Understanding provider cost of MRI for appendicitis in children: A Time-Driven Activity-Based Costing Analysis.

OBJECTIVE: To use time driven activity-based costing (TDABC) to characterize the provider cost of rapid MRI for appendicitis compared to other MRI examinations billed with the same current procedural technology (CPT) codes commonly used for MRI appendicitis examinations. METHODS: Rapid MRI appendicitis examination was compared to MRI pelvis without intravenous contrast, MRI abdomen/pelvis without intravenous contrast, and MRI abdomen/pelvis with intravenous contrast. Process maps for each examination were created through direct shadowing of patient procedures (n=20) and feedback from relevant healthcare professionals. Additional data were collected from the electronic medical record for 327 MRI examinations. Practical capacity cost rates were calculated for personnel, equipment, and facilities. The cost of each step was calculated by multiplying the capacity cost rate with the mean duration of each step. Stepwise costs were summed to generate a total cost for each MRI examination. RESULTS: The mean duration and costs for MRI examination type were as follows: MRI appendicitis: 11 (range: 6-25) min, $20.03 (7.80-44.24); MRI pelvis without intravenous contrast: 55 (29-205) min, $105.99 (64.18-285.13); MRI abdomen/pelvis without intravenous contrast: 65 (26-173) min, $144.83 (61.16-196.50; MRI abdomen/pelvis with intravenous contrast: 128 (39-303) min, $236.99 (102.62-556.54). CONCLUSION: The estimated cost of providing a rapid appendicitis MRI examination is significantly less than other MRI examinations billed using CPT codes typically used for appendicitis MRI. Mechanisms to appropriately bill rapid MRI examinations with limited sequences are needed to improve cost efficiency for the patient, and to enable wider use of limited MRI examinations in the pediatric population.

Vesicoureteral Reflux Imaging: A National Analysis in Commercially Insured Children From 2012 to 2021.

In this national commercial claims database analysis, the number of outpatient pediatric VUR imaging examinations decreased from 48,843 in 2012-2016 to 31,423 in 2017-2021. Imaging modalities' distribution varied over time, with increased use of VCUG (> 90% of examinations in both periods), decreased use of nuclear cystography, and emergence of CeVUS.

Meeting the Needs of Patient Preferences in Imaging.

Healthcare continues to transition toward a patient-centered paradigm, where patients are active in medical decisions. Fully embracing this new paradigm means updating how clinical guidelines are formulated, accounting for patient preferences for medical care. Recently, several societies have incorporated patient preference evidence in their updated clinical practice guidelines, and patients in their expert panels. To fully transition to a patient-centered-paradigm, imaging organizations should rethink the formulation of clinical guidelines, accounting for patient preference evidence.

Imaging of Vesicoureteral Reflux: AJR Expert Panel Narrative Review.

Vesicoureteral reflux (VUR) is a common congenital anomaly of the urinary tract that can present with collecting system dilation or as a febrile infection. VUR can lead to permanent renal sequela requiring surgery but can also spontaneously resolve without complication. Therefore, it is important to recognize those patient populations who warrant imaging for screening, confirmation, or ongoing surveillance for VUR, while avoiding overdiagnosis. In the appropriate patient populations, an accurate diagnosis of VUR allows early treatment and prevention of pyelonephritis and scarring. Various imaging modalities are available to diagnose and grade VUR, including voiding cystourethrogram (VCUG), radionucleotide cystography (RNC), and contrast-enhanced voiding urosonography (ceVUS). The objective of this article is to summarize the current understanding of VUR diagnosis and management and to discuss these imaging modalities' strengths and pitfalls. Considerations include indications for VUR imaging, patient preparation, conduct of the examination, issues related to radiologic reporting, and cost-effectiveness. An emphasis is placed on ceVUS, which is the most recently introduced of the three imaging modalities and is receiving growing support among pediatric radiologists.

Patient Preferences in Diagnostic Imaging: A Scoping Review.

BACKGROUND: As new diagnostic imaging technologies are adopted, decisions surrounding diagnostic imaging become increasingly complex. As such, understanding patient preferences in imaging decision making is imperative. OBJECTIVES: We aimed to review quantitative patient preference studies in imaging-related decision making, including characteristics of the literature and the quality of the evidence. METHODS: The Pubmed, Embase, EconLit, and CINAHL databases were searched to identify studies involving diagnostic imaging and quantitative patient preference measures from January 2000 to June 2022. Study characteristics that were extracted included the preference elicitation method, disease focus, and sample size. We employed the PREFS (Purpose, Respondents, Explanation, Findings, Significance) checklist as our quality assessment tool. RESULTS: A total of 54 articles were included. The following methods were used to elicit preferences: conjoint analysis/discrete choice experiment methods (n = 27), contingent valuation (n = 16), time trade-off (n = 4), best-worst scaling (n = 3), multicriteria decision analysis (n = 3), and a standard gamble approach (n = 1). Half of the studies were published after 2016 (52%, 28/54). The most common scenario (n = 39) for eliciting patient preferences was cancer screening. Computed tomography, the most frequently studied imaging modality, was included in 20 studies, and sample sizes ranged from 30 to 3469 participants (mean 552). The mean PREFS score was 3.5 (standard deviation 0.8) for the included studies. CONCLUSIONS: This review highlights that a variety of quantitative preference methods are being used, as diagnostic imaging technologies continue to evolve. While the number of preference studies in diagnostic imaging has increased with time, most examine preventative care/screening, leaving a gap in knowledge regarding imaging for disease characterization and management.

Trends in Anesthesia/Sedation for Computed Tomography and Magnetic Resonance Imaging Encounters in Pediatric Emergency Departments, 2012-2022.

This cross-sectional study assesses trends over time in sedation/anesthesia use for computed tomography (CT) and magnetic resonance imaging (MRI) across pediatric emergency departments (EDs).

Medicaid and the Children's Health Insurance Program: an overview for the pediatric radiologist.

In terms of number of beneficiaries, Medicaid is the single largest health insurance program in the US. Along with the Children's Health Insurance Program (CHIP), Medicaid covers nearly half of all births and provides health insurance to nearly half of the children in the country. This article provides a broad introduction to Medicaid and CHIP for the pediatric radiologist with a special focus on topics relevant to pediatric imaging and population health. This includes an overview of Medicaid's structure and eligibility criteria and how it differs from Medicare. The paper examines the means-tested programs within the context of pediatric radiology, reviewing pertinent topics such as the rise of Medicaid managed care plans, Medicaid expansion, the effects of Medicaid on child health, and COVID-19. Beyond the basics of benefits coverage, pediatric radiologists should understand how Medicaid and CHIP financing and reimbursement affect the ability of pediatric practices, radiology groups, and hospitals to provide services for children in a sustainable manner. The paper concludes with an analysis of future opportunities for Medicaid and CHIP.

Impact of coronavirus disease 2019 on pediatric intestinal intussusception in the United States.

BACKGROUND: Masking and social distancing to mitigate the spread of the SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) virus curbed the spread of other viruses. Given a potential link between viral illnesses and ileocolic intussusception, the purpose of this study is to characterize trends in incidence, diagnosis and management of pediatric intussusception in the United States in the context of the coronavirus disease 2019 (COVID-19) pandemic. MATERIALS AND METHODS: This cross-sectional retrospective study used the Pediatric Hospital Information System and included children (ages 0-17 years) with a primary diagnosis of intussusception (ICD-10 [International Classification of Diseases, Tenth Revision]: K56.1) from January 2018 to December 2021. Descriptive statistics and chi-square analyses were used to characterize and compare proportions pre-COVID (2018 and 2019) to 2020 and 2021. RESULTS: Eight thousand one hundred forty-three encounters met inclusion criteria. Intussusception diagnoses declined in 2020 (n = 1,480) compared to 2019 (n = 2,321) and 2018 (n = 2,171) but returned to pre-COVID levels in 2021 (n = 2,171). Patient age was similar across years (mean age in years: 2018: 2.3; 2019: 2.1; 2020: 2.3; 2021: 2.3). There was no significant change in the proportion of patients who underwent imaging in 2020 (96% [1,415/1,480]) compared to the other years in the study (2018: 96% [2,093/2,171], P = 0.21; 2019: 97% [2,253/2,321], P = 0.80; 2021: 96% [1,415/1,480], P = 0.85). There was a statistically significant but minimal increase in the proportion of cases treated with surgery in 2020 compared to 2019 (2020: 17.8% vs. 2019: 15%, P = 0.02); however, this was not replicated in the pairwise comparison of 2020 to 2018 (2020: 17.8% vs. 2018: 16.4%, P = 0.23). There was a statistically significant increase in the proportion of cases treated with surgery in 2020 compared to 2021 (2020: 17.8% vs. 2021: 14%, P = 0.001). CONCLUSION: Pediatric intussusception diagnoses decreased at a national level in 2020 compared to previous years, with a rebound increase in 2021. This may reflect a secondary benefit of public health interventions imposed to curb the spread of COVID-19.

Pediatric Outpatient Noncontrast Brain MRI: A Time-Driven Activity-Based Costing Analysis at Three U.S. Hospitals.

BACKGROUND. MRI utilization and the use of sedation or anesthesia for MRI have increased in children. Emerging alternative payment models (APMs) require a detailed understanding of the health system costs of performing these examinations. OBJECTIVE. The purpose of this study was to use time-driven activity-based costing (TDABC) to assess health system costs for outpatient noncontrast brain MRI examinations across three children's hospitals. METHODS. Direct costs for outpatient noncontrast brain MRI examinations at three academic free-standing pediatric hospitals were calculated using TDABC. Examinations were categorized as sedated MRI (i.e., sedation or anesthesia), nonsedated MRI, or limited MRI. Process maps were created to describe patient workflows based on input from key personnel and direct observation. Time durations for each process activity were determined; time stamps from retrospective EMR review were used when possible. Capacity cost rates were calculated for resource types within three cost categories (labor, equipment, and space); cost was calculated in a fourth category (supplies). Resources were allocated to each activity, and the cost of each process step was determined by multiplying step-specific capacity costs by the time required for each step. The costs of all steps were summed to yield a base-case total examination cost. Sensitivity analysis for sedated MRI was performed using minimum and maximum time duration inputs for each activity to yield minimum and maximum costs by hospital. RESULTS. The mean base-case cost for a sedated brain MRI examination was $842 (range, $775-924 across hospitals), for a nonsedated brain MRI examination was $262 (range, $240-285), and for a limited brain MRI examination was $135 (range, $127-141). For all examination types, the largest cost category as well as the largest source of difference in cost between hospitals was labor. Sensitivity analysis found that the greatest influence on overall cost at each hospital was the duration of the MRI acquisition. CONCLUSION. The health system cost of performing a sedated MRI examination was substantially greater than that of performing a nonsedated MRI examination. However, the cost of each individual examination type did not vary substantially among hospitals. CLINICAL IMPACT. Health systems operating within APMs can use this comparative cost information for purposes of cost reduction efforts and establishment of bundled prices.

Turnaround time and efficiency of pediatric outpatient brain magnetic resonance imaging: a multi-institutional cross-sectional study.

BACKGROUND: Aside from single-center reports, few data exist across pediatric institutions that examine overall MRI turnaround time (TAT) and the determinants of variability. OBJECTIVE: To determine average duration and determinants of a brain MRI examination at academic pediatric institutions and compare the duration to those used in practice expense relative value units (RVUs). MATERIALS AND METHODS: This multi-institutional cross-sectional investigation comprised four academic pediatric hospitals. We included children ages 0 to < 18 years who underwent an outpatient MRI of the brain without contrast agent in 2019. Our outcome of interest was the overall MRI TAT derived by time stamps. We estimated determinants of overall TAT using an adjusted log-transformed multivariable linear regression model with robust standard errors. RESULTS: The average overall TAT significantly varied among the four hospitals. A sedated brain MRI ranged from 158 min to 224 min, a non-sedated MRI from 70 min to 112 min, and a limited MRI from 44 min to 70 min. The most significant predictor of a longer overall TAT was having a sedated MRI (coefficient = 0.71, 95% confidence interval [CI]: 0.66-0.75; P < 0.001). The median MRI scan time for a non-sedated exam was 38 min and for a sedated exam, 37 min, approximately double the duration used by the Relative Value Scale (RVS) Update Committee (RUC). CONCLUSION: We found considerable differences in the overall TAT across four pediatric academic institutions. Overall, the significant predictors of turnaround times were hospital site and MRI pathway (non-sedated versus sedated versus limited MRI).

Trends in Pediatric Appendicitis and Imaging Strategies During Covid-19 in the United States.

RATIONALE AND OBJECTIVES: To determine if, during the first wave of the COVID-19 pandemic, 1) the proportion of complicated appendicitis changed, and 2) if imaging strategies for appendicitis in children changed. MATERIALS AND METHODS: Retrospective cross-sectional study using administrative data from the Pediatric Health Information System, inclusive of pediatric patients diagnosed with appendicitis from March to May in 2017, 2018, 2019 and 2020. We compared trends during COVID-19 pandemic (March-May 2020) with corresponding pre-COVID-19 periods in 2017-201.9 Study outcomes were the proportion of complicated appendicitis and trends in imaging for appendicitis explained by patient-level variables. RESULTS: The proportion of complicated appendicitis cases increased by 4.4 percentage points, from 46.5% pre-COVID-19 (2017-2019) to 50.9% during COVID-19 (2020), p < 0.001. Mean count of uncomplicated acute appendicitis cases decreased from pre-COVID-19 to the 2020 COVID-19 period (2017: n = 2555; 2018: n = 2679; 2019: n = 2722; 2020: n = 2231). Mean count of complicated appendicitis was unchanged between study periods (2017: n = 2189; 2018: n = 2302, 2019: n = 2442; 2020: n = 2311). Imaging approaches were largely unchanged between study periods; ultrasound was the most utilized modality in both study periods (68.3%, 70.2%; p = 0.033). CONCLUSION: During the first wave of the COVID-19 pandemic, the proportion of complicated appendicitis cases increased without an absolute increase in the number of complicated appendicitis cases, but instead a decrease in the number of uncomplicated acute appendicitis diagnoses.

Prospective cost implications with a clinical decision support system for pediatric emergency head computed tomography.

BACKGROUND: Unnecessary imaging is a potential cost driver in the United States health care system. OBJECTIVE: Using a clinical decision support tool, we determined the percentage of low-utility non-contrast head computed tomography (CT) examinations on emergency patients and calculated the prospective cost implications of providing low-value imaging using time-driven activity-based costing at an academic quaternary pediatric hospital. MATERIALS AND METHODS: A clinical decision support tool for imaging, CareSelect (National Decision Support Co., Madison, WI), was integrated in silent mode into the electronic health record from September 2018 through August 2019. Each non-contrast head CT order received a score from the clinical decision support tool based on the American College of Radiology Appropriateness Criteria. Descriptive statistics for all levels of appropriateness scores were compiled with an emphasis on low-utility exams. A micro-costing assessment was conducted using time-driven activity-based costing on head CT without contrast examinations. RESULTS: Within the 11-month time period, 3,186 head CT examinations without contrast were ordered for emergency center patients. Among these orders, 28% (896/3,186) were classified as low-utility studies. The base case CT pathway time was 43 min and base case total cost was $193.35. The base case opportunity cost of these low-utility exams extrapolated annually amounts to $188,902 for our institution. CONCLUSION: Silent mode implementation of a clinical decision support tool resulted in 28% of head CT non-contrast exams on emergency patients being graded as low-utility studies. Prospective cost implications resulted in an annual base case cost of $188,902 to Texas Children's Hospital.

Value Assessment of Evolving Pediatric Appendicitis Imaging Strategies Between 2004 and 2018.

OBJECTIVE: To assess diagnostic imaging utilization and the proportion of negative appendectomies for pediatric appendicitis at US children's hospitals between 2004 and 2018. METHODS: This was a retrospective study using data from the Pediatric Health Information System (PHIS) database. Pediatric patients (age: 0-17 years) who underwent an appendectomy at one of 32 children's hospitals from January 1, 2004, through September 30, 2018, were included. Patients were identified based on International Classification of Diseases, 9th revision and International Classification of Diseases, 10th revision procedure codes. Patient demographics, imaging performed, and the frequency of negative appendectomy were analyzed. RESULTS: The final study population consisted of 104,033 children. From 2004 to 2018, CT utilization decreased from 56.8% (2,951 of 5,198) to 18.6% (1,201 of 6,455; P < .001). Ultrasound utilization increased from 26.4% (1,371 of 5,198) to 63.4% (4,093 of 6,455; P < .001). Radiography utilization remained stable at 16.7% (870 of 5,198) and 15.8% (1,018 of 6,455; P = .160). MRI use increased from 0.1% (6 of 5,198) to 2.2% (143 of 6,455; P < .001). During the study period, the negative appendectomy rate slightly decreased, from 3.74% (4,742 of 126,778 in 2004-2011) to 3.14% (4,258 of 135,561 in 2012-2018; P < .001). CONCLUSION: There has been a shift in imaging of children with appendicitis over 15 years in the United States, because the use of CT has decreased and ultrasound use has increased. This shift has likely added value to the health care system without adversely affecting outcomes (negative appendectomy rate).

Time-Driven Activity-Based Cost Comparison of Three Imaging Pathways for Suspected Midgut Volvulus in Children.

OBJECTIVE: To use time-driven activity-based costing to compare the costs of pathways for evaluating suspected pediatric midgut volvulus using either fluoroscopic upper gastrointestinal examination (UGI) or focused abdominal ultrasound (US). METHODS: Process maps were created through patient shadowing, medical record review, and frontline staff interviews. Using time-driven activity-based costing methodology, practical capacity cost rates were calculated for personnel, equipment, and facility costs. Supply costs were included at institutional purchase prices. The cost of each process substep was determined by multiplying step-specific capacity costs by the median time required for each step, and substep costs were summed to generate total pathway cost. Multivariate sensitivity analyses were performed applying minimum and maximum labor costs. Assuming UGI would be used to troubleshoot nondiagnostic US, a break-even analysis was performed to determine the cost impact of varying frequencies of UGI on the total cost of the US-based pathway. RESULTS: Process maps were created from 105 (48 girls, 57 boys) patient encounters. Base case pathway times were 90 min (UGI) and 55 min (US). Base case cost for UGI was $282.74 (range: $170.86-$800.82) when performed by a radiology practitioner assistant and $545.66 (range: $260.97-$1,974.06) when performed by a radiologist. Base case cost for US was $155.67 (range: $122.94-$432.29) when performed by a sonographer and $242.64 (range: $147.46-$1,330.05) when performed by a radiologist. For a US-based pathway, the total cost break-even pathway mix (percent UGI required for troubleshooting) was 57%. CONCLUSION: US can be a faster and less costly alternative to UGI in pediatric patients with suspected midgut volvulus.