Author: Brian Casey

CT Changes Headache Workup

Posted on by Brian Casey

Recent studies have raised concerns about whether CT is overused in the emergency setting for patients with symptoms like headache, but a new study in JAMA Network Open suggests that higher CT utilization could be contributing to a decline in more invasive procedures like lumbar puncture. 

Earlier this month, we covered a study documenting the rapid rise of emergency head CT for patients presenting with acute-onset headache – which could be an indication of subarachnoid hemorrhage or other serious issues. 

  • Researchers theorized that higher CTA utilization could be a sign of overuse because the rate of positive findings over time fell 38%.

But the new study suggests that the growth in cerebral CTA use could have beneficial effects, by reducing the use of more invasive procedures and by detecting unruptured intracranial aneurysm. 

  • Some 5% of acute-onset headaches in emergency patients are caused by subarachnoid hemorrhage; these cases have a 50% risk of death or serious disability at one year, making accurate detection and workup a serious issue.

Researchers from Kaiser Permanente in Northern California analyzed 198k encounters for patients with headache at 21 community EDs from 2015 to 2021. 

  • They compared multiple workup protocols, ranging from CT only to others in which CT was used first, with nondiagnostic cases sent to either lumbar puncture or cerebral CTA. 

Dramatic changes occurred in headache workup over the study period, including … 

  • Overall use of CT grew at an average annual percent change of 5.4%
  • Cerebral CTA use grew 19% annually
  • Lumbar puncture use fell 11% annually
  • Detection of unruptured intracranial aneurysms grew 33%
  • The ratio of unruptured aneurysms to subarachnoid hemorrhage grew

The authors noted that the findings show clinicians are shifting away from a headache workup protocol that includes lumbar puncture to one that relies more on cerebral CTA.

  • The researchers were equivocal on the increase in detection of unruptured aneurysms; on the one hand, the absolute risk of rupture is low, but on the other, the consequences of rupture are severe.  

The Takeaway

The new study offers a more nuanced – and perhaps more positive – view of growing cerebral CTA use in the ED. In the end, it’s possible that two conflicting statements can be true: CT indeed may be overused in the emergency department, but its growing use is also having a beneficial impact on patient care.

Breast Screening Goes Green

Posted on by Brian Casey

Earth Day will be celebrated on April 22, and the event is a good opportunity to step back and take a look at medical imaging’s (not insignificant) contribution to climate change. Fortunately, a new paper in Health Policy details how one imaging service – breast screening – can be made more environmentally friendly. 

Previous studies have documented that medical imaging is a substantial contributor to greenhouse gas emissions, given the massive energy consumption required to keep all that big iron humming. 

  • Researchers have recommended a variety of solutions to reduce radiology’s environmental footprint, from powering equipment down overnight to switching to alternative energy sources to power medical facilities. 

The new study gets even more specific, analyzing the greenhouse emissions inherent in cancer screening – in particular patient travel – and offering ways to make it more planet-friendly. 

  • Researchers reviewed cancer screening programs in the Italian region of Tuscany, quantifying the CO2 emissions for different screening services. 

Greenhouse gas emissions could be cut dramatically by switching from a provider-centric model that requires patients to travel to centralized screening facilities to one in which mobile vans were sent into the field. Using model calculations for mammography screening, they found that in one district alone …

  • Breast screening was the most polluting cancer screening service, mostly because it had the highest number of invitees (3.4k women) traveling for screening
  • Institution-based breast screening generated CO2 emissions of 35,870 kgCO2-eq/km annually
  • Mobile breast screening had emissions of 805 kgCO2-eq/km – just 2.2% of emissions from site-based screening

The study is unique in that it views sustainability and environmental pollution as a healthcare issue that’s fully within the purview of providers to address. 

The Takeaway

The new study outlines a holistic approach to healthcare services that – right now – many US providers might believe is outside the scope of their operations. But as Earth Day approaches, it’s worth at least considering how in years to come healthcare could be delivered within a broader context of social and environmental stewardship.

Radiologist Pay Grows 3%

Posted on by Brian Casey

Annual salaries for US radiologists grew 3.1% in 2023 in the most recent physician salary report by Medscape. Although radiologist salaries are nearing the half-million-dollar mark, the increase actually represents a slowdown compared to 11% growth last year. 

The Medscape report shows that US radiologists had an average annual salary of $498k in 2023, compared to $483k in 2023 and $437k in 2022.

  • Radiologists ranked sixth on a list of 29 medical specialties, with orthopedic physicians topping the charts at $558k and diabetes and endocrinology doctors at the bottom at $256k. 

The report surveyed 7k practicing US physicians from October 2023 to January 2024, finding … 

  • 61% of those surveyed thought physicians overall are underpaid
  • 49% believe that they themselves are fairly paid
  • 83% said that pay was either no factor or only a minor factor in the specialty they chose, with only 14% saying it was the leading factor
  • Male specialists earned 31% more than female specialists, indicating a widening gender gap compared to 27% last year
  • 57% of radiologists were happy with their compensation, sixth among 29 medical specialties

Physician comments submitted to Medscape focused on the significant stress being experienced by many physicians, a phenomenon that’s been linked to burnout in other surveys. 

The Takeaway

Underlying this year’s Medscape data is an inconvenient truth for radiologists: their 3.1% pay gains for the year were not enough to keep pace with the US inflation rate of 3.4%. In that respect, radiologists find themselves in the same situation as most Americans.

RTs and Radiation Dose

Posted on by Brian Casey

There’s good news and bad news from a new study in Journal of Vascular and Interventional Radiology that tracks 40 years of occupational radiation dose to radiologic technologists who assist with fluoroscopically guided interventional procedures. The good news is that radiation dose is low and trending lower over time; the bad news is that dose to RTs can vary based on work setting. 

As we discussed last month, interventional radiology has delivered major benefits in patient care, replacing invasive surgery for many clinical applications. 

  • But the downside of interventional procedures is that they are performed for extended periods under fluoroscopy guidance, and more complex procedures are requiring longer times with the fluoro beam on – potentially leading to more radiation exposure. 

Researchers from the NIH wanted to investigate how changes in interventional use over the past 40 years affected occupational radiation dose exposure to RTs, while also looking at the impact of radiation exposure control methods. 

  • They reviewed records from 1980 to 2020, starting with RTs participating in the US Radiologic Technologists (USRT) research study who they then linked to data submitted to radiation dosimeter badge maker Landauer. 

In all, 19.7k RTs who reported assisting with fluoroscopically guided interventional procedures over the study period were included, with researchers finding … 

  • Median annual radiation dose of 0.65 mSv, well below the occupational limit of 20 mSv
  • Median doses were highest in the 1980s and decreased over time, reflecting greater awareness of patient radiation dose and better radiation protection gear
  • A second peak in radiation dose happened from 1999-2011, most likely due to more sensitive dosimeters
  • RTs who worked closer to patients (<3 feet) had higher median annual dose, at 1.20 mSv
  • RTs who reported assisting with ≥ 20 procedures per month had higher dose, at 0.75 mSv

The researchers concluded that their findings show that radiation dose control measures are working, and better radiation dosimetry technology offers a far more accurate picture of how much dose RTs are actually exposed to. 

The Takeaway

The study’s findings should give technologists who assist with interventional procedures peace of mind that their radiation dose exposure is well within established limits. But as always with radiation exposure, vigilance is warranted. 

MRI Makes Prostate Screening More Precise

Posted on by Brian Casey

Prostate cancer screening isn’t a guideline-directed screening test yet, but this could change with the use of MRI and other tools. A series of papers published in several JAMA journals late last week indicates the progress that’s being made. 

As we’ve discussed in previous issues, prostate screening with PSA tests hasn’t met the threshold for clinical benefit achieved by other population-based screening exams.

  • PSA-based screening has been characterized by lower mortality benefits and relatively high rates of overdiagnosis and complications from follow-up procedures. 

But some researchers believe that PSA screening could be made more effective by using additional diagnostic tools like imaging and blood tests to focus on potentially high-risk disease for biopsy while active surveillance is used for less threatening prostate lesions. 

In the ProScreen trial in Finland, researchers tested the combination of PSA, a kallikrein four-panel blood test, and MRI in selecting patients for biopsy. 

  • Patients were sent to MRI if they had PSA scores of 3.0 ng/mL or higher and kallikrein scores of 7.5% or higher; those with abnormal MRI scans got targeted biopsy. 

The researchers tested the ProScreen protocol in a study of 61.2k men, with 15.3k invited to screening and 7.7k getting screened. Over a preliminary three-year follow-up period, researchers found …

  • 9.7% of men met the PSA threshold for a suspicious lesion; this fell to 6.8% after the kallikrein test and 2.7% after MRI, illustrating the protocol’s ability to reduce biopsies
  • Biopsy yield for high-grade cancer was 1.7%, which an editorial called a “remarkably high yield”
  • Overdetection of low-grade disease was 0.4%, compared to 3.2% in a comparable previous study

In a second study, this one in JAMA Oncology, researchers performed a meta-analysis of 80.1k men from 12 studies in which MRI was used to direct patients to prostate biopsy after PSA testing, finding that MRI-directed protocols had …

  • Higher odds of detecting clinically significant prostate cancer (OR=4.15) compared to PSA screening alone
  • Lower odds ratio for biopsy (OR=0.28)
  • Lower odds ratio for detecting clinically insignificant cancer (OR=0.34)

Finally, a secondary analysis in JAMA of a large UK trial illustrates the challenges of prostate screening without MRI guidance. Researchers reviewed 15-year outcomes of the Cluster Randomized Trial of PSA Testing for Prostate Cancer (CAP), a study of 415k men,196k of whom were screened from 2002 to 2009 without the use of MRI, finding … 

  • PSA screening increased detection of low-grade cancer (2.2% vs. 1.6%) but not intermediate or high-grade disease
  • Screening reduced prostate cancer mortality by a small amount (0.69% vs. 0.78%)

The Takeaway

Taken together, new studies offer a roadmap toward making MRI an integral part of prostate screening, such that perhaps in years to come it can join other cancer tests as a population-based screening tool.

Teleradiology Malpractice Risk

Posted on by Brian Casey

A new study in Radiology comes to an explosive conclusion: medical malpractice cases involving teleradiology interpretation of medical images more frequently involved patient death and had higher payment amounts. 

Perhaps no technology has wrought greater changes on the field of medical imaging than teleradiology. 

  • By leveraging radiology’s conversion to digital imaging and the rapid expansion of Internet bandwidth, teleradiology makes it possible for medical images to be interpreted independent of the radiologist’s location, with studies sometimes literally sent around the world. 

But teleradiology has had its share of unintended consequences, such as the emergence of nighthawk and specialty teleradiology firms that have seized hospital contracts from traditional radiology groups. 

But this week’s study in Radiology adds a new wrinkle, suggesting that teleradiology could actually have an additional malpractice risk. Researchers analyzed 3,609 malpractice claims, of which 135 involved teleradiology, finding that teleradiology cases…

  • Saw patient death occur more often (36% vs. 20%)
  • More frequently saw communication problems among providers (26% vs. 13%)
  • More often closed with indemnity payments (59% vs. 41%)
  • Had higher median indemnity payments ($339k vs. $214k) 

Why might problems be more frequent in teleradiology? The authors offered several reasons, including …

  • Teleradiologists may not have access to EMR and other patient data
  • Teleradiology interpretations are often provided at night and on weekends/holidays
  • Claims involving neurology and the emergency setting were more common, illustrating the challenges in these areas

Potential solutions could involve making sure that teleradiologists have access to EMR data, and by performing overreads of interpretations delivered on nights and weekends. 

The Takeaway
The findings have disturbing implications, not only for dedicated teleradiology providers but also for traditional radiology practices that use teleradiology as part of their service offerings. And as noted in an accompanying editorial, they could provide ammunition to teleradiology’s opponents, who continue to rail against the technology that has done so much to change radiology. 

Is Head CT Overused in the ED?

Posted on by Brian Casey

A new study suggests that head CT could be overused in the emergency department for patients presenting with conditions like headache and dizziness. Writing in a paper in Internal and Emergency Medicine, researchers looking at CT angiography use at a large medical center found a big increase in CTA utilization – even as the rate of positive findings dropped. 

CTA is a powerful tool that can quickly and efficiently give clinicians information to guide treatment of acute neurovascular conditions like aneurysm and stroke. 

  • As such, many emergency departments have been installing their own CT scanners to enable them to scan emergent patients without transporting them to the radiology department. 

But with great power comes great responsibility, and there is always the temptation to scan first and ask questions later. 

  • To better understand changing CTA use in the emergency setting, researchers from the Harvey L. Neiman Health Policy Institute analyzed CTA exams at a level 1 trauma center that sees about 110k emergency patients a year.

Researchers analyzed 25k ED visits from 2017 to 2021 and correlated them to head and neck CTA exams for headache and/or dizziness, finding …

  • The rate of CTA exams rose 64%, from 7.9% of ED visits to 13%
  • Symptomatic patients were 15% more likely to have a CTA in 2021 versus 2017
  • The rate of positive CTA findings fell 38%, from 17% to 10%
  • Patients with private insurance were more likely to have CTA (OR=1.44)
  • Black patients were less likely to be scanned (OR=0.69)

The researchers said the findings indicate the need for better clinical decision support tools, which they believe can help emergency physicians provide an accurate diagnosis without exposing patients to unnecessary radiation and incurring additional cost. 

The Takeaway

This study further confirms widespread accounts that head and neck CTA is overused and on the rise. As the US government backs off on its attempt to force clinical decision support on referring physicians, it may be up to health systems and providers themselves to ensure more appropriate utilization – in a way that doesn’t rely on heavy-handed tools like prior authorization. 

Imaging and US Healthcare Costs

Posted on by Brian Casey

In the debate over rising US healthcare costs, medical imaging is often painted as a bad guy. But a new study in Health Affairs Scholar claims that since 2010, spending on imaging services has not grown at the same rate as other medical services. 

It’s no secret that the US spends far more on healthcare per capita than other developed countries, spending 16.6% of GDP as of 2022 according to OECD data. 

  • For point of reference, Germany spends 12.7%, France spends 12.1%, and most other developed countries spend under 12% of GDP. 

Reasons why the US is such an outlier have been blamed on a variety of factors, such as pharmaceutical prices, physician salaries, administrative costs, and the fragmented nature of the US healthcare system. 

  • But medical imaging is often singled out for criticism, perhaps due to the high cost of scanners and the explosion of imaging volume since the advent of cross-sectional technologies like CT and MRI in the 1970s and 1980s. 

This has led the US government to exert major pressure on imaging reimbursement in the Medicare and Medicaid systems, starting with the Deficit Reduction Act of 2005 and continuing to the present day, while private insurers have employed tools like prior authorization. 

The new study indicates that these efforts may have accomplished their mission. Researchers from the ACR’s Harvey L. Neiman Health Policy Institute analyzed imaging’s contribution to overall growth of medical costs from 2010 to 2021 in employer-sponsored insurance plans, finding …

  • Spending on medical imaging grew 36% 
  • Spending for all other healthcare services grew 64% 
  • Two-thirds of the growth in imaging spending was due to general price inflation
  • Only one-fifth was due to increased utilization
  • Imaging’s share of total US healthcare spending fell from 10.5% to 8.9%

The findings indicate that efforts by the US government and private payors to drive down imaging utilization are working … but at the price of overworked radiology staff.

  • Imaging cuts could also be leading to patient access issues, as the study found that the percentage of patients undergoing imaging fell from 46% in 2010 to 40% in 2021. 

The Takeaway

The new study reinforces what imaging advocates have been saying for years – that medical imaging isn’t a major cause for runaway healthcare spending in the US. The question is whether anyone outside of radiology is listening.

AI Speeds Up MRI Scans

Posted on by Brian Casey

In our last issue, we reported on a new study underscoring the positive return on investment when deploying radiology AI at the hospital level. This week, we’re bringing you additional research that confirms AI’s economic value, this time when used to speed up MRI data reconstruction. 

While AI for medical image analysis has garnered the lion’s share of attention, AI algorithms are also being developed for behind-the-scenes applications like facilitating staff workflow or reconstructing image data. 

  • For example, software developers have created solutions that enable scans to be acquired faster and with less input data (such as radiation dose) and then upscaled to resemble full-resolution images. 

In the new study in European Journal of Radiology, researchers from Finland focused on whether accelerated data reconstruction could help their hospital avoid the need to buy a new MRI scanner. 

  • Six MRI scanners currently serve their hospital, but the radiology department will be losing access to one of them by the end of the year, leaving them with five. 

They calculated that a 20% increase in capacity per remaining scanner could help them achieve the same MRI throughput at a lower cost; to test that hypothesis they evaluated Siemens Healthineers’ Deep Resolve Boost algorithm. 

  • Deep Resolve Boost uses raw-data-to-image deep learning reconstruction to denoise images and enable rapid acceleration of scan times; a total knee MRI exam can be performed in just two minutes. 

Deep Resolve Boost was applied to 3T MRI scans of 78 patients acquired in fall of 2023, with the researchers finding that deep learning reconstruction… 

  • Reduced annual exam costs by 399k euros compared to acquiring a new scanner
  • Enabled an overall increase in scanner capacity of 20-32%
  • Had an acquisition cost 10% of the price of a new MRI scanner, leading to a cost reduction of 19 euros per scan
  • Was a lower-cost option than operating five scanners and adding a Saturday shift

The Takeaway

As with last week’s study, the new research demonstrates that AI’s real value comes from helping radiologists work more efficiently and do more with less, rather than from direct reimbursement for AI use. It’s the same argument that was made to promote the adoption of PACS some 30 years ago – and we all know how that turned out.

Study Shows AI’s Economic Value

Posted on by Brian Casey

One of the biggest criticisms of AI for radiology is that it hasn’t demonstrated its return on investment. Well, a new study in JACR tackles that argument head on, demonstrating AI’s ability to both improve radiologist efficiency and also drive new revenues for imaging facilities. 

AI adoption into radiology workflow on a broad scale will require significant investment, both in financial cost and IT resources. 

  • So far, there have been few studies showing that imaging facilities will get a payback for these investments, especially as Medicare and private insurance reimbursement for AI under CPT codes is limited to fewer than 20 algorithms. 

The new paper analyzes the use of an ROI calculator developed for Bayer’s Calantic platform, a centralized architecture for radiology AI integration and deployment. 

  • The calculator provides an estimate of AI’s value to an enterprise – such as by generating downstream procedures – by comparing workflow without AI to a scenario in which AI is integrated into operations.

The study included inputs for 14 AI algorithms covering thoracic and neurology applications on the Calantic platform, with researchers finding that over five years … 

  • The use of AI generated $3.6M in revenue versus $1.8M in costs, representing payback of $4.51 for every $1 invested
  • Use of the platform generated 1.5k additional diagnoses, resulting in more follow-up scans, hospitalizations, and downstream procedures
  • AI’s ROI jumped to 791% when radiologist time savings were considered
  • These time savings included a reduction of 15 eight-hour working days of waiting time, 78 days in triage time, 10 days in reading time, and 41 days in reporting time  

Although AI led to additional hospitalizations, it’s possible that length of stay was shorter: for example, reprioritization of stroke cases resulted in 264 fewer hospital days for patients with intracerebral hemorrhage. 

  • Executives with Bayer told The Imaging Wire that while the calculator is not publicly available, the company does use it in consultations with health systems about new AI deployments. 

The Takeaway

This study suggests that examining AI through the lens of direct reimbursement for AI-aided imaging services might not be the right way to assess the technology’s real economic value. Although it won’t settle the debate over AI’s economic benefits, the research is a step in the right direction.

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