Addressing overutilization in medical imaging

Comparing the Diagnostic Performance of GPT-4-based ChatGPT, GPT-4V-based ChatGPT, and Radiologists in Challenging Neuroradiology Cases

PURPOSE

To compare the diagnostic performance among Generative Pre-trained Transformer (GPT)-4-based ChatGPT, GPT‑4 with vision (GPT-4V) based ChatGPT, and radiologists in challenging neuroradiology cases.

METHODS

We collected 32 consecutive "Freiburg Neuropathology Case Conference" cases from the journal Clinical Neuroradiology between March 2016 and December 2023. We input the medical history and imaging findings into GPT-4-based ChatGPT and the medical history and images into GPT-4V-based ChatGPT, then both generated a diagnosis for each case. Six radiologists (three radiology residents and three board-certified radiologists) independently reviewed all cases and provided diagnoses. ChatGPT and radiologists' diagnostic accuracy rates were evaluated based on the published ground truth. Chi-square tests were performed to compare the diagnostic accuracy of GPT-4-based ChatGPT, GPT-4V-based ChatGPT, and radiologists.

RESULTS

GPT‑4 and GPT-4V-based ChatGPTs achieved accuracy rates of 22% (7/32) and 16% (5/32), respectively. Radiologists achieved the following accuracy rates: three radiology residents 28% (9/32), 31% (10/32), and 28% (9/32); and three board-certified radiologists 38% (12/32), 47% (15/32), and 44% (14/32). GPT-4-based ChatGPT's diagnostic accuracy was lower than each radiologist, although not significantly (all p > 0.07). GPT-4V-based ChatGPT's diagnostic accuracy was also lower than each radiologist and significantly lower than two board-certified radiologists (p = 0.02 and 0.03) (not significant for radiology residents and one board-certified radiologist [all p > 0.09]).

CONCLUSION

While GPT-4-based ChatGPT demonstrated relatively higher diagnostic performance than GPT-4V-based ChatGPT, the diagnostic performance of GPT‑4 and GPT-4V-based ChatGPTs did not reach the performance level of either radiology residents or board-certified radiologists in challenging neuroradiology cases.

Interventions to Reduce Imaging in Children With Minor Traumatic Head Injury: A Systematic Review

CONTEXT

Reducing unnecessary imaging in emergency departments (EDs) for children with minor traumatic brain injuries (mTBIs) has been encouraged.

OBJECTIVE

Our objective was to systematically review the effectiveness of interventions to decrease imaging in this population.

DATA SOURCES

Eight electronic databases and the gray literature were searched.

STUDY SELECTION

Comparative studies assessing ED interventions to reduce imaging in children with mTBIs were eligible.

DATA EXTRACTION

Two independent reviewers screened studies, completed a quality assessment, and extracted data. The median of relative risks with interquartile range (IQR) are reported. A multivariable metaregression identified predictors of relative change in imaging.

RESULTS

Twenty-eight studies were included, and most (79%) used before-after designs. The Pediatric Emergency Care Applied Research Network (PECARN) rule was the most common intervention (71%); most studies (75%) used multifaceted interventions (median components: 3; IQR: 1.75 to 4). Before-after studies assessing multi-faceted PECARN interventions reported decreased computed tomography (CT) head imaging (relative risk = 0.73; IQR: 0.60 to 0.89). Higher baseline imagine (P < .001) and additional intervention components (P = .008) were associated with larger imaging decreases.

LIMITATIONS

The limitations of this study include the inconsistent reporting of important outcomes and that the results are based on non-randomized studies.

CONCLUSIONS

Implementing interventions in EDs with high baseline CT ordering using complex interventions was more likely to reduce head imaging in children with mTBIs. Including the PECARN decision rule in the intervention strategy decreased orders by a median of 27%. Further research could provide insight into which specific factors influence successful implementation and sustained effects.

Unnecessary diagnostic imaging requested by medical students during a first day of residency simulation: an explorative study

BACKGROUND

Physicians' choice of appropriate tests in the diagnostic process is crucial for patient safety. The increased use of medical imaging has raised concerns about its potential overuse. How appropriately medical students order diagnostic tests is unknown. We explored their ordering behavior of diagnostic imaging during a simulated first day of residency.

METHODS

In total, 492 undergraduate medical students participated in the simulation. After history taking with simulated patients, the students used an electronic system for requesting diagnostic tests. The analysis focused on 16 patient cases, each managed by at least 50 students. We calculated the total number of ordered images and unnecessary radiation exposure in millisievert per patient and performed one sample t-tests (one tailed) with an expected mean of zero on a Bonferroni-corrected alpha level of 0.003 for the independent variable of unnecessary radiation exposure.

RESULTS

Unnecessary diagnostic imaging was ordered across all patient cases. Ultrasound, especially abdominal ultrasound, X-rays of the thorax, and abdominal CTs were notably overused in 90.9%, 80.0%, and 69.2% of all patient cases, respectively. Unnecessary requests of imaging related to radiation resulted in radiation over-exposure for nearly all patients, with 37.5% of all patients being exposed to a significant radiation overdose on average.

CONCLUSION

Medical students' overuse of diagnostic imaging can be explained by patient-related factors like anxiety and medical factors like missing clinical information leading to cognitive biases in patient workup. This suggests the need for interventions to improve students' clinical decision-making and reduce cognitive biases. Investigating student-specific factors being associated with overuse of diagnostic imaging would be of additional interest.

Computed tomography referral guidelines adherence in Europe: insights from a seven-country audit

BACKGROUND

Ensuring appropriate computed tomography (CT) utilization optimizes patient care while minimizing radiation exposure. Decision support tools show promise for standardizing appropriateness.

OBJECTIVES

In the current study, we aimed to assess CT appropriateness rates using the European Society of Radiology (ESR) iGuide criteria across seven European countries. Additional objectives were to identify factors associated with appropriateness variability and examine recommended alternative exams.

METHODS

As part of the European Commission-funded EU-JUST-CT project, 6734 anonymized CT referrals were audited across 125 centers in Belgium, Denmark, Estonia, Finland, Greece, Hungary, and Slovenia. In each country, two blinded radiologists independently scored each exam's appropriateness using the ESR iGuide and noted any recommended alternatives based on presented indications. Arbitration was used in case auditors disagreed. Associations between appropriateness rate and institution type, patient's age and sex, inpatient/outpatient patient status, anatomical area, and referring physician's specialty were statistically examined within each country.

RESULTS

The average appropriateness rate was 75%, ranging from 58% in Greece to 86% in Denmark. Higher rates were associated with public hospitals, inpatient settings, and referrals from specialists. Variability in appropriateness existed by country and anatomical area, patient age, and gender. Common alternative exam recommendations included magnetic resonance imaging, X-ray, and ultrasound.

CONCLUSION

This multi-country evaluation found that even when using a standardized imaging guideline, significant variations in CT appropriateness persist, ranging from 58% to 86% across the participating countries. The study provided valuable insights into real-world utilization patterns and identified opportunities to optimize practices and reduce clinical and demographic disparities in CT use.

KEY POINTS

Question Largest multinational study (7 EU countries, 6734 CT referrals) assessed real-world CT appropriateness using ESR iGuide, enabling cross-system comparisons. Findings Significant variability in appropriateness rates across institution type, patient status, age, gender, exam area, and physician specialty, highlighted the opportunities to optimize practices based on local factors. Clinical relevance International collaboration on imaging guidelines and decision support can maximize CT benefits while optimizing radiation exposure; ongoing research is crucial for refining evidence-based guidelines globally.

Reducing low-value imaging - stakeholders' assessment of an intervention to improve imaging services

BACKGROUND

An intervention to reduce low-value magnetic resonance imaging (MRI) was designed and implemented in private imaging centres in Norway in October 2022. The intervention used return letters for poor referrals of MRI of the lower back, brain and knee at private imaging centres in Norway. The study aimed to investigate key stakeholders' experiences and assessment of the intervention and the specific research questions were: • How many return letters were sent during the study period? • What were the medical directors' and managers' experiences with and reflection on success factors for the intervention implementation and using return letters?

METHODS

The number of return letters sent was collected directly from Norway's two main private imaging providers. Two semi-structured individual interviews were conducted with the medical directors of the imaging providers, as well as two focus group interviews with nine managers from the various private imaging centres operated by the two imaging providers.

RESULTS

In total, 1,182 return letters were sent for patients undergoing one of the three types of MRI examinations, and the number of return letters was highest at the beginning of the intervention. The interview analysis resulted in five categories: general experience, anchoring, organisation, return letter procedure and outcome. Sufficient information, anchoring and support were identified as crucial success factors.

CONCLUSIONS

This study provides insights into the practical and crucial details of implementing interventions to reduce low-value imaging. The intervention was generally well received, and the high initial number of return letters decreased rapidly over the course of the study. Several key success factors were identified.

Clinical Impact of Radiologist's Alert System on Patient Care for High-risk Incidental CT Findings: A Machine Learning-Based Risk Factor Analysis

RATIONALE AND OBJECTIVES

Efficient communication between radiologists and clinicians ordering computed tomography (CT) examinations is crucial for managing high-risk incidental CT findings (ICTFs). Herein, we introduced a Radiologist's Alert and Patient Care Follow-up System (APCFS) for high-risk ICTFs. This study aimed to analyze the ICTFs detected by this system and the factors associated with them.

MATERIALS AND METHODS

This retrospective study was approved by the institutional review board. We analyzed 52,331 CT examinations conducted between 2019 and 2021. In cases where high-risk ICTFs were identified, radiologists utilized APCFS to prompt ordering clinicians for further patient care. We assessed the frequency, affected body organs, presence or absence of therapeutic interventions, and diagnoses of high-risk ICTFs. An automated machine learning platform was employed to analyze the factors associated with high-risk ICTFs.

RESULTS

Among the 52,331 CT examinations, 507 (0.96%) revealed high-risk ICTFs, primarily affecting the lung (18.0%). Of these 507 high-risk ICTFs, 117 (23.1%) underwent therapeutic interventions, while 362 (71.4%) required only follow-up. Of the 117 cases undergoing interventions, 61 (52.1%) required surgery. Of the 219 high-risk ICTFs leading to a confirmed diagnosis, 146 (66.7%) were neoplastic lesions, including 88 (60.3%) malignancies, and 73 (33.3%) were non-neoplastic lesions. The top three risk factors associated with high-risk ICTFs in the regularized logistic regression model were the imaging protocol (especially aortic valve implantation planning protocol), imaging area (especially whole-body imaging), and clinical department (especially cardiology).

CONCLUSION

Utilizing APCFS, high-risk ICTFs were detected in approximately 1% of all CT examinations, likely associated with specific imaging protocols, areas, and clinical departments.

Footprints in the scan: reducing the carbon footprint of diagnostic tools in urology

PURPOSE OF REVIEW

There is an ever-growing focus on climate change and its impact on our society. With healthcare contributing a sizeable proportion of carbon emissions, the sector has a duty to address its environmental impact. We highlight the recent progress, current challenges, and future prospects for reducing the carbon footprint in diagnostic urology, specifically for imaging, without compromising patient care.

RECENT FINDINGS

The review is separated into four key areas of recent research: the design of a green radiology department, considering both infrastructural as well as behavioural changes that promote sustainability; individual scanners, where we provide an update on recent technological advancements and changes in behaviour that may enhance sustainable use; responsible resource allocation, where it is important to derive the maximal benefit for patients through the smallest use of resources; the recent research regarding single versus reusable urologic endoscopes as a case example.

SUMMARY

We offer an overview of the present sustainability landscape in diagnostic urology with the aim of encouraging additional research in areas where existing practices may be challenged. To protect the environment, attention is drawn to both more simple steps that can be taken as well as some more complex and expensive ones.

Enhancing Imaging Anatomy Competency: Integrating Digital Imaging and Communications in Medicine (DICOM) Viewers Into the Anatomy Lab Experience

INTRODUCTION

Radiologic interpretation is a skill necessary for all physicians to provide quality care for their patients. However, some medical students are not exposed to Digital Imaging and Communications in Medicine (DICOM) imaging manipulation until their third year during clinical rotations. The objective of this study is to evaluate how medical students exposed to DICOM manipulation perform on identifying anatomical structures compared to students who were not exposed.

METHODS

This was a cross-sectional cohort study with 19 medical student participants organized into a test and control group. The test group consisted of first-year students who had been exposed to a new imaging anatomy curriculum (n = 9). The control group consisted of second-year students who had not had this experience (n = 10). The outcomes measured included quiz performance, self-reported confidence levels, and eye-tracking data.

RESULTS

Students in the test group performed better on the quiz compared to students in the control group (p = 0.03). Confidence between the test and control groups was not significantly different (p = 0.16), though a moderate to large effect size difference was noted (Hedges' g = 0.75). Saccade peak velocity and fixation duration between the groups were not significantly different (p = 0.29, p = 0.77), though a moderate effect size improvement was noted in saccade peak velocity for the test group (Hedges' g = 0.49).

CONCLUSION

The results from this study suggest that the early introduction of DICOM imaging into a medical school curriculum does impact students' performance when asked to identify anatomical structures on a standardized quiz.

Competence of radiologists in cardiac CT and MR imaging in Europe: insights from the ESCR Registry

RATIONALE

To provide an overview of the current status of cardiac multimodality imaging practices in Europe and radiologist involvement using data from the European Society of Cardiovascular Radiology (ESCR) MRCT-registry.

MATERIALS AND METHODS

Numbers on cardiac CT and MRI examinations were extracted from the MRCT-registry of the ESCR, entered between January 2011 and October 2023 (n = 432,265). Data collection included the total/annual numbers of examinations, indications, complications, and reporting habits.

RESULTS

Thirty-two countries contributed to the MRCT-registry, including 29 European countries. Between 2011 and 2022, there was a 4.5-fold increase in annually submitted CT examinations, from 3368 to 15,267, and a 3.8-fold increase in MRI examinations, from 3445 to 13,183. The main indications for cardiac CT were suspected coronary artery disease (CAD) (59%) and transcatheter aortic valve replacement planning (21%). The number of patients with intermediate pretest probability who underwent CT for suspected CAD showed an increase from 61% in 2012 to 82% in 2022. The main MRI indications were suspected myocarditis (26%), CAD (21%), and suspected cardiomyopathy (19%). Adverse event rates were very low for CT (0.3%) and MRI (0.7%) examinations. Reporting of CT and MRI examinations was performed mainly by radiologists (respectively 76% and 71%) and, to a lesser degree, in consensus with non-radiologists (19% and 27%, respectively). The remaining examinations (4.9% CT and 1.7% MRI) were reported by non-radiological specialties or in separate readings of radiologists and non-radiologists.

CONCLUSIONS

Real-life data on cardiac imaging in Europe using the largest available MRCT-registry demonstrate a considerable increase in examinations over the past years, the vast majority of which are read by radiologists. These findings indicate that radiologists contribute to meeting the increasing demands of competent and effective care in cardiac imaging to a relevant extent.

CLINICAL RELEVANCE STATEMENT

The number of cardiac CT and MRI examinations has risen over the past years, and radiologists read the vast majority of these studies as recorded in the MRCT-registry.

KEY POINTS

• The number of cardiac imaging examinations is constantly increasing. • Radiologists play a central role in providing cardiac CT and MR imaging services to a large volume of patients. • Cardiac CT and MR imaging examinations performed and read by radiologists show a good safety profile.

The Florida Geriatric Head Trauma CT Clinical Decision Rule

BACKGROUND

Several clinical decision rules have been devised to guide head computed tomography (CT) use in patients with minor head injuries, but none have been validated in patients 65 years or older. We aimed to derive and validate a head injury clinical decision rule for older adults.

METHODS

We conducted a secondary analysis of an existing dataset of consecutive emergency department (ED) patients >65 years old with blunt head trauma. The main predictive outcomes were significant intracranial injury and Need for Neurosurgical Intervention on CT. The secondary outcomes also considered in the model development and validation were All Injuries and All Intracranial Injuries. Predictor variables were identified using multiple variable logistic regression, and clinical decision rule models were developed in a split-sample derivation cohort and then tested in an independent validation cohort.

RESULTS

Of 5776 patients, 233 (4.0%) had significant intracranial injury and an additional 104 (1.8%) met CT criteria for Need for Neurosurgical Intervention. The best performing model, the Florida Geriatric Head Trauma CT Clinical Decision Rule, assigns points based on several clinical variables. If the points totaled 25 or more, a CT scan is indicated. The included predictors were arrival via Emergency Medical Services (+30 points), Glasgow Coma Scale (GCS) <15 (+20 points), GCS <14 (+50 points), antiplatelet medications (+17 points), loss of consciousness (+16 points), signs of basilar skull fracture (+50 points), and headache (+20 points). Utilizing this clinical decision rule in the validation cohort, a point total ≥25 had a sensitivity and specificity of 100.0% (95% CI: 96.0-100) and 12.3% (95% CI: 10.9-13.8), respectively, for significant intracranial injury and Need for Neurosurgical Intervention.

CONCLUSIONS

The Florida Geriatric Head Trauma CT Clinical Decision Rule has the potential to reduce unnecessary CT scans in older adults, without compromising safe emergency medicine practice.

Repeated radiological procedures in the last 6 months of life in old age: a retrospective study

OBJECTIVES

This novel study looks at the use of radiological procedures in an elderly cohort of patients in their last 6 months of life. Radiological imaging plays a central part of clinical investigations, but too many may override the judgement of benefits, risks and resources. There is little information on the burden of radiological procedures performed towards the end of life in patients of old age.

METHODS

Data from every fourth patient aged 80 years and over who died between 4 July 2021 and 30 December 2021 in a National Health Service (NHS) hospital were collected. All radiological procedures performed within the last 6 months of the patients' life were recorded from clinical documentation and related to their age.

RESULTS

96 patients were studied with a total of 699 radiological procedures performed. When scaled up, costs of CT and MRI scans alone are conservatively estimated as £312 000/annum in patients aged ≥80 years in their last 6 months of life for a single medium-sized NHS hospital.

CONCLUSIONS

A very large number of radiological procedures were performed towards the end of life among patients of old age. This is consistent with the national trend of increased medicalisation and poor recognition of dying.

Radiology education for medical students: a qualitative exploration of educational topics, teaching methods and future strategies

BACKGROUND

Imaging techniques play a central role in modern medicine and therefore it would be beneficial for all medical students to incorporate radiology education in medical school curricula. However, a formal undergraduate radiology curriculum with well-defined learning objectives remains lacking in The Netherlands. This study aims to qualitatively ascertain opinions from clinicians (radiologists and non-radiologists) with regard to radiology education in the medical school curricula, including topics, teaching methods and strategies.

METHODS

A qualitative study with in-depth semi-structured interviews was conducted. Inclusion was carried out until saturation was achieved, after which 2 additional interviews were held. Interviews were conducted using open-ended questions, following a predefined topic list. The constant comparative method was applied in order to include new questions when unexpected topics arose during the interviews. All interviews were transcribed verbatim and coded using a thematic analysis approach. Codes were organized into categories and themes by discussion between the researchers.

RESULTS

Forty-four clinicians were interviewed (8 radiologists, 36 non-radiologists). The three main themes that were derived from the interviews were: (1) expectations of indispensable knowledge and skills on radiology, (2) organization of radiology education within the medical curriculum and (3) promising educational innovations for the radiology curriculum. The qualitative study design provides more in-depth knowledge on clinicians' views on educational topics.

CONCLUSIONS

The themes and statements of this study provided new insights into educational methods, timing of radiology education and new topics to teach. More research is needed to gain consensus on these subjects and inclusion of the opinion of medical students with regard to radiology education is needed.

Diagnostic accuracy of vision-language models on Japanese diagnostic radiology, nuclear medicine, and interventional radiology specialty board examinations

PURPOSE

The performance of vision-language models (VLMs) with image interpretation capabilities, such as GPT-4 omni (GPT-4o), GPT-4 vision (GPT-4V), and Claude-3, has not been compared and remains unexplored in specialized radiological fields, including nuclear medicine and interventional radiology. This study aimed to evaluate and compare the diagnostic accuracy of various VLMs, including GPT-4 + GPT-4V, GPT-4o, Claude-3 Sonnet, and Claude-3 Opus, using Japanese diagnostic radiology, nuclear medicine, and interventional radiology (JDR, JNM, and JIR, respectively) board certification tests.

MATERIALS AND METHODS

In total, 383 questions from the JDR test (358 images), 300 from the JNM test (92 images), and 322 from the JIR test (96 images) from 2019 to 2023 were consecutively collected. The accuracy rates of the GPT-4 + GPT-4V, GPT-4o, Claude-3 Sonnet, and Claude-3 Opus were calculated for all questions or questions with images. The accuracy rates of the VLMs were compared using McNemar's test.

RESULTS

GPT-4o demonstrated the highest accuracy rates across all evaluations with the JDR (all questions, 49%; questions with images, 48%), JNM (all questions, 64%; questions with images, 59%), and JIR tests (all questions, 43%; questions with images, 34%), followed by Claude-3 Opus with the JDR (all questions, 40%; questions with images, 38%), JNM (all questions, 42%; questions with images, 43%), and JIR tests (all questions, 40%; questions with images, 30%). For all questions, McNemar's test showed that GPT-4o significantly outperformed the other VLMs (all P < 0.007), except for Claude-3 Opus in the JIR test. For questions with images, GPT-4o outperformed the other VLMs in the JDR and JNM tests (all P < 0.001), except Claude-3 Opus in the JNM test.

CONCLUSION

The GPT-4o had the highest success rates for questions with images and all questions from the JDR, JNM, and JIR board certification tests.

Demonstrating the use of population level data to investigate trends in the rate, radiation dose and cost of Computed Tomography across clinical groups: Are there any areas of concern?

INTRODUCTION

Increases in computed tomography (CT) use may not always reflect clinical need or improve outcomes. This study aimed to demonstrate how population level data can be used to identify variations in care between patient groups, by analysing system-level changes in CT use around the diagnosis of new conditions.

METHODS

Retrospective repeated cross-sectional observational study using West Australian linked administrative records, including 504,723 adults diagnosed with different conditions in 2006, 2012 and 2015. For 90 days pre/post diagnosis, CT use (any and 2+ scans), effective dose (mSv), lifetime attributable risk (LAR) of cancer incidence and mortality from CT, and costs were assessed.

RESULTS

CT use increased from 209.4 per 1000 new diagnoses in 2006 to 258.0 in 2015; increases were observed for all conditions except neoplasms. Healthcare system costs increased for all conditions but neoplasms and mental disorders. Effective dose increased substantially for respiratory (+2.5 mSv, +23.1%, P < 0.001) and circulatory conditions (+2.1 mSv, +15.4%, P < 0.001). The LAR of cancer incidence and mortality from CT increased for endocrine (incidence +23.4%, mortality +18.0%) and respiratory disorders (+21.7%, +23.3%). Mortality LAR increased for circulatory (+12.1%) and nervous system (+11.0%) disorders. The LAR of cancer incidence and mortality reduced for musculoskeletal system disorders, despite an increase in repeated CT in this group.

CONCLUSIONS

Use and costs increased for most conditions except neoplasms and mental and behavioural disorders. More strategic CT use may have occurred in musculoskeletal conditions, while use and radiation burden increased for respiratory, circulatory and nervous system conditions. Using this high-level approach we flag areas requiring deeper investigation into appropriateness and value of care.

Cost of Low-Value Imaging Worldwide: A Systematic Review

BACKGROUND AND OBJECTIVE

Imaging with low or no benefit for the patient undermines the quality of care and amounts to vast opportunity costs. More than 3.6 billion imaging examinations are performed annually, and about 20-50% of these are of low value. This study aimed to synthesize knowledge of the costs of low-value imaging worldwide.

METHODS

This systematic review was based on the PRISMA statement. The database search was developed in Medline and further adapted to Embase-Ovid, Cochrane Library, and Scopus. Primary empirical studies assessing the costs of low-value diagnostic imaging were included if published between 2012 and March 2022. Studies designed as randomized controlled trials, non-randomized trials, cohort studies, cross-sectional studies, descriptive studies, cost analysis, cost-effectiveness analysis, and mixed-methods studies were eligible. The analysis was descriptive.

RESULTS

Of 5,567 records identified, 106 were included. Most of the studies included were conducted in the USA (n = 76), and a hospital or medical center was the most common setting (n = 82). Thirty-eight of the included studies calculated the costs of multiple imaging modalities; in studies with only one imaging modality included, conventional radiography was the most common (n = 32). Aggregated costs for low-value examinations amounts to billions of dollars per year globally. Initiatives to reduce low-value imaging may reduce costs by up to 95% without harming patients.

CONCLUSIONS

This study is the first systematic review of the cost of low-value imaging worldwide, documenting a high potential for cost reduction. Given the universal challenges with resource allocation, the large amount used for low-value imaging represents a vast opportunity cost and offers great potential to improve the quality and efficiency of care.

Imaging overuse in the emergency department: The view of radiologists and emergency physicians

PURPOSE

To identify the perceived factors contributing to imaging overuse in the emergency department, according to radiologists and emergency physicians.

METHOD

A survey study on imaging overuse in the emergency department was conducted among 66 radiologists and 425 emergency physicians. Five-point Likert scales (not a problem at all/strongly disagree [score 1] to very serious problem/strongly agree [score 5]) were used to score the various aspects of overimaging.

RESULTS

Both radiologists and emergency physicians gave a median score of 4 to the question if imaging overuse is a problem in their emergency department. CT accounts for the vast majority of imaging overuse, according to both radiologists (84.8%) and emergency physicians (75.3%). Defensive medicine/fear of malpractice, the presence of less experienced staff, and easy access to imaging all were given a median score of 4 as factors that influence imaging overuse, by both physician groups. Median ratings regarding the influence of pressure from patients and a lack of time to examine patients on imaging overuse varied between 3 and 4 for radiologists and emergency physicians. Pressure from consultants to perform imaging, the use of imaging to decrease turnaround time in the emergency department, a lack of space in the emergency department, a lack of proper medical education, and inability to access outside imaging studies, were also indicated to give rise to imaging overuse.

CONCLUSIONS

Imaging overuse in the emergency department (particularly CT overuse) is a problem according to most radiologists and emergency physicians, and is driven by several factors.

Automatic Protocolling of Non-contrast Musculoskeletal MRIs Does Not Result in Increase in Patient Recall Rates for Contrast-Enhanced Studies

RATIONALE AND OBJECTIVES

Physicians spend large amounts of time on protocolling imaging studies, limiting their time spent on other essential clinical tasks. Most musculoskeletal (MSK) MRI studies are performed for the evaluation of joint pain and internal derangements and usually require no intravenous contrast. Contrast-enhanced MRI studies are performed for the evaluation of infection, suspected or established tumor, and rheumatological conditions. Protocolling all MSK MRI studies takes time away from other important tasks during the workday. Routine joint MRI scans have established set of sequences, and thus, could be scheduled and performed without special protocols by the radiologists. In a large tertiary care center like ours with multiple MRI magnets, we set up a process of automated protocoling and scheduling of non-contrast joint MRI scans ordered by referring doctors. This project's purpose was to assess the effect of this newly established process of 'automatic protocoling and scheduling' of MSK MRI scans on the rate of overlooked MRI exams that may have required contrast examinations, and on the patient recall-rate to obtain follow-up post-contrast sequences for further diagnostic characterization.

METHODS

All MSK reports of MRIs during the last two months of the years before and after the implementation of automatic protocolling (intervention) were searched for the presence of indications related to neoplasms, infections, and rheumatological conditions. For each of the three disease categories, we determined the number of MRIs obtained with and without contrast before and after the intervention. For each matching study obtained without contrast, the patient chart was reviewed for contraindications to contrast, positive final diagnosis, whether interpreting radiologist mentioned the exam being limited by lack of contrast, and recommendations for a follow-up contrast enhanced study.

RESULTS

A total of 846 MSK MRIs were performed prior to intervention and 822 MRIs were performed afterwards. Overall, 25% of the studies were performed without contrast prior to the intervention, and 31% of studies were performed without contrast afterwards (Chi square 0.07, p-value 0.79). No report contained a recommendation for contrast enhanced follow-up study before or after the intervention.

CONCLUSION

Automatic protocolling of routine MSK non-contrast MRI studies resulted in statistically insignificant, minimal increase in the overall number of non-contrast enhanced studies obtained for work up of neoplasms, infections, and rheumatological conditions. There was no increase in patient recall rate for additional post contrast sequences and the new process resulted in time savings to fellows and other physicians, being not distracted from other important tasks.

The development of recommendations for the assessment and management of sesamoiditis by podiatrists: A Delphi and content validity study

INTRODUCTION

Sesamoiditis is a common, and often painful, musculoskeletal pathology frequently encountered by podiatrists. However, there are currently no recommendations to guide podiatrists in the assessment and management of people with sesamoiditis. The aim of this study was to develop consensus-driven clinical recommendations on the assessment and management of people with sesamoiditis.

METHODS

A four-round online Delphi survey was conducted with a panel of New Zealand and Australian podiatrists. In the first round, panellists answered open-ended questions that were used to create statements. In round two, the panellists scored the statements from 1 to 9 (1 = not at all important, 9 = absolutely essential). Consensus was defined using the RAND/University of California Los Angles Disagreement Index. Panellists were asked to reconsider statements that did not achieve consensus in round three. In the final round, content validity and acceptability of the statements for inclusion in clinical recommendations were determined using content validity ratios and the Content Validity Index (CVI).

RESULTS

Eighteen panellists completed round one with 16 (89%) completing all four rounds. A total of 118 statements were generated following round one. Following rounds two and three, 78 statements were accepted by panellists as being important, with 62 statements achieving sufficient content validity for inclusion in clinical recommendations. The CVI for these 62 statements was 0.58. These recommendations provide guidance on subjective assessment (pain characteristics/symptomology, activity/sports/training history and medical history) objective assessment (establishing a diagnosis, identifying contributing biomechanical factors, footwear/orthoses, ruling out differential diagnoses) and management (temporary padding/strapping, education, footwear, foot orthoses and when to consider referral).

CONCLUSION

This consensus exercise has provided a set of consensus-based recommendations for the assessment and management of people with sesamoiditis. In the current absence of research-based evidence in this area, these recommendations are intended to support clinicians. The recommendations may also serve as a basis for future clinical trials evaluating the efficacy of conservative interventions for people with sesamoiditis.

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

PURPOSE

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

METHODS

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

RESULTS

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

DISCUSSION

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

Sustainability in healthcare by reducing low-value imaging - A narrative review

OBJECTIVES

This narrative review aims to present the concept of value in imaging and explore why we conduct low-value procedures, how to reduce this wasteful use, and what we could gain from reducing low-value imaging.

KEY FINDINGS

Imaging of low value to the patient contributes to thousands of metric tons of CO2 emissions, costing several billion US dollars annually. With a 20% reduction in low-value imaging, we would reduce the waste of resources related to 7.2 million procedures and, at the same time, reduce the risk of incidentalomas, overdiagnosis, and overtreatment and reduce wait times for patients in need of imaging services of high value. Multi-component initiatives targeting barriers in all levels of society and healthcare are needed to reduce low-value imaging. Radiographers are key actors in medical imaging and can make substantial contributions to this effort by, together with the radiologists, referrers, and managers, ensuring that all imaging procedures conducted are sustainable along four dimensions of sustainability: value, cost, risk, and environment.

CONCLUSION

Efforts to secure sustainable imaging considering the four crucial dimensions (value, cost, radiation, and environment) should be made at all levels of society and healthcare, from governmental management to the individual healthcare worker. Radiographers are vital in obtaining sustainability to ensure only sustainable imaging procedures are conducted.

IMPLICATIONS FOR PRACTICE

When assessing the appropriateness of imaging procedures, we need to consider the environment, safety, effectiveness, and efficiency. To obtain this, we need a collective and coordinated effort locally, nationally, and internationally to deliver sustainable imaging services.

Imaging 3.0: A scoping review

We aim to provide a comprehensive summary of the current body of literature concerning the Imaging 3.0 initiative and its implications for patient care within the field of radiology. We offer a thorough analysis of the literature pertaining to the Imaging 3.0 initiative, emphasizing the practical application of the five pillars of the program, their cost-effectiveness, and their benefits in patient management. By doing so, we hope to illustrate the impact the Imaging 3.0 Initiative can have on the future of radiology and patient care.

Temporal and geographical variations in diagnostic imaging in Norway

BACKGROUND

Unwarranted temporal and geographical variations are acknowledged as a profound problem for equal access and justice in the provision of health services. Even more, they challenge the quality, safety, and efficiency of such services. This is highly relevant for imaging services.

OBJECTIVE

To analyse the temporal and geographical variation in the number of diagnostic images in Norway from 2013 to 2021.

METHODS

Data on outpatient imaging provided by the Norwegian Health Economics Administration (HELFO) and inpatient data afforded by fourteen hospital trusts and hospitals in Norway. Data include the total number of imaging examinations according to the Norwegian Classification of Radiological Procedures (NCRP). Analyses were performed with descriptive statistics.

RESULTS

More than 37 million examinations were performed in Norway during 2013-2021 giving an average of 4.2 million examinations per year. In 2021 there was performed and average of 0.8 examinations per person and 2.2 examinations per person for the age group > 80. There was a 9% increase in the total number of examinations from 2013 to 2015 and a small and stable decrease of 0.5% per year from 2015 to 2021 (with the exception of 2020 due to the pandemic). On average 71% of all examinations were outpatient examinations and 32% were conducted at private imaging centres. There were substantial variations between the health regions, with Region South-East having 53.1% more examinations per inhabitant than Region West. The geographical variation was even more outspoken when comparing catchment areas, where Oslo University Hospital Trust had twice as many examinations per inhabitant than Finnmark Hospital Trust.

CONCLUSION

As the population in Norway is homogeneous it is difficult to attribute the variations to socio-economic or demographic factors. Unwarranted and supply-sensitive variations are challenging for healthcare systems where equal access and justice traditionally are core values.

Environmental Sustainability and MRI: Challenges, Opportunities, and a Call for Action

The environmental impact of magnetic resonance imaging (MRI) has recently come into focus. This includes its enormous demand for electricity compared to other imaging modalities and contamination of water bodies with anthropogenic gadolinium related to contrast administration. Given the pressing threat of climate change, addressing these challenges to improve the environmental sustainability of MRI is imperative. The purpose of this review is to discuss the challenges, opportunities, and the need for action to reduce the environmental impact of MRI and prepare for the effects of climate change. The approaches outlined are categorized as strategies to reduce greenhouse gas (GHG) emissions from MRI during production and use phases, approaches to reduce the environmental impact of MRI including the preservation of finite resources, and development of adaption plans to prepare for the impact of climate change. Co-benefits of these strategies are emphasized including lower GHG emission and reduced cost along with improved heath and patient satisfaction. Although MRI is energy-intensive, there are many steps that can be taken now to improve the environmental sustainability of MRI and prepare for the effects of climate change. On-going research, technical development, and collaboration with industry partners are needed to achieve further reductions in MRI-related GHG emissions and to decrease the reliance on finite resources. LEVEL OF EVIDENCE: 5 TECHNICAL EFFICACY: Stage 6.

Low-value MRI of the knee in Norway: a register-based study to identify the proportion of potentially low-value MRIs and estimate the related costs

OBJECTIVES

The objective of this study is to investigate the proportion of potentially low-value knee MRI in Norway and to provide an estimate of the related costs.

DESIGN

Register study based on conditional data extraction and analysis of data from Control and Reimbursement of Healthcare Claims registry in Norway.

SETTING

MRI in public specialist healthcare with universal health coverage (Norway).

PARTICIPANTS

48 212 MRIs for 41 456 unique patients and 45 946 reimbursement claims.

OUTCOME MEASURES

Proportion of MRIs of the knee that (1) did not have a relevant tentative diagnosis prior to the knee MRI, (2) did not have a relevant alternative image of the knee before the MRI or (3) did not have a relevant code from the specialist care within 6 months after the MRI, and those that had combinations of 1, 2 and 3. Estimated costs for those that had combinations of 1, 2 and 3.

RESULTS

Very few patients (6.4%) had a relevant diagnosis code or prior imaging examination when having the MRI and only 14.6% got a knee-related diagnosis code from the specialist care within 6 months after the MRI. 21.8% of the patients had knee X-ray, CT or ultrasound within 6 months before the MRI. Between 58% and 85% of patients having knee MRIs in Norway have no relevant examinations or diagnoses six months prior to or after the MRI examination. These examinations are unlikely to benefit patients and they correspond to between 24 108 and 35 416 MRIs at a cost of €6.7-€9.8 million per year.

CONCLUSION

A substantial proportion of MRIs of the knee in Norway have no relevant examinations or diagnoses before or after the MRI and are potentially of low value. Reducing low-value MRIs could free resources for high-value imaging, reduce waiting times, improve the quality of care and increase patient safety and professional integrity.

Upper Extremity Surgeon Recommendations for Imaging Do Not Correspond with Imaging Appropriateness Guidelines

Background

Utilization of magnetic resonance imaging (MRI) and computed tomography (CT) increases annually, raising concerns about overuse. Imaging appropriateness guidelines have the potential to standardize decisions regarding imaging based on best evidence, which might reduce unhelpful or potentially misleading imaging. We studied expert use of advanced imaging for musculoskeletal illness compared to published appropriateness recommendations.

Methods

First, 15 imaging guidelines with recommendations for advanced imaging of the upper extremity were collated. Next, members of the Science of Variation Group (SOVG) were invited to participate in a survey of 11 patient scenarios of common upper extremity illnesses and asked whether they would recommend MRI or CT. Guideline recommendations for imaging were compared with surgeon recommendations using Fisher's exact tests. We used Fleiss' kappa to measure the interobserver agreement among surgeons.

Results

For the 11 scenarios, most imaging appropriateness guidelines suggested that MRI or CT is useful, while most surgeons (n = 108) felt it was not. There was no correlation between surgeons and guidelines recommendations for imaging (ρ = 0.28; p = 0.40). There was slight agreement among surgeons regarding imaging recommendations (kappa: 0.17; 95% confidence interval: 0.023-0.32).

Conclusion

The available imaging appropriateness guidelines appear to be too permissive and therefore seem to have limited clinical utility for upper extremity surgeons. The notable surgeon-to-surgeon variation (unreliability) in recommendations for advanced imaging in this and other studies suggests a role for strategies to ensure that patient decisions about imaging are consistent with their values (what matters most to them) and not unduly influenced by patient misconceptions about imaging or by surgeon beliefs and habits.

Level Of Evidence

II, diagnostic.

Rising use of diagnostic imaging in Australia: An analysis of Medicare-funded radiology services between 2000 and 2021

INTRODUCTION

The use of diagnostic imaging services is increasing worldwide. This has important impacts on healthcare resource allocation and potential risks to the population. This study aimed to quantify trends in medical imaging in Australia over the past two decades.

METHODS

Data were extracted from the Australian Medicare Benefits Schedule (MBS) between 2000 and 2021. Simple linear regression analyses were performed to assess changes in absolute utilisation and utilisation rate per 100,000 population of total imaging services as well as by each imaging modality. Logistic regression analysis was performed to assess changes in total imaging services as a proportion of total Medicare services over time. Chi-squared test was used to assess for change in modality composition of imaging services.

RESULTS

There were 436,255,500 imaging studies performed between 2000 and 2021. The absolute utilisation of total imaging services increased annually by an average of 864,404 (95% CI: 808,235-920,573, p < 0.001). For each consecutive year, the proportion of total Medicare services attributed to total imaging services increased by 0.01% (95% CI: 0.01-0.01, p < 0.01). There was also a statistically significant increase in the utilisation rates of imaging services per 100,000 population for each imaging modality. The number of imaging services per radiologist increased on average by 74 (95% CI: 26-122, p < 0.05) annually.

CONCLUSION

The utilisation of diagnostic imaging services has increased in Australia between 2000 and 2021, outpacing the population growth, total healthcare services, and the radiologist workforce.

Environmental Sustainability and AI in Radiology: A Double-Edged Sword

According to the World Health Organization, climate change is the single biggest health threat facing humanity. The global health care system, including medical imaging, must manage the health effects of climate change while at the same time addressing the large amount of greenhouse gas (GHG) emissions generated in the delivery of care. Data centers and computational efforts are increasingly large contributors to GHG emissions in radiology. This is due to the explosive increase in big data and artificial intelligence (AI) applications that have resulted in large energy requirements for developing and deploying AI models. However, AI also has the potential to improve environmental sustainability in medical imaging. For example, use of AI can shorten MRI scan times with accelerated acquisition times, improve the scheduling efficiency of scanners, and optimize the use of decision-support tools to reduce low-value imaging. The purpose of this Radiology in Focus article is to discuss this duality at the intersection of environmental sustainability and AI in radiology. Further discussed are strategies and opportunities to decrease AI-related emissions and to leverage AI to improve sustainability in radiology, with a focus on health equity. Co-benefits of these strategies are explored, including lower cost and improved patient outcomes. Finally, knowledge gaps and areas for future research are highlighted.

Accuracy of ChatGPT generated diagnosis from patient's medical history and imaging findings in neuroradiology cases

PURPOSE

The noteworthy performance of Chat Generative Pre-trained Transformer (ChatGPT), an artificial intelligence text generation model based on the GPT-4 architecture, has been demonstrated in various fields; however, its potential applications in neuroradiology remain unexplored. This study aimed to evaluate the diagnostic performance of GPT-4 based ChatGPT in neuroradiology.

METHODS

We collected 100 consecutive "Case of the Week" cases from the American Journal of Neuroradiology between October 2021 and September 2023. ChatGPT generated a diagnosis from patient's medical history and imaging findings for each case. Then the diagnostic accuracy rate was determined using the published ground truth. Each case was categorized by anatomical location (brain, spine, and head & neck), and brain cases were further divided into central nervous system (CNS) tumor and non-CNS tumor groups. Fisher's exact test was conducted to compare the accuracy rates among the three anatomical locations, as well as between the CNS tumor and non-CNS tumor groups.

RESULTS

ChatGPT achieved a diagnostic accuracy rate of 50% (50/100 cases). There were no significant differences between the accuracy rates of the three anatomical locations (p = 0.89). The accuracy rate was significantly lower for the CNS tumor group compared to the non-CNS tumor group in the brain cases (16% [3/19] vs. 62% [36/58], p < 0.001).

CONCLUSION

This study demonstrated the diagnostic performance of ChatGPT in neuroradiology. ChatGPT's diagnostic accuracy varied depending on disease etiologies, and its diagnostic accuracy was significantly lower in CNS tumors compared to non-CNS tumors.

Inappropriate requests for cranial CT scans in emergency departments increase overuse and reduce test performance

PURPOSE

The number of non-traumatic urgent cranial computed tomography (NT-UCCT) is exponentially increasing but limited research has been conducted on the quality of clinical justification. Accordingly, we aimed (1) to assess how clinical information in the electronic NT-UCCT request agreed with that provided in the patient's emergency department discharge summary and (2) to analyze the potential effect of those discrepancies on the NT-UCCT overload.

MATERIAL AND METHODS

Patients undergoing NT-UCCT in 2017-2021 were randomly selected for this retrospective research-board-approved study. Signs and symptoms (S/S) in electronic request and emergency department discharge summary, acute and relevant computed tomography (CT) findings (acute ischemia or hemorrhage, masses, brain edema, or previously undetected hydrocephalus), and final diagnosis at emergency department discharge summary were collected. Concordance between digital request and emergency department discharge summary and their association with both acute and relevant CT findings and final diagnosis were analyzed.

RESULTS

We recruited 156 patients: 80 men; mean age, 55. Acute, relevant CT findings were detected in 28 cases (17.9%). The final diagnosis was neurological disease, non-neurological disease, and no definitive diagnosis in 46 (29.5%), 58 (37.2%), and 51 (32.7%) cases, respectively. Full agreement between the electronic request and emergency department discharge summary occurred in only 36 patients (23.1%). Motor deficit was the most frequent false positive electronic request S/S (18; 11.54%), having low positive predictive value (30.30%; 95%CI 15.59-48.71%) and worst association with acute relevant CT findings than when true positive (OR 2.54; 95%CI 0.04-6.21 vs. OR 6.26, 95%CI 2.21-17.78). Nausea/vomiting was the third most common false negative electronic request S/S (13; 10.26%) and reduced the likelihood of acute and relevant CT findings (OR 0.126; 95%CI 0.016-0.971; p = 0.020). False S/S in electronic request predominated in non-neurological diseases (50-60.2% vs. 33-39.8%; p = 0.068).

CONCLUSION

Discrepancies between electronic request and emergency department discharge summary were observed in >75% of patients, leading to unnecessary NT-UCCT tests.

Variations in wait times for imaging services: a register-based study of self-reported wait times for specific examinations in Norway

BACKGROUND

While the number of medical images has increased substantially, the demand has outpaced access, resulting in long wait times in many countries. Long wait times are a key problem for patient safety and quality of care as they can result in prolonged suffering, delayed diagnosis and treatment, as well as poorer prognosis and loss of lives. Surprisingly, little is known about wait times for imaging services.

OBJECTIVE

Investigate wait times for specific imaging services in Norway and to compare wait times with the total number of examinations and their development over time.

METHODS

Data from the wait time registry at the Norwegian Directorate of Health from 2018 to 2021 as well as data on outpatient imaging provided by the Norwegian Health Economics Administration (HELFO) and in-patient data afforded by fourteen hospital trusts and hospitals in Norway were analysed. Data include the total number of imaging examinations according to the Norwegian Classification of Radiological Procedures (NCRP). Analyses were performed with descriptive statistics.

RESULTS

Wait times vary through the months of the year. Conventional X-ray (XR) had the shortest wait times (3.0-4.4 weeks), and Magnetic Resonance Imaging (MRI) and ultrasound (US) had the lengthiest (8.7-12.0 and 7.9-11.4 weeks respectively). The wait times were lengthiest during the summer and winter holidays. Variations in wait times were also found for specific examination types between Norway's four public health regions. In addition, there was variation over time within the health regions. The wait times with the private health providers were substantially lower than with the public health providers. From 2018 to 2021, the wait time for MRIs increased by 6.6%, while the number of examinations (per 10,000) increased by 8.6%. Those regions with the highest number of examinations per 1,000 inhabitants per year had the lowest wait times.

CONCLUSION

Wait times for diagnostic imaging procedures varied with time, region, and modality in Norway from 2018 to 2021. Long wait times may entail many negative consequences for patients, professionals, and the healthcare system. Reducing long wait times is an obvious way to improve the quality, safety, and efficiency of care.

COVID-Necessitated Online Radiology Elective Improves Student Imaging Appropriateness in Clinical Case Vignettes

RATIONALE AND OBJECTIVES

The use of imaging in medicine has increased considerably over the previous decades, contributing to significant inefficiency of use. Radiology education varies amongst institutions without standardized learning objectives. Consequently, many physicians and student doctors are unprepared to make appropriate choices regarding imaging. In response to COVID-19-engendered restrictions, we created a fully online, image-intensive radiology curriculum to introduce students to clinical radiology and appropriate imaging usage.

MATERIALS AND METHODS

A 2-week radiology elective curriculum was created that adopted accessible, free, online-based learning to foster student education and patient safety while upholding academic standards. Each unit included an emphasis on imaging appropriateness. Students assembled an elective portfolio including self-assessments and prepared a clinical radiology conference to present as a radiologist in training. Two final assessments were required. One consisted of clinical vignettes based on American College of Radiology (ACR) Appropriateness Criteria (AC). The second was an MRI safety quiz.

RESULTS

Third and fourth year students at five institutions (N = 97) completed the elective. Examination scores on an assessment adapted from the ACR AC were significantly improved compared to previously published scores of medical students who took ACR AC-based assessments without taking a radiology course. The course was published and shared with medical schools worldwide.

CONCLUSION

The elective successfully educated students in radiology through a virtual platform and introduced them to the concept of appropriateness in medical imaging. These goals were accomplished using a free, online, easily accessible curriculum. Incorporation of additional topics within the discipline of radiology should be included in the curriculum in the future.

Failure to receive prescribed imaging is associated with increased early mortality after injury in Cameroon

Despite having the highest rates of injury-related mortality in the world, trauma system capacity in sub-Saharan Africa remains underdeveloped. One barrier to prompt diagnosis of injury is limited access to diagnostic imaging. As part of a larger quality improvement initiative and to assist priority setting for policy makers, we evaluated trauma outcomes among patients who did and did not receive indicated imaging in the Emergency Department (ED). We hypothesize that receiving imaging is associated with increased early injury survival. We evaluated patterns of imaging performance in a prospective multi-site trauma registry cohort in Cameroon. All trauma patients enrolled in the Cameroon Trauma Registry (CTR) between 2017 and 2019 were included, regardless of injury severity. Patients prescribed diagnostic imaging were grouped into cohorts who did and did not receive their prescribed study. Patient demographics, clinical course, and outcomes were compared using chi-squared and Kruskal-Wallis tests. Multivariate logistic regression was used to explore associations between radiologic testing and survival after injury. Of 9,635 injured patients, 47.5% (4,574) were prescribed at least one imaging study. Of these, 77.8% (3,556) completed the study (COMPLETED) and 22.2% (1,018) did not receive the prescribed study (NC). Compared to COMPLETED patients, NC patients were younger (p = 0.02), male (p<0.01), and had markers of lower socioeconomic status (SES) (p<0.01). Multivariate regression adjusted for age, sex, SES, and injury severity demonstrated that receiving a prescribed study was strongly associated with ED survival (OR 5.00, 95% CI 3.32-7.55). Completing prescribed imaging was associated with increased early survival in injured Cameroonian patients. In a resource-limited setting, subsidizing access to diagnostic imaging may be a feasible target for improving trauma outcomes.

The Rationality to Requesting in-ward Magnetic Resonance Imaging Investigation

Background

Magnetic Resonance imaging (MRI) is a valuable diagnostic tool by its non-invasive/non-ionizing nature.

Objective

This study aims to determine justification of MRI in hospitalized patients at a tertiary provincial referent medical center in a one-year period.

Material and Methods

In the present retrospective and descriptive cross-sectional study, 438 admitted patients referred for MRI during 2017 were selected using systematic random sampling. The age, gender, investigated organ, the specialty of requesting physician, MRI with and without contrast, MRI diagnostic outcome were collected using checklists. Descriptive statistics and chi-square test were used for data analysis.

Results

The mean age of the patients was 42±26 years-old and female represented 53% of enrolled patients. The most and less prevalent investigated organs were the cerebrum and the orbit. After excluding cancer diagnosis, cancer staging, and therapeutic follow-up exams, MRI request was oriented in 64.3% and 77.2% of positive results was concordant with aforementioned diagnostic orientation (P<0.001). Oriented diagnostic MRI requesting is influenced by age, medical specialists and, investigated organ (P<0.001). The positive MRI is influenced significantly by oriented MRI request, gender, medical specialists and investigated organ (P<0.001). The diagnosis concordance of MRI is influenced significantly by oriented MRI request, medical specialists and investigated organ (P<0.001).

Conclusion

Appropriate implementation of medical imaging requires boosting employed rationality by the concerned physicians. The current suboptimal results to requesting MRI rationality should mandate supplementary educational programs as to incite the medical corpus more closely implementing the published medical practice guidelines.

American College of Radiology Appropriateness Criteria®: a bibliometric analysis of panel members

OBJECTIVE

To assess the features of panel members involved in the writing of the ACR-AC and identify alignment with research output and topic-specific research publications.

METHODS

A cross-sectional analysis was performed on the research output of panel members of 34 ACR-AC documents published in 2021. For each author, we searched Medline to record total number of papers (P), total number of ACR-AC papers (C) and total number of previously published papers that are relevant to the ACR-AC topic (R).

RESULTS

Three hundred eighty-three different panel members constituted 602 panel positions for creating 34 ACR-AC in 2021 with a median panel size of 17 members. Sixty-eight (17.5%) of experts had been part of ≥10 previously published ACR-AC papers and 154 (40%) were members in ≥ 5 published ACR-AC papers. The median number of previously published papers relevant to the ACR-AC topic was 1 (IQR: 0-5). 44% of the panel members had no previously published paper relevant to the ACR-AC topic. The proportion of ACR-AC papers (C/P) was higher for authors with ≥ 5 ACR-AC papers (0.21) than authors with < 5 ACR-AC papers (0.11, p < 0.0001); however, proportion of relevant papers per topic (R/P) was higher for authors with < 5 ACR-AC papers (0.10) than authors with ≥ 5 ACR-AC papers (0.07).

CONCLUSION

The composition of the ACR Appropriateness Criteria panels reflects many members with little or no previously published literature on the topic of consideration. Similar pool of experts exists on multiple expert panels formulating imaging appropriateness guidelines.

KEY POINTS

There were 68 (17.5%) panel experts on ≥ 10 ACR-AC panels. Nearly 45% of the panel experts had zero median number of relevant papers. Fifteen panels (44%) had > 50% of members having zero relevant papers.

A new medical imaging postprocessing and interpretation concept to investigate the clinical relevance of incidentalomas: can we keep Pandora's box closed?

BACKGROUND

Incidental imaging findings (incidentalomas) are common, but there is currently no effective means to investigate their clinical relevance.

PURPOSE

To introduce a new concept to postprocess a medical imaging examination in a way that incidentalomas are concealed while its diagnostic potential is maintained to answer the referring physician's clinical questions.

MATERIAL AND METHODS

A deep learning algorithm was developed to automatically eliminate liver, gallbladder, pancreas, spleen, adrenal glands, lungs, and bone from unenhanced computed tomography (CT). This deep learning algorithm was applied to a separately held set of unenhanced CT scans of 27 patients who underwent CT to evaluate for urolithiasis, and who had a total of 32 incidentalomas in one of the aforementioned organs.

RESULTS

Median visual scores for organ elimination on modified CT were 100% for the liver, gallbladder, spleen, and right adrenal gland, 90%-99% for the pancreas, lungs, and bones, and 80%-89% for the left adrenal gland. In 26 out of 27 cases (96.3%), the renal calyces and pelves, ureters, and urinary bladder were completely visible on modified CT. In one case, a short (<1 cm) trajectory of the left ureter was not clearly visible due to adjacent atherosclerosis that was mistaken for bone by the algorithm. Of 32 incidentalomas, 28 (87.5%) were completely concealed on modified CT.

CONCLUSION

This preliminary technical report demonstrated the feasibility of a new approach to postprocess and evaluate medical imaging examinations that can be used by future prospective research studies with long-term follow-up to investigate the clinical relevance of incidentalomas.

Measuring appropriateness of diagnostic imaging: a scoping review

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.

Applications of Artificial Intelligence in the Radiology Roundtrip: Process Streamlining, Workflow Optimization, and Beyond

There are many impactful applications of artificial intelligence (AI) in the electronic radiology roundtrip and the patient's journey through the healthcare system that go beyond diagnostic applications. These tools have the potential to improve quality and safety, optimize workflow, increase efficiency, and increase patient satisfaction. In this article, we review the role of AI for process improvement and workflow enhancement which includes applications beginning from the time of order entry, scan acquisition, applications supporting the image interpretation task, and applications supporting tasks after image interpretation such as result communication. These non-diagnostic workflow and process optimization tasks are an important part of the arsenal of potential AI tools that can streamline day to day clinical practice and patient care.

Drivers for low-value imaging: a qualitative study of stakeholders' perspectives in Norway

BACKGROUND

One kind of overutilization of diagnostic imaging is low-value imaging, i.e., imaging that does not lead to altered clinical pathways or improved health outcomes. Despite having well-documented extension and consequences, low-value imaging is still widespread. The objective of this study was to identify the drivers for the use of low-value imaging in the Norwegian healthcare services.

METHODS

We conducted individual, semi-structured interviews among representatives from the health authorities, general practitioners, specialists working in hospitals, radiologists, radiographers, and managers of imaging departments. Data analysis was carried out in line with framework analysis consisting of five steps: Familiarization, indexing, charting, mapping, and interpretation.

RESULTS

The analysis included 27 participants and resulted in two themes. The stakeholders identified drivers in the healthcare system and in the interaction between radiologists, referrers, and patients. The identified drivers were categorized in sub-themes, such as organization, communication, competence, expectations, defensive medicine, roles and responsibilities, and referral quality and time constraints. The drivers interact with each other and may strengthen the effect of other drivers.

CONCLUSIONS

Several drivers for low-value imaging in Norway were identified at all levels of the healthcare system. The drivers work simultaneously and synergistically. To free resources for high-value imaging, drivers should be targeted by appropriate measures at several levels to reduce low-value imaging.

An economic impact of incorrect referrals for MRI and CT scans: A retrospective analysis

Background and Aims

Up to date, no research on the economic efficacy of diagnostic modalities, such as magnetic resonance imaging (MRI) and computerized tomography (CT), has been done in Central Asia. The aim of this study was to analyse the inappropriate appointments of MRI and CT scanning procedures in Kazakhstan.

Methods

We used the imaging diagnostic reports and medical records from 9725 planned outpatient CT and MRI exams performed in two major hospitals in Almaty. The study period was for the period 2014-2019. The independent experts-radiologists evaluated the MRI and CT exams for validity using the ACR® compliance standards and RCR recommendations.

Results

The results showed that the combined costs of MRI and CT scans increased by $17.982 between 2014 ($22.537) and 2019 ($40.519), p = 0.002. The highest rate of MRI examinations was observed in 2019, with a rate of 6.9 per 10,000 people. It was determined that in 2019 the highest rate for men who undertook CT was equal to 12.4 per 10,000 people, while for women it was equivalent to 5.7 per 10,000 patients. The majority of non-corresponding imaging examinations (n = 1304) were referred for MRI and CT scans by general practitioners. We detected the irrational referrals for head and neck radiological examinations in n = 178 (13.7%) cases, and the abdominal cavity checks in n = 249 (19.1%) cases (p = 0.001). The main portion of erroneously unreasonable referrals for examination of the abdominal organs was made by surgeons in n = 43 (3.3%) cases.

Conclusion

The findings indicated an increase in the number of referrals for unnecessary CT and MRI tests over the research period (2014-2019). It had a substantial impact on the rise in healthcare system expenses. The results demonstrate the need for the education of GPs and improving the approaches for diagnostics.

Imaging acute cholecystitis, one test is enough

BACKGROUND

Patients with right upper quadrant pain are often imaged using multiple modalities with no established gold standard. A single imaging study should provide adequate information for diagnosis.

METHODS

A multicenter study of patients with acute cholecystitis was queried for patients who underwent multiple imaging studies on admission. Parameters were compared across studies including wall thickness (WT), common bile duct diameter (CBDD), pericholecystic fluid and signs of inflammation. Cutoff for abnormal values were 3 mm for WT and 6 mm for CBDD. Parameters were compared using chi-square tests and Intra-class correlation coefficients (ICC).

RESULTS

Of 861 patients with acute cholecystitis, 759 had ultrasounds, 353 had CT and 74 had MRIs. There was excellent agreement for wall thickness (ICC = 0.733) and bile duct diameter (ICC = 0.848) between imaging studies. Differences between wall thickness and bile duct diameters were small with nearly all <1 mm. Large differences (>2 mm) were rare (<5%) for WT and CBDD.

CONCLUSIONS

Imaging studies in acute cholecystitis generate equivalent results for typically measured parameters.

Renal lesion characterization: clinical utility of single-phase dual-energy CT compared to MRI and dual-phase single-energy CT

OBJECTIVES

To assess the impact of dual-energy CT (DECT) utilization in practice by measuring the readers' confidence, the need for additional image requests, and diagnostic performance in renal lesion assessment, compared to single-energy CT (SECT) using contrast-enhanced MRI to establish the reference standard.

MATERIALS AND METHODS

Sixty-nine patients (M/F = 47/22) who underwent a dual-phase renal SECT (n = 34) or DECT (n = 35) and had a contrast-enhanced MRI within 180 days were retrospectively collected. Three radiologists assessed images on different sessions (SECT, DECT, and MRI) for (1) likely diagnosis (enhancing/non-enhancing); (2) diagnostic confidence (5-point Likert scale); (3) need for additional imaging test (yes/no); and (4) need for follow-up imaging (yes/no). Diagnostic accuracy was compared using AUC; p value < 0.05 was considered significant.

RESULTS

One hundred fifty-six lesions consisting of 18% enhancing (n = 28/156, mean size: 30.37 mm, range: 9.9-94 mm) and 82% non-enhancing (n = 128/156, mean size: 23.91 mm, range: 5.0-94.2 mm) were included. The confidence level was significantly lower for SECT than their MRI (4.50 vs. 4.80, p value < 0.05) but not significantly different for DECT and the corresponding MRI (4.78 vs. 4.78, p > 0.05). There were significantly more requests for additional imaging in the SECT session than the corresponding MRI (20% vs. 4%), which was not significantly different between DECT and their MRI counterpart session (5.7% vs. 4.9%). Inter-reader agreement was almost perfect for DECT and MRI (kappa: 0.8-1) and substantial in SECT sessions (kappa: 0.6-0.8) with comparable diagnostic accuracy between SECT, DECT, and MRI (p value > 0.05).

CONCLUSION

Single-phase DECT allows confident and reproducible characterization of renal masses with fewer recommendation for additional and follow-up imaging tests than dual-phase SECT and a performance similar to MRI.

KEY POINTS

• DECT utilization leads to similar additional image requests to MRI (5.7% vs. 4.9%, p value > 0.05), whereas single-energy CT utilization leads to significantly higher image requests (20% vs. 4%, p value < 0.05). • DECT and MRI utilization bring highly reproducible results with almost perfect inter-reader agreement (kappa: 0.8-1), better than the inter-reader agreement in SECT utilization (kappa: 0.6-0.8). • Readers' confidence was not significantly altered between DECT and their MRI readout session (p value > 0.05). In contrast, confidence in the diagnosis was significantly lower in the SECT session than their MRI readout (p value < 0.05).

Incidental findings on brain magnetic resonance imaging (MRI) in adults: a review of imaging spectrum, clinical significance, and management

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.

Radiology Technologists' Perspective on Medical Imaging Device Use and Related Technologies: a Cross-sectional Survey with Respect to Hospital Type

This study aimed to evaluate radiology technicians' view on the use of medical imaging devices and related technology. A total of 142 radiology technicians from Turkey were included on a voluntary basis in this cross-sectional questionnaire-based study. The questionnaire form elicited items on sociodemographic and occupational characteristics and personal opinions regarding the use of medical imaging devices and related technology. Majority of technicians agreed or strongly agreed that they prefer the latest technology medical imaging devices (32.4 and 54.2%) and there is an increase in the number of medical imaging devices (36.6 and 35.9%) and medical imaging examinations (32.4 and 43.7%), while the growing societal demands in field of health have a role in the increase in the number of medical imaging devices (34.5 and 32.4%). However, a relatively lower percentage of technicians agreed or strongly agreed that the latest technology medical imaging devices should be purchased no matter how much it costs (31.7 and 33.8%) and the yearly increase in the number of imaging examinations indicates provision of an improved healthcare (21.1 and 23.2%). A higher agreement was reported by private hospital (3.9 ± 1.1, p = 0.035) and university hospital (4.1 ± 1.1, p = 0.009) employees vs. state hospital employees (3.4 ± 1.3) on the growing societal demands in field of health to have a role in the increase in the number of medical imaging devices. Apart from this, no significant difference was noted in opinions of technicians on the use of medical imaging devices and related technology with respect to hospital types. Our findings indicate that radiology technicians report a considerable imaging workload volume and a preference for working with higher number of medical imaging devices particularly those with the latest technology, whereas they also emphasize that the yearly increase in the number of imaging examinations does not indicate provision of an improved healthcare, and the cost should always be a criterion when purchasing the latest technology devices.

Brain cancer after radiation exposure from CT examinations of children and young adults: results from the EPI-CT cohort study

BACKGROUND

The European EPI-CT study aims to quantify cancer risks from CT examinations of children and young adults. Here, we assess the risk of brain cancer.

METHODS

We pooled data from nine European countries for this cohort study. Eligible participants had at least one CT examination before age 22 years documented between 1977 and 2014, had no previous diagnosis of cancer or benign brain tumour, and were alive and cancer-free at least 5 years after the first CT. Participants were identified through the Radiology Information System in 276 hospitals. Participants were linked with national or regional registries of cancer and vital status, and eligible cases were patients with brain cancers according to WHO International Classification of Diseases for Oncology. Gliomas were analysed separately to all brain cancers. Organ doses were reconstructed using historical machine settings and a large sample of CT images. Excess relative risks (ERRs) of brain cancer per 100 mGy of cumulative brain dose were calculated with linear dose-response modelling. The outcome was the first reported diagnosis of brain cancer after an exclusion period of 5 years after the first electronically recorded CT examination.

FINDINGS

We identified 948 174 individuals, of whom 658 752 (69%) were eligible for our study. 368 721 (56%) of 658 752 participants were male and 290 031 (44%) were female. During a median follow-up of 5·6 years (IQR 2·4-10·1), 165 brain cancers occurred, including 121 (73%) gliomas. Mean cumulative brain dose, lagged by 5 years, was 47·4 mGy (SD 60·9) among all individuals and 76·0 mGy (100·1) among people with brain cancer. A significant linear dose-response relationship was observed for all brain cancers (ERR per 100 mGy 1·27 [95% CI 0·51-2·69]) and for gliomas separately (ERR per 100 mGy 1·11 [0·36-2·59]). Results were robust when the start of follow-up was delayed beyond 5 years and when participants with possibly previously unreported cancers were excluded.

INTERPRETATION

The observed significant dose-response relationship between CT-related radiation exposure and brain cancer in this large, multicentre study with individual dose evaluation emphasises careful justification of paediatric CTs and use of doses as low as reasonably possible.

FUNDING

EU FP7; Belgian Cancer Registry; La Ligue contre le Cancer, L'Institut National du Cancer, France; Ministry of Health, Labour and Welfare of Japan; German Federal Ministry of Education and Research; Worldwide Cancer Research; Dutch Cancer Society; Research Council of Norway; Consejo de Seguridad Nuclear, Generalitat de Catalunya, Spain; US National Cancer Institute; UK National Institute for Health Research; Public Health England.

The impact of performance feedback reports on physician ordering behavior in the use of computed tomography pulmonary angiography (CTPA)

PURPOSE

The increased utilization, and potential overutilization, of computed tomography pulmonary angiography (CTPA) is a well-recognized issue within emergency departments (EDs). The objective of this study is to determine the impact of performance feedback reports on CTPA ordering behavior among ED physicians.

METHODS

We conducted a prospective study of the impact of individualized performance feedback reports on the ordering behavior of physicians working at two high-volume community EDs in Ontario, Canada. We generated individualized reports (or "Dashboards") for each ED physician containing detailed feedback and peer comparison for each physician's CTPA ordering. Our baseline pre-intervention period was January 1 to December 31, 2018, and our intervention period was January 1, 2019, to December 31, 2021. We tracked individual and group ordering behavior through the study period. Our primary outcomes are impact of feedback on (1) overall group ordering rate and (2) overall diagnostic yield. Secondary analysis was done to determine the impact of the intervention on those physicians with the highest CTPA utilization rate.

RESULTS

There was no statistically significant difference in the diagnostic yield of the included physicians in either of the years of the intervention period. There was a statically significant increase in the utilization rate for CTPA from 2018 to 2020 and 2021 from 5.9 to 7.9 and 11.4 CTPAs per 1000 ED visits respectively (p < 0.5).

CONCLUSION

Our study found no consistent significant impact of individualized feedback and peer comparison on physician ordering of CTPAs. This points to a potentially greater impact of environmental and institutional factors, as opposed to physician-targeted quality improvement measures, on physician ordering behavior.

Did medical doctors who order abdominal CT scans during on-call hours truly become worse at clinical reasoning? Yes, they did

OBJECTIVE

To investigate temporal changes in clinical reasoning quality of physicians who requested abdominal CT scans at a tertiary care center during on-call hours within a 15-year period.

METHODS

This retrospective study included 531 patients who underwent abdominal CT at a tertiary care center during on-call hours on 36 randomly sampled unique calendar days in each of the years between 2005 and 2019. Clinical reasoning quality was expressed as a percentage (0-100%), taking into account the degree by which the differential diagnoses on the CT request form matched the CT diagnosis. Temporal changes in the quality of clinical reasoning and number of CT scans were assessed using Mann-Kendall tests. Associations between the quality of clinical reasoning with patient age and gender, requesting department, and time of CT scanning were determined with linear regression analyses.

RESULTS

The median annual clinical reasoning score was 0.4% (interquartile range: 0.3 to 0.6%; range: 0.1 to 1.9%). The quality of clinical reasoning significantly decreased between 2005 and 2019 (Mann-Kendall Tau of -0.829, p < 0.001), while the number of abdominal CT scans significantly increased (Mann-Kendall tau of 0.790, p < 0.001). There was a significant association between the quality of clinical reasoning and patient age (β coefficient of 0.210, p = 0.002). The quality of clinical reasoning was not significantly associated with patient gender, requesting department, or time of CT scanning.

CONCLUSION

The clinical reasoning quality of physicians who request abdominal CT scans during on-call hours has deteriorated over time. Clinical reasoning appears to be worse in younger patients.

KEY POINTS

• In patients with suspected acute abdominal pathology who are scheduled to undergo CT scanning, referring physicians generally have difficulties in making an accurate pretest (differential) diagnosis. • Clinical reasoning quality of physicians who request acute abdominal CT scans has deteriorated over the years, while the number of CT scans has shown a significant increase. • Clinical reasoning quality appears to be worse in younger patients in this setting.

The Dense Breast Clinic: Initial Experience of a Patient-Centered Breast Imaging Clinic

OBJECTIVE

Establish a radiologist-run consultation clinic to review breast density and supplemental screening exams (SSEs) directly with patients in response to breast density reporting laws.

METHODS

Breast radiologists opened and staffed a clinic for formal patient consultations regarding breast density and SSEs. An IRB-approved questionnaire assessed patient knowledge of breast density, SSEs, and encounter satisfaction. Comparative statistical analyses were performed on knowledge-based questions.

RESULTS

From February 2019 to February 2021, 294 reimbursable consultations were performed with 215 patients completing pre- and post-consultation questionnaires (survey response rate, 73%). Median patient age was 58 years (range, 34-86 years) and 9% (19/210) had a personal history of breast cancer. An increase in patient knowledge of breast density and SSEs was observed as follows: breast density categories (9% correct pre-consultation (20/215), 86% correct post-consultation (185/215), P < 0.001), dense breast effects on cancer risk (39% correct pre-consultation (83/215), 84% post-consultation (180/215)), mammogram sensitivity (90% correct pre-consultation (193/215), 94% post-consultation (201/215)), and increased cancer detection with SSEs (82% correct pre-consultation (177/215), 95% post-consultation (205/215)) (P < 0.001). Post-consultation, 96% (200/209) were satisfied with the usefulness of information, 89% (186/209) strongly agreed they had sufficient knowledge of SSEs, and 81% (167/205) agreed they would like future opportunities to meet with a breast radiologist.

CONCLUSION

A consultation clinic staffed by breast radiologists focused on breast density and supplemental breast cancer screening can provide personalized patient counseling, engage patients in shared decision making, assist referring clinicians, and support high quality patient-centered care.

Factors affecting hospital services overutilization and reductive strategies in Iran: a qualitative study to explore experts' views

OBJECTIVES

This study aimed to investigate the viewpoints of the main stakeholders of the Iranian healthcare system about the overutilization of hospital services and strategies to eliminate or reduce it in Iran.

METHODS

This is a qualitative study and thematic data analysis using face-to-face semi-structured interviews and Focus Group Discussions (FGDs). We conducted eight interviewers and two FGDs with hospital stakeholders including faculty members, insurance organizations' authorities, experienced hospital administrative staff, hospital managers, and health-care providers.

RESULTS

The factors leading to the overutilization of hospital services were categorized into four main themes including site of service, quality, supplier push, and demand pull. Strategies for eliminating or reducing the overutilization of hospital services are also identified based on the influential factors.

CONCLUSION

Addressing overutilization of hospital services in the health system and adherence to policies for reducing or eliminating overutilization is a way to make preventive strategies to overcome overutilization. Developing a national plan to integrate utilization management into health system programs is a strategy to combat overutilization in various levels of the health system including hospital setting.