Can’t Keep CT Down | The Specialist Shift

“…anonymized data in health records might thus have to be treated as precious resources of potential benefit to human health, in much the same way as public utilities such as drinking water are currently treated.”

Harvard’s Etta D. Pisano MD calling for greater AI training data access as part of her response to Google’s latest AI study.

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The Imaging Wire

Can’t Keep CT Down

New research in the Radiology Journal reveals that although imaging utilization has stabilized or declined for most modalities since 2010, CT utilization is once again on the rise.

The Study – The study looked at adult noninvasive diagnostic imaging exams between 2003 and 2016 (n = ~39m Medicare enrollees, ~9m commercially insured patients), including CT, MRI, nuclear imaging, echocardiography, US, and radiography exams.

Medicare Declines – Medicare enrollees generally had the highest utilization rate for each modality, but also achieved the greatest declines (2008 ~4.4k images per 1k enrollees; 2016: ~3.4k images per 1k enrollees) due in part to code bundling changes. Meanwhile, imaging utilization was far more stable among the commercially-covered 18–44yr (2008: ~1.2k/1k; 2016 ~1k/1k) and 45–64yr groups (2008: ~2.2k/1k; 2016 ~2k/1k).

CT Still Growing – Although utilization has remained flat for most modalities since the early 2010s, CT use began trending upward between 2012 and 2016 among 45–64yr commercially-covered patents (+17 images/1k enrollees annually) and Medicare patients (+11 images/1k enrollees annually). These CT utilization increases were still only at half the annual growth rates seen in the mid-2000s, but the fact that the researchers can’t specify why CT is once again increasing suggests that further adjustments may be necessary.

Questioning Benefits Management – The similar imaging utilization trends seen between the study’s Medicare and commercially insured groups also prompted the researchers to suggest that radiology benefits management might not be working as intended, since it’s specifically intended to control non-Medicare utilization. Instead it appears that radiology benefits management is controlling costs through “alternate mechanisms, such as steerage to lower-cost providers and cost shifting,” rather than reducing imaging volume.

The Specialist Shift

A new study in JACR reveals that “the national radiologist workforce has become increasingly subspecialized” and that’s not necessarily a good thing.

The Study – The Harvey L. Neiman Health Policy Institute-associated team reviewed practicing radiologists from 2012 to 2017 CMS data, using RVUs to identify radiologists who billed over 50% of their work within a specific subspecialty.

The Results – The share of radiologists practicing as subspecialists increased from 37.1% in 2012 to 44.6% in 2017 (so general radiologists fell by 7.6%), with the greatest increases in breast (+3.7%), abdominal (+2.4%), and neuroradiology (+1.8%). The specialist shift was greatest among female radiologists (+12.1%), radiologists who have been in practice for under 10 years (+10.2%), and rads in larger ≥100 member groups (+7.2%).

The Significance – Although this subspecialization shift may lead to more sophisticated imaging care, the study suggested that “a diminishing supply of generalists could affect patient access and potentially separate radiologists across workforce sectors.” The authors believe that this change could lead to changes in everything from certification processes and quality metrics to hiring and managing practices.

The Wire

  • Nursing home providers in 11 states and Washington, D.C., may have to send more residents to the hospital for X-ray scans, rather than relying on on-site scans provided by portable X-ray suppliers. Medicare Administrative Contractor, Novitas Solutions, is considering reducing the transportation rates that it pays to portable X-ray suppliers by so much (e.g. by between 15% in Mississippi to 56% in Colorado) that many suppliers might limit or eliminate their support for nursing homes.
  • Remote ultrasound guidance played a key role in the first official treatment of a spaceflight medical event after an in-space ultrasound exam revealed that an astronaut on the International Space Station might have a blood clot. The astronaut performed a follow up ultrasound that was guided and interpreted in real-time by two independent radiologists back on earth who confirmed the finding, allowing the astronaut to begin treatment. Interestingly (or incidentally), the clot was found as part of a study on the effects of long-duration spaceflight on vascular health.
  • Research by a UPenn interventional radiology team found that magnification spot radiographs acquired before attempting IVC filter removal improve detection of filter fractures (vs. CT alone) and should be performed routinely for optimal treatment planning. The study reviewed 96 patients’ complex IVC filter removals that used magnification spot radiographs and CT scans prior to venous access, finding that first and second reader accuracy increased significantly when magnification spot radiographs were included (98% and 97% vs. 88% and 68%).
  • It didn’t take long for the first reactions to Google’s breast cancer screening AI study to hit the scientific presses. Harvard’s Etta D. Pisano MD response in Nature praised Google’s “impressive” study, but also reminded readers that the “real world is more complicated and potentially more diverse” than the study’s controlled research environment, along with a list of other warnings and critiques. Pisano pointed out that most of the scans in the study were obtained using a single OEM’s mammography systems (unlikely in the real world), noted that Google didn’t differentiate DBT and 2D mammography performance, and called for more transparency on study demographics. She also reminded readers of CAD’s early challenges, called for more data access, and warned that even effective AI software may lead to more callbacks and other unintended consequences.
  • The NEJM’s recent study revealing that hospital consolidation doesn’t improve care (and may make it worse), was quickly followed by statements from hospital and insurer lobbying groups. Fierce Healthcare detailed how America’s Health Insurance Plans (AHIP) promoted the study as evidence that consolidation is bad for patients (not just bad for payers’ negotiating power), while the American Hospital Association (AHA) quickly called the study flawed because it relied on patient feedback.
  • A pair of GE Healthcare-commissioned surveys covered on auntminnie.com highlighted handheld ultrasound’s momentum among primary care patients, but lower awareness/agreement among general practitioners. The patient survey (n = 1,000 online surveys) revealed that ~40% of patients want GPs to have access to handheld ultrasound systems, while the general practitioner survey (n = 500 phone surveys) revealed that only 37% are using the devices or are interested in doing so. Among the GPs who do use handheld ultrasounds, 60% said it positively impacted their practices and 85% believe it will positively impact the overall healthcare industry.
  • MEDNAX returned to acquisition mode, adding Boca Radiology Group (36 radiologists, 6 imaging centers, teleradiology practice) and integrating it with its Radiology Associates of South Florida practice. MEDNAX is no stranger to acquisitions (10 so far, 5 in 2017-2018, 825 radiologists on staff), but this move may come as a surprise given that MEDNAX recently revealed plans to pause radiology practice M&A. However, this acquisition probably has more to do with the July 2019 merger of Baptist Health South Florida (a major MEDNAX account) with Boca Raton Regional Hospital (a Boca Radiology’s main account), rather than a change in MEDNAX’s strategy. In fact, MEDNAX’s last radiology practice acquisition was also directly tied to Baptist Health’s expansion.
  • A new NYU study found that stimulated Raman histology (SRH – an optical imaging technique that captures tumor infiltration by collecting scattered laser light), combined with a CNN algorithm supports real-time intraoperative diagnosis of brain tumors with 94.6% accuracy (vs. 93.9% w/ pathologist-based interpretation of standard histologic image). The researchers suggest that the combination of SRH and AI can improve speed and accuracy in the OR, while reducing the risk of misdiagnosis.
  • A new story in the Economic Times detailed India’s struggles adopting electronic health records and how that challenge stands in the way on the country’s plans to adopt healthcare AI. Although many of the country’s public hospitals have adopted some form of EHR, the vast majority of Indian patients are treated at private hospitals (75% of outpatients, 60% of inpatients), which limits how AI and big data can be adopted.
  • A new study in Academic Radiology revealed that an AI Algorithm can be used to rule out obstructive coronary artery disease (CAD) using patients’ coronary artery calcium scoring (CACS) test, potentially reducing CTA scan volumes. The study used data from 435 patients with low to moderate probability of CAD who underwent both CACS and CTA exams, applying the data to a gradient boosting machine (GBM) model that achieved 100% sensitivity and 38% specificity within a 126-patient control group (so 73 of these patients could have avoided CTA scans).
  • New research from a Thomas Jefferson University team found that non-radiologist physicians (NRPs) experienced massive decreases in Medicare payments for in-office MRI and CT since peaking in 2006 and 2008. Medicare MRI payments to NRPs (primarily: orthopedists, neurologists, PCPs) fell significantly from 2006 to 2007 ($247.7 million to $189.5 million) as a result of the Deficit Reduction Act and eventually fell to $101.6 million by 2016. Meanwhile, Medicare CT payments to NRPs (primarily: cardiologists, PCPs, internal medicine specialists, urologists, and oncologists) fell from $284.1 million in 2008 to $94.7 million in 2016 (−67% from peak).
  • New research from a Hofstra team found that clinical decision support (CDS) use led to a 38% higher diagnostic yield for CT pulmonary angiography (CTPA) for the evaluation of pulmonary embolism. The retrospective study reviewed 7,367 CTPAs (2,568 using CDS) performed at two EDs that routed clinicians to an optional CDS tool, finding that the CDS-use group had a higher CTPA yield than the CDS-dismissal group (11.99% vs. 8.70%), while physicians, residents, and physician assistant who used the CDS tool had much higher yields than peers who dismissed CDS (+56.5%, +38.7%, +16.7%).

The Resource Wire

  • The GE Healthcare Venue Go combines a uniquely adaptable design with AI-enabled tools to support fast triage and help you make confident diagnoses and informed decisions.
  • In this Nuance video, Penn Medicine professor, Warren B. Gefter, shared how PowerScribe One leverages AI, structured data, and automation to drive improved patient care.
  • By partnering with Medmo, imaging centers can keep their schedules full, their equipment busy, and increase revenue. Here’s where to get started.
  • The first patients were recently treated in a clinical trial using focused ultrasound to enhance the effectiveness of chemotherapy drugs in those with Her2+ breast cancer that has metastasized to the brain.

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