Tag: ACR

Interventional Radiology’s Practice Evolution

Posted on by Brian Casey

Interventional radiology has proven benefits for patient care, enabling life-saving procedures to be performed less invasively than open surgery. But interventional radiology procedures are being concentrated among fewer radiologists, based on findings from a new study in JVIR by researchers from the ACR’s Neiman HPI group. 

From its origins in pioneering work conducted in the 1960s by Charles Dotter, MD, in image-guided minimally invasive procedures, interventional radiology has evolved into a field with one foot in diagnostic radiology and another in therapy.

  • The field achieved a major milestone in 2012, when it was recognized as an independent, primary medical specialty, and shortly thereafter an integrated IR/DR pathway was adopted that gives trainees additional dedicated interventional training. 
  • This replaced the previous practice of just tacking an extra interventional fellowship on to a diagnostic radiology program.

Has the new training structure changed who’s performing interventional procedures in the U.S.? Neiman HPI researchers examined this issue by analyzing Medicare claims from 2008 to 2023 for 46k radiologists. 

  • They focused on the volume of interventional procedures being performed by radiologists, and any shifts in volume that could have resulted from changes in the training program.

Over the study period, researchers found…

  • The percentage of all radiologists who performed at least some interventional work fell (from 67% to 50%).
  • But the percentage of super-specialists – those who spent more than 90% of their time doing interventional work – more than doubled (from 4.1% to 8.8%).
  • Among radiologists who primarily performed interventional work, more were younger compared to older (25% vs. 12%).
  • And super-specialists tended to be younger as well (9.2% vs. 6.8%). 

The changes are most likely due to the new IR/DR training pathway. But they also raise new questions, such as whether interventional radiology should completely separate from diagnostic radiology in both training and practice settings.  

  • The authors weren’t ready to go that far, noting that the integrated IR/DR pathway was designed to ensure dual competency in both image interpretation and procedures, and such flexibility is still valuable in today’s healthcare environment. 

The Takeaway

The new findings on the concentration of interventional radiology practice generally reflect the trend toward increased specialization that’s being seen in both radiology and healthcare. Patients are benefiting, as their procedures are more likely to be performed by specialists who not only received more training but also have more experience than in the past.

Who’s Reading Office-Based Medical Images?

Posted on by Brian Casey

Non-radiologist providers are reading almost half of medical images acquired in the office practice setting. A new analysis in AJR raises questions about both the quality of these interpretations as well as whether they are contributing to imaging overutilization. 

Radiologists have jealously guarded their role as the primary interpreters of medical images, but keeping referring physicians away is like holding back the tide – especially when they control the patients.

  • Progress was made in the 1990s with the passage of Stark legislation prohibiting doctors from referring patients to sites where they have a financial interest, but Stark includes an exemption for imaging performed in the doctors’ own offices.

This in-office exemption is a loophole big enough to drive a truck through, and as in-office imaging has grown radiologists have raised questions about:

1. Whether non-radiologist providers have adequate training in image interpretation. 

2. If the economic incentive behind in-office imaging contributes to imaging overutilization. 

So to learn more about who’s reading in-office images, researchers from the ACR’s Harvey L. Neiman Health Policy Institute analyzed 1.6M office-based imaging studies from 2022, discovering … 

  • 44% of office-based medical images are self-interpreted by the provider who ordered them.
  • Self-interpretation rates varied by modality: ultrasound (52%), X-ray (50%), nuclear medicine (40%), MRI (6.1%), and CT (5.3%). 
  • As well as by specialty: orthopedic/sports medicine (76%), cardiology (73%), non-physician providers (31%), primary care (20%), and other specialties (38%). 
  • Larger practices had lower self-interpretation rates, as did practices with a radiologist on-staff.

High image self-interpretation rates could be a patient care issue given that – other than cardiology – non-radiologist physicians don’t usually receive extensive training in image interpretation. 

  • Imaging overutilization could also be occurring as there are no reimbursement restrictions on in-office self-referring physicians, and studies have shown that the Stark laws failed to achieve reductions in self-referred imaging volumes.

The Takeaway

The new study sheds light on one of healthcare’s most persistent problems – in-office physician self-referral. The question is whether it’s a problem that will eventually take care of itself as healthcare consolidation leads to larger medical practices that are more likely to have radiologists on staff. 

Non-Physicians Are Reading More Medical Images

Posted on by Brian Casey

Non-physician practitioners are reading more medical images in U.S. medical offices. That’s according to a new study in JACR by researchers who found that the share of images interpreted by NPPs has doubled in the last 10 years. 

In the U.S., radiologists consider themselves to be the primary interpreters of medical images, but inroads have been made not only by other physicians but also by non-physician practitioners like nurses and physician assistants. 

  • NPPs are supposed to receive specialized training in image interpretation, but radiologists question whether such training is adequate, especially compared to the years of training that radiologists receive. 

Previous research has documented the rise in NPP image interpretation, but the new study takes a longer view, examining the period 2013-2022. 

  • It also specifically focuses on the medical office setting, where it’s believed NPP interpretation is growing faster than in hospitals, where radiologists still dominate interpretations. 

In their analysis of Medicare claims, researchers from the ACR’s Harvey L. Neiman Health Policy Institute found … 

  • NPPs’ share of office-based image interpretations grew 9% annually (2.5% to 5.5%).
  • Growth rates varied by modality, with MRI growing at 9.9% annually, followed by CT (9.4%), ultrasound (9.4%), radiography (8.9%), and nuclear medicine (7.2%).
  • Despite the growth, just 5.6% of NPPs were interpreting images.
  • By specialty, the share of NPP interpretation was most common with primary care (40%) and orthopedic offices (34%).

The researchers also tracked variability in NPP interpretation rates by state, finding the highest rates ( ~13%) in Western states with large rural areas like Montana, Alaska, and Idaho, where presumably there are fewer radiologists available to read images. 

The Takeaway

The findings provide a good news/bad news look at non-physician image interpretation. The good news for radiologists is that NPP interpretation is still pretty rare; the bad news is that rates are growing quickly. And given the ongoing radiologist shortage, there is sure to be continuing pressure to allow allied health staff to read images on their own.

ACR Grants NPPs’ Contrast Supervision

Posted on by Jake Fishman

The American College of Radiology (ACR) rolled out a significant change to its imaging contrast guidelines, allowing non-radiologists and non-physician practitioners (NPPs) to supervise intravenous CT and MRI contrast administration at accredited imaging centers.

A range of NPPs (NPs, PAs, RNs) and qualifying non-radiologist physicians will be able to directly supervise contrast administration under the “general supervision” of on-site radiologists, as long as it’s supported by state scope of practice laws. 

  • Superving radiologists must be available for “assistance or direction” and trained to handle acute contrast reactions/situations, but they won’t have to be in the same room as the patient.

These guidelines mirror the ACR’s new practice parameters for contrast supervision (adopted in May), and follow CMS’ recent efforts to expand more diagnostic tasks to non-physicians.

  • CMS granted radiology assistants the ability perform a range of imaging tasks in 2020 and permitted NPPs to directly supervise Level 2 tests in 2021 (like contrast-enhanced CT and MRI), in both cases requiring “general” radiologist supervision (on-site, but not in room… and virtual during the pandemic).

Although NPPs’ radiology expansion has historically sparked heated debates, the new ACR contrast supervision guidelines hasn’t faced many public objections so far. 

  • That’s potentially because some (busy) radiologists don’t view directly supervising contrast administration as a practical or efficient use of their time (even if they still have to drive to the imaging center), especially considering that technologists often spot adverse reactions before anyone else.
  • However, there’s surely plenty of radiologists who are concerned about whether these new guidelines might exacerbate scope creep, cut their earning potential (especially trainees), reduce radiologists’ patient-facing opportunities, and undermine patient care.

The Takeaway

The ACR’s decision to grant NPPs greater contrast supervision rights and loosen radiologists’ contrast supervision requirements might not be surprising to folks paying attention to recent ACR and CMS policies. That said, it’s still a notable step (and potential contributor) in the NPPs’ expanding role within radiology – and opinions might differ regarding whether that’s a good thing.

The MARCA Divide

Posted on by Jake Fishman

The American College of Radiology might have a neutral stance on the Medicare Access to Radiology Care Act (MARCA), but a new survey confirmed that most ACR members are far from neutral about non-physicians’ role in radiology. 

MARCA Madness – MARCA would require Medicare to reimburse supervising radiologists for imaging services performed by radiologist assistants, as long as RAs work within physician-led teams. The ACR revealed its neutral position on MARCA in August, enraging some members who are concerned that MARCA will undermine radiologists’ role, and accused the ACR of selling out to PE. 

The Opinion Divide – The ACR survey (n = 4,207, or 16% of members) revealed overwhelming opposition to MARCA, but more balanced views on working with non-physician radiology providers (NPRPs). By NPRPs, they mean radiology assistants, advanced practice registered nurses, and physician assistants.

  • 60% are against MARCA (vs. 19% in favor, 21% neutral)
  • 86% are concerned about NPRP scope creep
  • 55% view NPRPs as a threat to patient care
  • However, just 43% are against using NPRPs in their practice
  • And 62% believe it’s up to practices whether they employ NPRPs

Behind the Divide – A deeper look into the ACR’s (very detailed) survey results revealed that members’ MARCA and NPRP opinions seem largely influenced by their professional situation. 

Career Stage

  • 80% of residents/fellows and 65% of early-career rads view NPRPs as a threat to patient care 
  • 51% of mid-career rads and 41% of late-career rads view NPRPs as a threat to patient care

Practice Type

  • 61% of respondents from academic settings view NPRPs as a threat to patient care
  • 69% of respondents from national and private practices think NPRP use is a practice decision 

Practice Role

  • 61% of non-leaders view NPRPs as a threat to patient care
  • 65% of practices leaders view NPRPs use as a practice decision

NPRP Experience

  • 69% of respondents who do not work with NPRPs view them as a threat to patient care
  • 57% of respondents who work with NPRPs believe they play an important role
  • 84% of respondents who support MARCA currently work with NPRPs

The Takeaway – We now have data confirming what most of you already knew: the majority of radiologists are firmly against MARCA and a small minority support it. However, the data also shows that plenty of radiologists see value in NPRPs, especially if they already work with non-physicians and if their careers are less threatened by them. What’s still unclear is what it will take for the ACR to break its neutrality on MARCA (in either direction).

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