“The solution to the rising volume of chest radiographs is not training more radiologists.”

Saurabh Jha, MBBS, MRCS, MS in support of using physician extenders for some X-ray reporting.

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The Imaging Wire

Prioritized Imaging

Amid rising imaging volumes and growing radiologist burnout, a new JACR paper proposed a framework that would adjust imaging and interpretation levels depending on patients’ clinical scenarios. This is part of JACR’s new “controversial issues” edition, so if this proposal makes you uncomfortable, that’s the point:

• The Proposal – Rather than applying the same imaging / interpretation efforts to all patient scenarios, the authors propose right-sizing imaging protocols, interpretation focus, and reporting details depending on each order’s clinical intent.

• New Imaging Categories – This new context-based approach would require a more specific list of imaging categories, adding emergency, surveillance, precautionary, and exclusionary imaging to the current list (diagnostic, screening, surgical planning, research). In theory, referring providers would specify their patients’ imaging category with each imaging order.

• Reporting Prioritization – Although diagnostic imaging would still justify full imaging protocols and complete interpretation / reporting, other imaging categories would be right-sized. For example, emergency patients would receive full-protocol imaging but their radiologist reports would specifically focus on the clinical situation that brought the patient into the ED (reducing radiologist labor). Meanwhile, other categories (e.g. exclusionary, precautionary) would see reduced imaging protocols and more-targeted reporting (streamlining all imaging workflows).

• Pros & Cons – The authors noted that this framework could risk its share of unintended consequences (missed incidentals, lower reimbursements, legal risks), but it could also bring a range of benefits (improved workflow, more clinical collaboration, more appropriate imaging).

There’s no doubt that rising imaging volumes is creating problems that need to be addressed, and even if these right-sizing efforts might be “controversial,” the authors bring up some interesting points. And they did it without including AI in their proposal.

The Case for Physician Extenders

Dr. Saurabh Jha just shared a solid case for using physician extenders to support X-ray reporting, which can be a tough argument given widespread concerns that non-physicians pose as much of a threat to radiologists’ role as AI.

In fact, this paper comes with a 2+ month-old backstory. In mid-October JACR published a UPenn study highlighting radiology extenders’ ability to speed up CXR workflows, which it quickly pulled after considerable backlash, and then rushed to publish a paper that was supposed to be in response to Dr. Jha’s physician extenders paper. Yes, the response came out 2.5 months before the paper it was responding to. No judgement about JACR’s decisions (we’re all doing our best), but that week in October says a lot about how touchy this subject is.

Here’s how Dr. Saurabh Jha made his case:

• Supply & Demand – Although imaging is now ubiquitous across healthcare, radiologists are still scarce. That combination has made radiology a high-demand and well-compensated profession, but that only works for hospitals if reimbursements remain high (they are falling) and if radiologists can keep up with demand (that’s getting harder).

• Know Your History – Historically, one of the ways healthcare organizations lowered labor costs and allowed physicians to focus on more-complex tasks is to train physician extenders to perform some of those tasks. Radiologists were even OK with this in some instances, like when they started using technologists to perform ultrasound to give the rads more time to read higher-paid CT and US scans.

• What’s Wrong With Lower Costs – The controversy over using lower-cost clinical team members to perform work that was once physician territory has existed for years, but Jha argues that “nothing is wrong in saving costs so long as the cost-saving measures do not significantly reduce quality.”

• Not All Reads Are Equal – Dr. Jha suggests radiologists spend too much time on low-complexity cases and too little on high-complexity cases. Using radiologist-trained physician extenders could help rads apply their skill and experience where it’s needed most.

• Envision the Future – With less time devoted to trainable reporting, radiologists would be able to spend more time on complex reads, do intensive care unit film rounds, advise clinical teams, and train physician extenders to read portable chest X-rays, “which should eventually be relinquished to them.”

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The Wire

• Sunsetting Haven: Three years after setting out to “transform health care,” Amazon, Berkshire Hathaway, and JPMorgan announced the end of their Haven Health venture. The industry heavyweights highlighted their progress “exploring solutions” to the U.S. healthcare system’s challenges, but sources suggest that the companies’ unique situations (workforce, geography, etc.) proved to be too diverse for a unified entity to address effectively. Fittingly, the companies will split Haven up and pursue their healthcare ambitions separately.

• Employee Whole-Body Screening: Here’s a way to manage your employees’ healthcare that Haven might not have considered. After Japanese imaging component firm, Hamamatsu Photonics, lost several “highly skilled” employees to cancer, they launched a whole-body FDG-PET/CT screening program. They found that the program successfully detected early stage cancers, reduced cancer treatment costs, and reduced cancer-related mortality, suggesting that companies “with highly skilled employees with very little attrition” could be motivated to adopt these programs.

• United & Envision Break Up: UnitedHealthcare cancelled its longstanding partnership with Envision Healthcare, meaning that Envision’s 25k physicians clinicians (900 radiologists) are now out-of-network for United-covered patients. The companies decided to stick together in 2018 after fierce negotiations ended once Envision lowered its physician pay rates. However, Envision claims that United’s latest reduction demands were unreasonable (United might have a different view).

• Buffalo VA’s $1.95M Delay: A Western NY man received a $1.95M judgement (largely for pain & suffering) after a Buffalo VA Medical Center radiologist missed signs of tonsil cancer, delaying his treatment by 20 months. Although the man’s initial September 2013 CT was found to not justify a biopsy, his April 2015 CT and biopsy revealed squamous cell carcinoma of the tonsil. He then underwent 40 radiation treatments and seven cycles chemotherapy, but eventually required a radical tonsillectomy and a modified neck dissection after his cancer recurred in 2017.

• Joining Emergency Radiology & Medicine: Another JACR “controversial issues” paper called for the integration of emergency radiology into emergency medicine, noting the combo’s efficiency and patient care benefits and suggesting that it would essentially eliminate the liability that comes from communicating findings across departments.

• Optum Acquires Change: Optum announced its $13B acquisition of Change Healthcare (a 40% premium), making Change a core part of its OptumInsight software and analytics business. The combined companies bring a diverse set of technologies and services, with Change’s imaging business likely living within OptumInsight’s clinical workflow and analytics business. Although Optum’s acquisitions aren’t usually imaging-related (except its outpatient imaging acquisitions), Optum / UnitedHealth has become one of the most disruptive forces in healthcare as it leads healthcare’s vertical integration shift.

• MR’s High AIS Costs: A new JACR-published study confirmed that CT is far more cost-effective than MRI for identifying patients who require acute ischemic stroke treatment. The researchers used the AHA’s AIS decision simulation model to review the various AIS neuroimaging pathways, finding that comprehensive CT and comprehensive MR have the highest lifetime quality-adjusted life-years (4.81 and 4.82 QALYs). However, comprehensive MR’s significantly higher costs and very similar quality-adjusted life-years gives it a massive $233k-higher cost per QALY than comprehensive CT.

• Hologic’s Continuum Moves: Hologic made two more additions to its breast health portfolio, acquiring breast and metastatic cancer diagnostic tests company Biotheranostics ($230m) and German biopsy site marker and localization company SOMATEX Medical Technologies ($64m). Hologic’s strategy to support the entire breast health continuum has arguably made it imaging tech’s most active acquirer over the last few years, previously buying SuperSonic Imagine ($85m, ultrasound), Faxitron ($125m, digital specimen radiography) and Focal ($85m, 3D surgery markers).

• A Call for Screening Subspecialists: A new JACR paper called for the creation of a “screening radiology” subspecialty, noting that radiologists play a central role in screening but have little influence on national screening policies (mainly influenced by primary care and epidemiologists). The proposed fellowship track would follow a specific area of interest (e.g. colorectal cancer screening with CT colonography), include a range of screening-focused training (health sciences, epidemiology, radiation biology, AI, quality assurance), along with clinical experience and mentorship.

• Nanox’s Telerad Service: Nanox and USARAD provided more details on their radiology diagnostics service that will combine USARAD’s panel of >300 teleradiologists with AI decision support to interpret images from the Nanox platform (once Nanox gains FDA clearance). The platform will launch with 20 FDA-approved algorithms (Zebra, AIDOC, Qure.ai, maybe others) with an initial focus on population health screening (coronary arterial disease, stroke, osteoporosis), triage for urgent conditions (pneumothorax, acute fractures, pneumonia), and peer review and quality assurance (lung nodules, tumors, and incidental vertebral compression fractures).

• QT US Beats Mammography: A new study performed by QT Ultrasound showed that quantitative transmission ultrasound (QT US) could achieve improved sensitivity, specificity, and recall rates versus 2D digital mammography. Using retrospective data from 108 patients who received both FFDM and QT US scans (42 normal, 39 benign, and 27 cancerous), a team of 22 readers detected 4% more lesions with QT US, improved non-cancer recalls by 16%, but also posted a 2% lower mean cancer recall rate. Although this is a solid research milestone for QT US, more studies with larger samples, comparisons versus DBT, and a research team not affiliated with QT Ultrasound are still needed.

• Olympus & Hitachi Extend EUS Alliance: Olympus and Hitachi extended their Endoscopic Ultrasound Systems joint development alliance for another five years, ensuring that their long standing partnership will remain intact after Fujifilm officially acquires Hitachi’s imaging business.
  

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The Resource Wire

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