Unnecessary Imaging

“The specialty of diagnostic radiology may thus need to change focus: instead of training radiologists primarily to read images, they may need to be trained as gatekeepers who mostly regulate or are consulted about what tests should be ordered and, even more so, which ones should not be ordered.”

A JAMA editorial on ways to reduce unnecessary imaging, suggesting that given improvements in imaging technology, radiologists’ focus may shift to serving as an imaging decision consultant and gatekeeper. The editorial highlighted plenty of other approaches to curbing imaging overuse, too.

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The Imaging Wire

Butterfly Network Hits CES
Butterfly Network hit CES 2019 in Las Vegas last week, garnering about as much press as a medical device company can get at the massive consumer electronics show (see: WIRED and CNET coverage), while highlighting a pair of forthcoming technologies intended to make the Butterfly iQ more user friendly. About half of Butterfly’s CES booth focused on its tele-guidance system, with live demos showing how the system can help users (including patients) capture the best images for analysis by combining the Butterfly iQ ultrasound with traditional telemedicine support and augmented reality technology. Butterfly’s artificial intelligence demonstration on the other side of its booth embraced a similar user-friendly theme, showing how forthcoming artificial intelligence tech can help Butterfly iQ users know when they’ve captured a “good” image, then providing an automated ejection fraction interpretation that the user can apply or adjust, with the ultimate goal of allowing patients to scan themselves. Given the Butterfly iQ’s consumer electronics-inspired product design and the company’s goal to expand the device far beyond the hands of traditional ultrasound users, the fact that Butterfly Network was among the two radiology players at CES made sense (Korean AI player JLK Inspection was there, too), and helped to build its message that its medical device is also a personal device.

Unnecessary Imaging
A new JAMA Viewpoint from a team of Mayo and Stanford researchers called on the US healthcare industry to address its increasingly evident imaging overuse problem. The team highlighted the US’ spot at the top of the global imaging usage rankings (CT = 245 per 1000 people, MRI = 118 per 1000 people), suggesting that aggressive testing yields only slight increases in useful info and generates incidental findings that rarely prove to be malignant (Justice RBG excluded) but almost always create more costs and patient anxiety. The team reviewed a long list of strategies to curb unnecessary imaging (e.g. education, appropriate use criteria, ordering and reimbursement changes, requiring radiologist approval, avoiding/obscuring non-target areas in scans, and much more). However, the researchers don’t believe a solution has been found yet, calling for new randomized clinical trials to figure out how to curb unnecessary imaging, and suggesting that public funders and reimbursors “should consider seriously supporting such trials.”

QT Ultrasound Goes Direct
In what appears to be an unprecedented move for an imaging manufacturer, QT Ultrasound is opening a chain of QTbreasthealth-branded commercial breast imaging centers, equipped with the company’s own radiation/compression/injection-free QTScan Ultrasound Breast Scanners. QTbreasthealth will start with three locations in Novato and Walnut Creek, California (both SF Bay area) and Grand Rapids, Michigan, with plans to open more centers throughout 2019 (a San Jose, CA location is coming soon). The announcement also appears to mark the QT Ultrasound Breast Scanner’s commercial launch, as it comes just days after contract manufacturer NEO Tech announced a deal to produce components for the system, suggesting that the QTbreasthealth centers will play a primary role in the QT Ultrasound system’s commercial rollout. It also appears that the QTbreasthealth centers will (at least initially) be QT Ultrasound’s main route to market, although the QTScan’s positioning as an “adjunct to mammography” suggests that these systems may eventually also find a home in independent breast imaging centers.

Another Big Partnership from RP
Radiology Partners (RP) continued its hot start to 2019, announcing a partnership with major Austin Texas-based practice, Austin Radiological Association (ARA, 113 radiologists, 20 hospitals, 17 imaging centers, #9 in RBJ’s Radiology 100). The addition comes just a day after Radiology Partners announced a deal with Las Vegas’ Desert Radiology (70 radiologists, RBJ #24) and follows RP’s notable partnership spree throughout much of 2018, expanding the PE-backed firm to about 1,200 radiologists across 18 states and 850 hospitals. The ARA partnership was apparently big enough to require a new round of funding for RP, which had financial support from Barclays and Golub Capital for the deal, after using a $234m funding round in March 2018 to support much of its 2018 partnerships. Top ten practices don’t come cheap. RP’s ongoing acquisition spree certainly has folks in the industry concerned, causing some to question the future of the private practice and others to reconsider the best career path for young radiologists, many of which don’t see “making partner” with nearly as much certainty as when they started med school.

Who’s Following-up
Research from The Hospital of the University of Pennsylvania explored the societal determinants of imaging follow-ups, revealing a number of factors associated with lower follow-up rates including age (<40 and >80yrs), initial scan setting (emergency), and race (black patients). The study looked at 1513 patients who received indeterminate abdominal imaging findings in 2013/2014, finding that a surprisingly-high 36.62% of patients (554) did not return for follow-up imaging procedures within a year. Site apparently was a strong determinant, as 60% of emergency department patients did not attend their follow-ups (vs. 28% outpatient), although some would argue that this has to do with the way certain types of patients use EDs. The non-follow-up group included a disproportionate number of patients under 40 years old (13.72% of non-follow-up group vs. 9.28% of follow-up group) and patients over 80 years old (12.64% of non-follow-up group vs. 5.63% of follow-up group), as well as a higher number of black patients (36.82% of non-follow-up group vs. 28.15% of follow-up group). This study is partially supported by previous research on imaging exam no-shows, which found that no-shows were most likely to happen when the exam has a lead time over of 6 months and among patients over 60 years old (in addition to other factors like modality type and day of the week).

  • A pair of radiology-related mishaps garnered widespread news coverage, underscoring what’s at stake with each study and report. The biggest headlines and dollars went to a ‘wrongful birth’ lawsuit in Iowa, where a $14.5 million judgement was awarded to the parents of a severely disabled child due to a misdiagnosed follow-up fetal ultrasound. Meanwhile, a Massachusetts urologist received an official reprimand for removing a patient’s healthy kidney in 2016, due to a case of mistaken identity (two patients with the same name, similar symptoms, same type of CT performed on same day) and the urologist’s failure to use a second patient identifier beyond first/last name (like birth date) when accessing the patient’s EHR records.

  • New research from Reaction Data (n=152) provided more evidence of the growing adoption and appreciation of machine learning-based solutions among radiology professionals in 2018. A significant 77% of respondents viewed machine learning as important (12% neutral, 11% not important), marking a big shift from 2017 when 65% of respondents viewed ML as important (19% neutral, 16% not important). Understanding of machine learning jumped to 59% (20% partially understand, 21% don’t understand), improving from 52% in 2017 (16% partially understand, 32% don’t understand), but still underscoring the need for ML education. The survey revealed that ML adoption is greatest for breast and lung applications (both ~22% adoption rates), with lung applications achieving the greatest annual increase from about 12% in 2017.

  • The US FDA approved RFPi’s iCertainty imaging device, which shows real-time blood flow and perfusion in vascular structures and critical tissues during surgeries (initially targeting GI, plastic, and lower-leg vascular procedures). iCertainty is based on multi-spectral physiologic visualization (MSPV), which uses a combination of lasers, cameras, and analysis techniques to allow imaging of patient blood flow without injections, dyes, radiation, direct patient contact, or surgical interruptions.

The Resource Wire

This is sponsored content.

  • In this interview, the Cancer Research Institute leader, Jill O’Donnell-Tormey, PhD, discussed CRI’s partnership with the Focused Ultrasound Foundation, their vision for the combination of focused ultrasound and immunotherapy, and their achievements so far.

  • POCUS Systems is approved as a Veteran Owned Business with the US Government Office of Veterans Business Development, paving the way for partnerships with the federal healthcare delivery systems.

  • Did you know that imaging patients are most likely to no-show for their procedures on Mondays and Saturdays? By partnering with Medmo, imaging centers can keep their schedules full, despite the inevitable Monday no-shows.

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