Evaluation for Blunt Cerebrovascular Injury: Review of the Literature and a Cost-Effectiveness Analysis.

BACKGROUND AND PURPOSE: Evaluation for blunt cerebrovascular injury has generated immense controversy with wide variations in recommendations regarding the need for evaluation and the optimal imaging technique. We review the literature and determine the most cost-effective strategy for evaluating blunt cerebrovascular injury in trauma patients. MATERIALS AND METHODS: A comprehensive literature review was performed with data extracted to create a decision-tree analysis for 5 different strategies: anticoagulation for high-risk (based on the Denver screening criteria) patients, selective DSA or CTA (only high-risk patients), and DSA or CTA for all trauma patients. The economic evaluation was based on a health care payer perspective during a 1-year horizon. Statistical analyses were performed. The cost-effectiveness was compared through 2 main indicators: the incremental cost-effectiveness ratio and net monetary benefit. RESULTS: Selective anticoagulation in high-risk patients was shown to be the most cost-effective strategy, with the lowest cost and greatest effectiveness (an average cost of $21.08 and average quality-adjusted life year of 0.7231). Selective CTA has comparable utility and only a slightly higher cost (an average cost of $48.84 and average quality-adjusted life year of 0.7229). DSA, whether performed selectively or for all patients, was not optimal from both the cost and utility perspectives. Sensitivity analyses demonstrated these results to be robust for a wide range of parameter values. CONCLUSIONS: Selective CTA in high-risk patients is the optimal and cost-effective imaging strategy. It remains the dominant strategy over DSA, even assuming a low CTA sensitivity and irrespective of the proportion of patients at high-risk and the incidence of blunt cerebrovascular injury in high-risk patients.

Relative attractiveness of diagnostic radiology: assessment with data from the National Residency Matching Program and comparison with the strength of the job market.

PURPOSE: To quantify medical students' preferences for various specialties and to compare shifts in specialty preference with overall employment market prospects. MATERIALS AND METHODS: By using National Residency Matching Program data, a previously validated help-wanted index (HWI), and American Medical Association (AMA) salary data, the authors quantified medical students' preferences for various specialties and examined the association of shifts in specialty preference with overall trends as seen in the strength of the diagnostic radiology match and its relationship with the job market. The authors established a proxy for the relative attractiveness (RA) of diagnostic radiology (relative to all specialties) in the match, which was calculated by subtracting the percentage fill rate for all specialties from that for radiology. The RA values were plotted for 1990-2000 and compared with trends in the HWI, American College of Radiology data, and AMA salary data. RESULTS: The RA of diagnostic radiology varied greatly during the past 10 years, with a low in 1996 and a return to its high in recent years. There is a relationship between the RA and economic vitality of diagnostic radiology, with the RA lagging behind the HWI and AMA salary data by 2 years. CONCLUSION: Medical students appear to have an in-depth understanding of the economic forces at play in the health care job market and incorporate this information into their choice of a specialty.

Pediatric radiology at the millennium.

PURPOSE: To evaluate the current practice of and job market for pediatric radiologists in the United States and Canada with a 1998 survey and compare findings with those of surveys from 1980 and 1989. MATERIALS AND METHODS: Surveys were mailed to the 728 active members of the Society for Pediatric Radiology. Questions covered professional practice, subspecialization, and involvement in evolving technologies. A pediatric radiology help-wanted index was generated from a diagnostic radiology help-wanted index. RESULTS: Increasing involvement in the interpretation of computed tomographic, ultrasonographic, and magnetic resonance images was found among the 57% (411 of 728) of the members who responded. The attainment of a certificate of added qualification in pediatric radiology was found in nearly three-fourths of the membership, and 85% (348 of 408) had completed a fellowship. More than half of the respondents were involved in interventional procedures amid a continued increase in volume; 24% (100 of 409) of the membership, as compared with 7% in the 1980 survey, was practicing in a community or "other" setting. Subspecialization within pediatric radiology had diminished, and there was a larger percentage of female pediatric radiologists, particularly among the newest members. The job market was robust, having recovered substantially since the middle 1990s. CONCLUSION: The practice of pediatric radiology has evolved, with increasing involvement in advanced techniques and modalities, as well as a greater presence in community settings. The help-wanted index supports the recent discussions of a personnel shortfall.

Changes in the job market for interventional radiology as detected through a help-wanted index of job advertisements.

RATIONALE AND OBJECTIVES: The purpose of this study was to study trends in the job market in interventional radiology. MATERIALS AND METHODS: Each job advertisement for a diagnostic radiologist in the American Journal of Roentgenology and Radiology between January 1991 and December 1999 was coded by practice type (academic vs private), location, and subspecialty. Positions for interventional radiologists were compared with positions for noninterventional radiologists. Data from the first 48 months (January 1991 through December 1994) were compared with data from the second 48 months (January 1995 through December 1998). Data from 1999 were grouped separately. RESULTS: The nadir for all noninterventional and interventional radiology positions was seen in July 1995, and both areas have experienced great recovery since then. In December 1999, the last month of data collection, the absolute peak number of advertisements for interventional radiologists was reached. In fact, during the last half of the decade, an increasing percentage of jobs advertised for diagnostic radiologists was specifically for interventional radiologists. Statistically significant trends also occurred toward the private sector and toward positions in the Midwest and California. CONCLUSION: With a help-wanted index, dramatic shifts toward the private sector and toward jobs in the Midwest and California were demonstrated in the interventional radiology job market.

The job market in diagnostic radiology 1999: updated findings from a help wanted index of job advertisements.

OBJECTIVE: The purpose of this article is to report 1999 data on the job market in diagnostic radiology detected using a help wanted index of job advertisements and to profile trends in practice type, location, and subspecialty using our previously published data as a basis for comparison. MATERIALS AND METHODS: Each advertised job for a diagnostic radiologist in the American Journal of Roentgenology and RADIOLOGY: between January 1991 and December 1999 was coded by practice type, location, and subspecialty. RESULTS: In 1999, 3926 positions were advertised for diagnostic radiologists, representing a 75% increase from 1998. Private practice jobs, which represented 53% of advertisements from 1991 through 1994 and 64% of ads from 1995 through 1998, increased to 66% of ads in 1999. Geographic trends in 1999 were characterized by a relative increase of jobs in the Midwest and California and a decrease in percentage (but increase in total number of ads) in the Northeast and Southwest. The demand for subspecialists continued in 1999, with only 34% of ads placed for general radiologists. A relative increase in demand for neuroradiologists, mammographers, and abdominal imagers was also seen in 1999 in comparison with previously published data from 1995 through 1998. CONCLUSION: The demand for diagnostic radiologists continues to rise, with more ads placed in 1999 than any other year from 1991 through 1998. Using a help wanted index of job advertisements, we have created an indicator of changes in the diagnostic radiology job market with specific reference to practice type, geographic location, and subspecialty training.

Changes in the market for diagnostic radiologists as measured through a help wanted index.

OBJECTIVE: We sought to create and validate a help wanted index for tracking changes in the radiology job market. SUBJECTS AND METHODS: All jobs advertised in Radiology and the American Journal of Roentgenology from January 1991 through December 1998 were tracked according to three separate parameters: academic versus private practice, subspecialty, and region. Statistical comparison was made between the first and second 48-month subperiods to identify changes. RESULTS: Thirteen thousand seven hundred one advertised positions were coded. A dramatic decrease in job advertisements was noted after December 1991, with advertisements falling to one eighth of their late 1991 peak. A recovery has occurred, with advertising now approaching peak levels. Shifts were seen toward more private practice, midwestern location, vascular and interventional, and mammography positions. Declines occurred in the share of positions in California, the Southwest, and several radiology subspecialties. Other trends were noted but were statistically less significant. A strong correlation (R = 0.98) was found between the annual number of positions advertised and radiologists' median incomes relative to those of all physicians. CONCLUSION: The job market in radiology, much as in other fields, can be tracked in a coincident manner with the use of a help wanted index. Changes in the makeup of radiology practice are important and are identified in a well-constructed index. These findings have validity and can be useful as an adjunct to other information for policy and planning purposes.

Efficacy of prone positioning during intravenous urography in patients with hematuria or urothelial tumor but no obstruction.

RATIONALE AND OBJECTIVES: The authors prospectively explored the efficacy of using prone positioning during intravenous urography to improve diagnostic visualization and eliminate the need for retrograde pyeloureterography in patients with no obstruction but with hematuria, history of urothelial tumor, or abnormal results of urine cytology. MATERIALS AND METHODS: Prone radiography was added to the usual intravenous urography protocol in 510 patients (347 men, 163 women) without urinary tract obstruction. Interpretations of intravenous urograms and recommendations for retrograde pyeloureterography were made before and after evaluation of the prone image. RESULTS: Confidence in the urographic interpretation was improved with acquisition of the prone radiograph in 100 of 510 patients (19.6%) (95% confidence interval, 82.1, 118). Retrograde pyeloureterography was obviated in 46 of 510 patients (9.0%) (95% confidence interval, 33.1, 58.9). The prone image was most helpful in evaluating the distal ureters (sacral and pelvic segments). CONCLUSION: Prone patient positioning during intravenous urography is useful when complete visualization of the upper urinary tract is desirable. Obtaining the additional image is cost-effective, even when only a few retrograde pyeloureterography studies are obviated.

Cost analysis and the practicing radiologist/manager: an introduction to managerial accounting.

Cost analysis is inherently one of the most tedious tasks falling on the shoulders of any manager. In today's world, whether in a service business such as radiology or medicine or in a product line such as car manufacturing, accurate cost analysis is critical to all aspects of management: marketing, competitive strategy, quality control, human resource management, accounting (financial), and operations management, to name but a few. This is a topic that we will explore with the intention of giving the radiologist/manager the understanding and the basic skills to use cost analysis efficiently, making sure that major financial decisions are being made with adequate cost information, and showing that cost accounting is really managerial accounting in that it pays little attention to the bottom line of financial statements but places much more emphasis on equipping managers with the information to determine budgets, prices, salaries, and incentives and influences capital budgeting decisions through an understanding of product profitability rather than firm profitability.

Evaluating health services: the importance of patients' preferences and quality of life.

With limited resources available, we all would like to allocate health care dollars to do the most good. Clinical research tells us what outcomes to expect (in many cases) from the introduction of a health care program, a test, or a therapy. Even primitive cost analysis can assess the cost of such programs. The ability to place a value on health states is vital when assessing how patient outcomes influence the relative cost-effectiveness of medical procedures, therapies, and programs. Without a means to measure the value of a particular health state, one is left to compare apples with oranges and oranges with vacuum cleaners. In fact, comparisons of fruit and home appliances is relatively easy, because one can readily apply monetary values to apples, oranges, and vacuum cleaners and compare dollar amounts. How can one do the same for the outcomes of medical procedures and diagnostic tests? This is the challenge for health services and outcomes researchers throughout the world and, more urgently, the focus of policy makers, governments, and health insurers. The purpose of this paper is to describe quality-adjusted life-years (QALYs), a method that has successfully measured the outcomes of disparate health programs. We will introduce the QALY method, summarize the various methods of measuring and classifying health states, describe three methods that have been used to measure patients' preferences (utilities) for health states, and discuss the limitations of utility assessment and some controversies that result from the measurement and use of utilities and concerning health-related quality of life. Readers who are interested in general topics of radiology technology assessment and cost-effectiveness analysis should consult other review articles [1-4].

Hepatic spiral CT: reduction of dose of intravenous contrast material.

PURPOSE: To assess the potential for reduction of contrast material dose in hepatic spiral computed tomography (CT). MATERIALS AND METHODS: Four hundred eighty-seven outpatients were randomized prospectively into nine biphasic and eight uniphasic injection protocols: 75, 100, or 125 mL of 240, 300, or 350 mg of iodine per milliliter of iohexol (18-44 grams of iodine). Protocols were compared according to the maximum hepatic enhancement (MAX) and the contrast enhancement index (CEI). RESULTS: Uniphasic injection was superior to biphasic injection for all protocols. No statistically significant difference in contrast enhancement was present for 38-44 grams of iodine with the uniphasic technique. Adequate enhancement thresholds (MAX > 50 HU, CEI at 30 HU > 300 HU x sec) were exceeded in more than 70% of heavy patients ( > 183 lb [83 kg]) with uniphasic injection of 38 g. For thin patients ( < 183 lb [83 kg]), uniphasic injection of 26 g produced adequate enhancement. CONCLUSION: Contrast material dose may be reduced by up to 40% in thin patients undergoing hepatic spiral CT after uniphasic injection of contrast material; this may result in substantial cost savings.

Chest radiography in patients with early stage prostatic carcinoma. Effect on treatment planning and cost analysis.

STUDY OBJECTIVE: An evaluation of the impact of routine preoperative chest radiographs was retrospectively undertaken in a pilot group of 292 patients with prostatic carcinoma who were part of a prospective study of prostate specific antigen screening for prostate carcinoma. DESIGN: Retrospective. SETTING: Hospital-based outpatients. PATIENTS AND PARTICIPANTS: A cost-effectiveness model was used to assess the value of routine chest radiography in this patient population. Chest radiography findings were categorized into four groups based on follow-up and impact. MEASUREMENTS AND RESULTS: Forty-three patients (15 percent) had a total of 45 positive findings on their chest radiographs. No patient had intrathoracic metastases from prostatic carcinoma. Only two patients (both with unsuspected second neoplasms) had findings that impacted on their treatment and one avoided retropubic radical prostatectomy. Total cost was $2,000 (based on Medicare reimbursement), or $14,000 (based on physician and hospital charges). CONCLUSION: Although benefit is small in terms of number of patients affected, clinical impact, in the two patients with significant findings, was great. Although cost-effectiveness cannot be confirmed on the basis of this series, further evaluation of its utility for this application should be undertaken.

Health services research in radiology: opportunities and imperatives.

"Health services research is a field of inquiry that examines the impact of the organization, financing, and management of health care services on the delivery, quality, cost, access to, and outcomes of such services." This organizational definition, from the Association for Health Services Research (AHSR; membership services, personal communication), is a new buzz word in the current era of health care reform. Radiologists will be asked or expected to become active participants in this field. If they do not take part, they will be shut out of important policy making. The process and outcome of this research often determine whether examinations and procedures will be reimbursed in the future and at what level. This article addresses the particular need for trained health service researchers in radiology, opportunities for formal research training, and available sources of funding for health services training and research. It is not intended to be a definitive resource for those wishing to enter this field; rather, it provides a foundation for beginning pursuit of this evolving academic discipline.