-2.8%) after implementation, avoiding approximately $400,000 in costs, 22 days of scanning time, and radiation exposure equivalent to 33,000 chest films annually. These changes occurred across physicians and mid-level providers, regardless of the number years of practice or board certification. CONCLUSIONS Implementation of a feedback mechanism reduced CT use by emergency medicine practitioners, with concomitant reductions in cost and radiation exposure. The change was similar across levels of medical care. Future studies will examine the effect of the feedback reporting system at other institutions in our hospital network.
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R-SCAN: Imaging for Headache. J Am Coll Radiol 2016; 13:1534-1535.e1. [DOI: 10.1016/j.jacr.2016.08.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Revised: 08/16/2016] [Accepted: 08/19/2016] [Indexed: 11/18/2022]
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Abstract
Health care costs in the US have grown rapidly over the past several decades. As a result, there has been increasing interest in strategies to contain health care costs, without sacrificing the quality of medical care. While many factors contribute to rising costs, one major contributor to health care expenditure is diagnostic imaging. In this article, we address the growth of diagnostic imaging, the financial and clinical adverse effects of over-utilization, and discuss a variety of strategies to encourage appropriate use of diagnostic testing.
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Affiliation(s)
- Patricia E Litkowski
- Department of Internal Medicine at Washington University School of Medicine, St. Louis, Mo
| | - Gerald W Smetana
- Department of Medicine, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, Mass
| | - Mark L Zeidel
- Department of Medicine, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, Mass
| | - Melvin S Blanchard
- Department of Internal Medicine at Washington University School of Medicine, St. Louis, Mo.
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Radiologic Knowledge and Ordering Habits of Clinical Residents: ACR Appropriateness Criteria Awareness and Perceptions. J Am Coll Radiol 2016; 13:725-9. [DOI: 10.1016/j.jacr.2015.12.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 12/26/2015] [Indexed: 11/17/2022]
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[Acceptability and quality of abdominal ultrasound studies requested by medical professionals]. GASTROENTEROLOGIA Y HEPATOLOGIA 2016; 39:516-25. [PMID: 27006137 DOI: 10.1016/j.gastrohep.2016.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 12/18/2015] [Accepted: 01/27/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To evaluate the acceptability/quality of abdominal ultrasound studies requested by primary care physicians in Barcelona; to develop ultrasound guidelines and assess their impact on acceptability. METHODS DESIGN 2-phase study, one retrospective, descriptive phase evaluating the acceptability/quality of requests (pre-intervention phase) and another to assess the impact of guidelines on acceptability/quality (post-intervention phase). SUBJECTS Requests for ultrasound studies from January-June 2010 from 10 primary care centers and the same number of requests from the same centers after the intervention. VARIABLES Pre-intervention phase: reason for consultation and request; presence of diagnostic orientation; results of ultrasound; acceptability/quality of the request. INTERVENTION design guidelines using the nominal group technique, dissemination of guidelines in the same centers. Post-intervention phase: three months after dissemination analyze the same number of requests assessing the same variables included in the pre-intervention phase. RESULTS Pre-intervention phase: 1,063 requests, 52.4% women, mean age 52±16years (range 11-94). Post-intervention phase: 1,060 requests, 57.6% women, mean age 54±17years (range 6-91). Main reasons for requests: abdominal pain/discomfort 38.3% (pre-intervention) and 43.1% (post-intervention). Diagnostic orientation in 14.5% (pre-intervention) and 40.8% (post-intervention). Normal ultrasound results in 46.0% (pre-intervention) and 42.3% (post-intervention). Good quality of requests in 42.7% (pre-intervention) and 46.5% (post-intervention). Acceptability of ultrasound: 70.5% (pre-intervention) and 94.1% (post-intervention). The better the quality of the request, the better the acceptability of the studies and the greater the number of pathological conditions identified. CONCLUSIONS Guidelines for ultrasound improve the quality of requests, diagnostic orientation and acceptability of the studies.
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Awareness, Utilization, and Education of the ACR Appropriateness Criteria: A Review and Future Directions. J Am Coll Radiol 2016; 13:131-6. [DOI: 10.1016/j.jacr.2015.08.026] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Accepted: 08/24/2015] [Indexed: 12/13/2022]
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Abu-Ghanem S, Cohen O, Lazutkin A, Abu-Ghanem Y, Fliss DM, Yehuda M. Evaluation of clinical presentation and referral indications for ultrasound-guided fine-needle aspiration biopsy of the thyroid as possible predictors of thyroid cancer. Head Neck 2015; 38 Suppl 1:E991-5. [PMID: 26044944 DOI: 10.1002/hed.24143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2015] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Whether initial clinical presentation and thyroid ultrasonography referral indications can significantly predict malignant/suspicious for malignancy (Bethesda System for Reporting Thyroid Cytopathology [Bethesda] V/VI) thyroid ultrasound-guided fine-needle aspiration (FNA) cytology results is unknown. METHODS Between January 2010 and May 2014, we performed 705 thyroid ultrasound-guided FNA biopsies, according to the American Thyroid Association (ATA) guidelines. Univariate analysis was used to identify significant predictors for Bethesda V/VI thyroid ultrasound-guided FNA cytology, including age, sex, imaging modality, thyroid dysfunction, neck pain, breathing difficulties, dysphagia, odynophagia, fatigue, lateral cervical mass, parotid mass, and hyperparathyroidism. RESULTS Sixty percent of patients were referred to thyroid ultrasound-guided FNA because of thyroid incidentalomas and 40% because of palpable thyroid nodules found on physical examination. Only positron emission tomography (PET)-CT emerged as being a significant predictor for Bethesda V/VI thyroid ultrasound-guided FNA cytology (odds ratio [OR] = 5.64; 95% confidence interval [CI] = 1.16-27.33; p = .03). CONCLUSION Patient symptomatology and initial clinical thyroid ultrasound-guided FNA referral indications cannot predict the nature of thyroid nodules. © 2015 Wiley Periodicals, Inc. Head Neck 38: E991-E995, 2016.
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Affiliation(s)
- Sara Abu-Ghanem
- Department of Otolaryngology Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Oded Cohen
- Department of Otolaryngology Head and Neck Surgery, Kaplan Medical Center, Hadassah School of Medicine, Hebrew University, Rehovot, Israel
| | - Anna Lazutkin
- Department of Otolaryngology Head and Neck Surgery, Kaplan Medical Center, Hadassah School of Medicine, Hebrew University, Rehovot, Israel
| | - Yasmin Abu-Ghanem
- Department of Otolaryngology Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Dan M Fliss
- Department of Otolaryngology Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Moshe Yehuda
- Department of Otolaryngology Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Rao S, Rao S, Harvey HB, Avery L, Saini S, Prabhakar AM. Low Back Pain in the Emergency Department—Are the ACR Appropriateness Criteria Being Followed? J Am Coll Radiol 2015; 12:364-9. [DOI: 10.1016/j.jacr.2014.10.020] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Accepted: 10/27/2014] [Indexed: 12/14/2022]
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Castillo J, Caruana C, Morgan P, Westbrook C. Optimizing a magnetic resonance care pathway: A strategy for radiography managers. Radiography (Lond) 2015. [DOI: 10.1016/j.radi.2014.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Carnevale TJ, Meng D, Wang JJ, Littlewood M. Impact of an Emergency Medicine Decision Support and Risk Education System on Computed Tomography and Magnetic Resonance Imaging Use. J Emerg Med 2015; 48:53-7. [DOI: 10.1016/j.jemermed.2014.07.033] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Revised: 05/29/2014] [Accepted: 07/01/2014] [Indexed: 11/29/2022]
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Sistrom CL, Weilburg JB, Dreyer KJ, Ferris TG. Provider Feedback about Imaging Appropriateness by Using Scores from Order Entry Decision Support: Raw Rates Misclassify Outliers. Radiology 2014; 275:469-79. [PMID: 25423147 DOI: 10.1148/radiol.14141092] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To determine the relevant physician- and practice-related factors that jointly affect the rate of low-utility imaging examinations (score of 1-3 out of 9) ordered by means of an order entry system that provides normative appropriateness feedback. MATERIALS AND METHODS This HIPAA-compliant study was approved by the institutional review board under an expedited protocol for analyzing anonymous aggregated administrative data. This is a retrospective study of approximately 250 000 consecutive scheduled outpatient advanced imaging examinations (computed tomography, magnetic resonance imaging, nuclear medicine) ordered by 164 primary care and 379 medical specialty physicians from 2008 to 2012. A hierarchical logistic regression model was used to identify multiple predictors of the probability that an examination received a low utility score. Physician- and practice-specific random effects were estimated to articulate (odds ratio) and quantify (intraclass correlation) interphysician variation. RESULTS Fixed effects found to be statistically significant predictors of low-utility imaging included examination type, whether the examination was cancelled, status of the person entering the order, and the total number of examinations ordered by the clinician. Neither patient age nor sex had any effect, and there were no secular trends (year of study). The remaining amount of interphysician variation was moderate (intraclass correlation, 22%), whereas the variation between medical specialties and primary care practices was low (intraclass correlation, 5%). The estimated physician-specific effects had reliability of 70%, which makes them just suitable for identifying outliers. CONCLUSION The authors found that 22% of the variation in the rate of low-utility examinations is attributable to ordering providers and 5% to their specialty or clinic.
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Affiliation(s)
- Chris L Sistrom
- From the Physician's Organization (C.L.S., J.B.W., T.G.F.) and Department of Radiology (C.L.S., K.J.D.), Massachusetts General Hospital, Boston, Mass
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Finestone AS, Vulfsons S, Milgrom C, Lahad A, Moshe S, Agar G, Greenberg D. The case for orthopaedic medicine in Israel. Isr J Health Policy Res 2013; 2:42. [PMID: 24245773 PMCID: PMC3834558 DOI: 10.1186/2045-4015-2-42] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2013] [Accepted: 10/03/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Musculoskeletal complaints are probably the most frequent reasons for visiting a doctor. They comprise more than a quarter of the complaints to primary practitioners and are also the most common reason for referral to secondary or tertiary medicine. The clinicians most frequently consulted on musculoskeletal problems, and probably perceived to know most on the topic are orthopaedic surgeons. But in Israel, there is significant ambivalence with various aspects of the consultations provided by orthopaedic surgeons, both among the public and among various groups of clinicians, particularly family practitioners and physiotherapists. METHODS In order to understand this problem we integrate new data we have collected with previously published data. New data include the rates of visits to orthopaedic surgeons per annum in one of Israel's large non-profit HMO's, and the domains of the visits to an orthopaedic surgeon. RESULTS Orthopaedic surgeons are the third most frequently contracted secondary specialists in one of the Israeli HMO's. Between 2009 and 2012 there was a 1.7% increase in visits to orthopaedists per annum (P < 0.0001, after correction for population growth). Almost 80% of the domains of the problems presented to an orthopaedic surgeon were in fields orthopaedic surgeons have limited formal training. DISCUSSION While orthopaedic surgeons are clearly the authority on surgical problems of the musculoskeletal system, most musculoskeletal problems are not surgical, and the orthopaedic surgeon often lacks training in these areas which might be termed orthopaedic medicine. Furthermore, in Israel and in many other developed countries there is no accessible medical specialty that studies these problems, trains medical students in the subject and focuses on treating these problems. The neglect of this area which can be called the "Orthopaedic Medicine Lacuna" is responsible for inadequate treatment of non-surgical problems of the musculoskeletal system with immense financial implications. We present a preliminary probe into possible solutions which could be relevant to many developed countries.
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Affiliation(s)
- Aharon S Finestone
- Department of Orthopaedics, Assaf Harofeh Medical Center, Zerifin, Israel.
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Reduction in the Number and Associated Costs of Unindicated Dual-Phase Head CT Examinations After a Quality Improvement Initiative. AJR Am J Roentgenol 2013; 201:1049-56. [DOI: 10.2214/ajr.12.10393] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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How Radiologists Get Paid: Resource-Based Relative Value Scale and the Revenue Cycle. AJR Am J Roentgenol 2013; 201:947-58. [DOI: 10.2214/ajr.12.9715] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Appropriateness of Imaging Studies Ordered by Emergency Medicine Residents: Results of an Online Survey. AJR Am J Roentgenol 2013; 201:W619-25. [DOI: 10.2214/ajr.12.10487] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Willens HJ, Nelson K, Hendel RC. Appropriate Use Criteria for Stress Echocardiography. JACC Cardiovasc Imaging 2013; 6:297-309. [DOI: 10.1016/j.jcmg.2012.11.009] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2012] [Revised: 09/28/2012] [Accepted: 11/09/2012] [Indexed: 11/15/2022]
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Patel V, Buckstein M, Perini R, Hill-Kayser C, Svoboda J, Plastaras JP. Computed tomography and positron emission tomography/computed tomography surveillance after combined modality treatment of supradiaphragmatic Hodgkin lymphoma: a clinical and economic perspective. Leuk Lymphoma 2013; 54:2168-76. [DOI: 10.3109/10428194.2013.767902] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Schneider JE, Ohsfeldt RL, Scheibling CM, Jeffers SA. Organizational boundaries of medical practice: the case of physician ownership of ancillary services. HEALTH ECONOMICS REVIEW 2012; 2:7. [PMID: 22828324 PMCID: PMC3402929 DOI: 10.1186/2191-1991-2-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/09/2011] [Accepted: 04/05/2012] [Indexed: 06/01/2023]
Abstract
Physician ownership of in-office ancillary services (IOASs) has come under increasing scrutiny. Advocates of argue that IOASs allow physicians to supervise the quality and coordination of care. Critics have argued that IOASs create financial incentives for physicians to increase ancillary service volume. In this paper we develop a conceptual framework to evaluate the tradeoffs associated with physician ownership of IOASs. There is some evidence supporting the existence of scope and transaction economies in IOASs. Improvement in flow and continuity of care are likely to generate scope economies and improvements in quality monitoring and reductions in consumer transaction costs are likely to generate transaction economies. Other factors include the capture of upstream and downstream profits, but these incentives are likely to be small compared to scope and transaction economies. Policy debates on the merits of IOASs should include an explicit assessment of these tradeoffs.This research was supported in part by funding from the American Association of Orthopaedic Surgeons (AAOS).
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Affiliation(s)
- John E Schneider
- Oxford Outcomes Ltd., Morristown, USA
- Senior Director, Health Economics, Oxford Outcomes Ltd., 161 Madison Avenue Suite 205, Morristown, NJ 07960, USA
| | - Robert L Ohsfeldt
- Oxford Outcomes Ltd., Morristown, USA
- Texas A&M Health Sciences, Department of Health Management and Policy, College Station, USA
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Linet MS, Slovis TL, Miller DL, Kleinerman R, Lee C, Rajaraman P, Berrington de Gonzalez A. Cancer risks associated with external radiation from diagnostic imaging procedures. CA Cancer J Clin 2012; 62:75-100. [PMID: 22307864 PMCID: PMC3548988 DOI: 10.3322/caac.21132] [Citation(s) in RCA: 220] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
The 600% increase in medical radiation exposure to the US population since 1980 has provided immense benefit, but increased potential future cancer risks to patients. Most of the increase is from diagnostic radiologic procedures. The objectives of this review are to summarize epidemiologic data on cancer risks associated with diagnostic procedures, describe how exposures from recent diagnostic procedures relate to radiation levels linked with cancer occurrence, and propose a framework of strategies to reduce radiation from diagnostic imaging in patients. We briefly review radiation dose definitions, mechanisms of radiation carcinogenesis, key epidemiologic studies of medical and other radiation sources and cancer risks, and dose trends from diagnostic procedures. We describe cancer risks from experimental studies, future projected risks from current imaging procedures, and the potential for higher risks in genetically susceptible populations. To reduce future projected cancers from diagnostic procedures, we advocate the widespread use of evidence-based appropriateness criteria for decisions about imaging procedures; oversight of equipment to deliver reliably the minimum radiation required to attain clinical objectives; development of electronic lifetime records of imaging procedures for patients and their physicians; and commitment by medical training programs, professional societies, and radiation protection organizations to educate all stakeholders in reducing radiation from diagnostic procedures.
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Affiliation(s)
- Martha S Linet
- Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD 20892-7238, USA.
| | - Thomas L Slovis
- Chief, Pediatric Radiology, Department of Radiology, Children's Hospital of Michigan, Detroit, MI
| | - Donald L Miller
- Acting Chief, Diagnostic Devices Branch, Division of Mammography Quality and Radiation Program Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, MD
| | - Ruth Kleinerman
- Epidemiologist, Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD
| | - Choonsik Lee
- Investigator, Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD
| | - Preetha Rajaraman
- Investigator, Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD
| | - Amy Berrington de Gonzalez
- Senior Investigator, Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD
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Rubin DL. Informatics in radiology: Measuring and improving quality in radiology: meeting the challenge with informatics. Radiographics 2012; 31:1511-27. [PMID: 21997979 DOI: 10.1148/rg.316105207] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Quality is becoming a critical issue for radiology. Measuring and improving quality is essential not only to ensure optimum effectiveness of care and comply with increasing regulatory requirements, but also to combat current trends leading to commoditization of radiology services. A key challenge to implementing quality improvement programs is to develop methods to collect knowledge related to quality care and to deliver that knowledge to practitioners at the point of care. There are many dimensions to quality in radiology that need to be measured, monitored, and improved, including examination appropriateness, procedure protocol, accuracy of interpretation, communication of imaging results, and measuring and monitoring performance improvement in quality, safety, and efficiency. Informatics provides the key technologies that can enable radiologists to measure and improve quality. However, few institutions recognize the opportunities that informatics methods provide to improve safety and quality. The information technology infrastructure in most hospitals is limited, and they have suboptimal adoption of informatics techniques. Institutions can tackle the challenges of assessing and improving quality in radiology by means of informatics.
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Affiliation(s)
- Daniel L Rubin
- Department of Radiology, Stanford University, Richard M. Lucas Center, 1201 Welch Rd, Office P285, Stanford, CA 94305-5488, USA. dlrubin@ stanford.edu
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Armao D, Semelka RC, Elias J. Radiology's ethical responsibility for healthcare reform: Tempering the overutilization of medical imaging and trimming down a heavyweight. J Magn Reson Imaging 2011; 35:512-7. [DOI: 10.1002/jmri.23530] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2011] [Accepted: 11/09/2011] [Indexed: 11/12/2022] Open
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Appropriateness use criteria for transthoracic echocardiography: relationship with radiology benefit managers preauthorization determination and comparison of the new (2010) criteria to the original (2007) criteria. Am Heart J 2011; 162:772-9. [PMID: 21982672 DOI: 10.1016/j.ahj.2011.07.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2011] [Accepted: 07/14/2011] [Indexed: 11/24/2022]
Abstract
BACKGROUND In response to growth in cardiac imaging, medical societies have published appropriateness use criteria (AUC) and payers have introduced preauthorization mandates, largely through radiology benefits managers (RBM). The correlation of algorithms used to determine preauthorization with the AUC is unknown. In addition, studies applying the 2007 AUC for transthoracic echocardiography revealed that many echocardiograms could not be classified. We sought to examine the impact of the revised 2010 AUC on appropriateness ratings of transthoracic echocardiograms previously classified by the 2007 AUC and the relationship of preauthorization determination to AUC rating. METHODS We reclassified indications for transthoracic echocardiography as appropriate, inappropriate, uncertain, or unclassifiable using the 2010 AUC in the same 625 patients previously reported using 2007 AUC. We also evaluated the relationship between preauthorization status by 2 RBM precertification algorithms and appropriateness rating by 2007 AUC. RESULTS The appropriateness classification of 148 (24%) transthoracic echocardiograms was changed by the updated AUC (P < .001). The number of unclassifiable echocardiograms was markedly reduced from 99 (16%) to 8 (1%), and more echocardiograms were classified as inappropriate (95 [15%] vs 45 [7%]) or uncertain (43 [7%] vs 0 [0%]). Limited correlation between the 2007 AUC rating and RBM preauthorization determinations was noted, with only moderate agreement with RBM no. 1 (90%, κ = 0.480, P < .001) and poor agreement with RBM no. 2 (72%, κ = 0.177, P < .001). CONCLUSION The updated AUC (2010) provide enhanced clinical value compared with 2007 AUC. There is limited agreement between RBM preauthorization determination and 2007 AUC rating.
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Lee DW, Rawson JV, Wade SW. Radiology Benefit Managers: Cost Saving or Cost Shifting? J Am Coll Radiol 2011; 8:393-401. [DOI: 10.1016/j.jacr.2010.11.016] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2010] [Accepted: 11/23/2010] [Indexed: 11/28/2022]
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Brenner DJ. Slowing the Increase in the Population Dose Resulting from CT Scans. Radiat Res 2010; 174:809-15. [DOI: 10.1667/rr1859.1] [Citation(s) in RCA: 102] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Hofmann B. Too much of a good thing is wonderful? A conceptual analysis of excessive examinations and diagnostic futility in diagnostic radiology. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2010; 13:139-148. [PMID: 20151206 DOI: 10.1007/s11019-010-9233-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
It has been argued extensively that diagnostic services are a general good, but that it is offered in excess. So what is the problem? Is not "too much of a good thing wonderful", to paraphrase Mae West? This article explores such a possibility in the field of radiological services where it is argued that more than 40% of the examinations are excessive. The question of whether radiological examinations are excessive cries for a definition of diagnostic futility. However, no such definition is found in the literature. As a response, this article addresses the issue of diagnostic futility in five steps. First, it investigates whether the concept of therapeutic futility can be adapted to diagnostics. A closer analysis of the concept of therapeutic futility reveals that this will not do the trick. Second, the article scrutinizes whether there are sources for clarifying diagnostic futility in the extensive debate on excessive radiological examination. Investigating the debate's terms and definitions reveals a disparate terminology and no clear concepts. On the contrary, the study uncovers that quite different and incompatible issues are at stake. Third, the article examines a procedural approach, which is widely used for settling controversies over utility by focusing on the role of the professionals. On scrutiny however, a procedural approach will not solve the problem in diagnostics. Fourth, a value analysis reveals how we have to decide on the negative value of excessive examinations before we can measure excess. The final and constructive part presents a definition of diagnostic futility drawing upon the lessons from the previous analytical steps. Altogether, too much radiological examination is not a good thing. This is simply because radiological examinations are not unanimously good. Excessive radiological examinations can be defined, but not by one simple general and value-neutral definition. We have to settle with contextually framed value-related definitions. Such definitions will state how bad "too much of a good thing" is and make it possible to assess how much of the bad thing there is. Hence we have to know how bad it is before we can tell how much of it there is in the world.
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Affiliation(s)
- Bjørn Hofmann
- Faculty of Health Care and Nursing, University College of Gjøvik, PO Box 191, 2802, Gjøvik, Norway.
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Lysdahl KB, Hofmann BM, Espeland A. Radiologists’ responses to inadequate referrals. Eur Radiol 2009; 20:1227-33. [DOI: 10.1007/s00330-009-1640-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2009] [Revised: 07/26/2009] [Accepted: 08/30/2009] [Indexed: 11/28/2022]
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Abstract
Status epilepticus (SE), both convulsive and nonconvulsive, is a rare adverse effect of electroconvulsive therapy (ECT). This case report describes SE post-ECT associated with central nervous system (CNS) metastatic melanoma and reviews pertinent literature. The authors recommend that when CNS pathology is suspected, pre-ECT neurology consultation, neuroimaging, and EEG all may be indicated. This is especially important for patients with histories of primary cancers, such as melanoma, that metastasise to the brain.
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Wachtel RE, Dexter F, Dow AJ. Growth Rates in Pediatric Diagnostic Imaging and Sedation. Anesth Analg 2009; 108:1616-21. [DOI: 10.1213/ane.0b013e3181981f96] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Sistrom CL, Dang PA, Weilburg JB, Dreyer KJ, Rosenthal DI, Thrall JH. Effect of computerized order entry with integrated decision support on the growth of outpatient procedure volumes: seven-year time series analysis. Radiology 2009; 251:147-55. [PMID: 19221058 DOI: 10.1148/radiol.2511081174] [Citation(s) in RCA: 208] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE To determine the effect of a computerized radiology order entry (ROE) and decision support (DS) system on growth rate of outpatient computed tomography (CT), magnetic resonance (MR) imaging, and ultrasonography (US) procedure volumes over time at a large metropolitan academic medical center. MATERIALS AND METHODS Institutional review board approval was obtained for this study of deidentified aggregate administrative data. The research was compliant with HIPAA; informed consent was waived. This was a retrospective study of outpatient advanced imaging utilization before, during, and after implementation of a Web-based ROE and DS system. Dependent variables were the quarterly volumes of outpatient CT, MR imaging, and US examinations from quarter 4 of 2000 through quarter 4 of 2007. Outpatient visits during each quarter were included as control variables. These data were analyzed as three separate time series with piecewise linear regression for simultaneous estimation of quarterly examination volume trends before and after ROE and DS system implementation. This procedure was repeated with log-transformed quarterly volumes to estimate percentage growth rates. RESULTS There was a significant decrease in CT volume growth (274 per quarter) and growth rate (2.75% per quarter) after ROE and DS system implementation (P < .001). For MR imaging, growth rate decreased significantly (1.2%, P = .016) after ROE and DS system implementation; however, there was no significant change in quarterly volume growth. With US, quarterly volume growth (n = 98, P = .014) and growth rate (1.3%, P = .001) decreased significantly after ROE implementation. These changes occurred during a steady growth in clinic visit volumes in the associated referral practices. CONCLUSION Substantial decreases in the growth of outpatient CT and US procedure volume coincident with ROE implementation (supplemented by DS for CT) were observed. The utilization of outpatient MR imaging decreased less impressively, with only the rate of growth being significantly lower after interventions were in effect.
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Affiliation(s)
- Christopher L Sistrom
- Department of Radiology, University of Florida Health Center, PO Box 100374, Gainesville, FL 32610, USA.
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Sistrom CL. In Support of the ACR Appropriateness Criteria®. J Am Coll Radiol 2008; 5:630-5; discussion 636-7. [DOI: 10.1016/j.jacr.2007.12.016] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2007] [Indexed: 11/16/2022]
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Abstract
The public, governmental agencies, and payers expect medical professional organisations to develop practice guidelines and technical standards. The American College of Radiology proactively addresses these topics as well as other quality and safety interests including appropriateness criteria and accreditation. The College is also actively involved in development of a national radiology data base to collect data regarding quality and safety metrics in multiple areas. In addition, the College has developed RADPEER™, a simple, cost-effective process that allows peer review to be performed during the routine interpretation of current images. This paper discusses the efforts of the ACR in all of these areas.
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