Current State of Peer Learning in Radiology: A Survey of ACR Members.

PURPOSE: Peer learning (PL) programs seek to improve upon the limitations of score-based peer review and incorporate modern approaches to improve patient care. The aim of this study was to further understand the landscape of PL among members of the ACR in the first quarter of 2022. METHODS: Members of the ACR were surveyed to evaluate the incidence, current practices, perceptions, and outcomes of PL in radiology practice. The survey was administered via e-mail to 20,850 ACR members. The demographic and practice characteristics of the 1,153 respondents (6%) were similar to those of the ACR radiologist membership and correspond to a normal distribution of the population of radiologists and can therefore be described as representative of that population. Therefore, the error range for the results from this survey is ±2.9% at a 95% confidence level. RESULTS: Among the total sample, 610 respondents (53%) currently use PL, and 334 (29%) do not. Users of PL are younger (mode age ranges, 45-54 years for users and 55-64 years for nonusers; P < .01), more likely to be female (29% vs 23%, P < .05), and more likely to practice in urban settings (52% vs 40%, P = .0002). Users of PL feel that it supports an improved culture of safety and wellness (543 of 610 [89%]) and fosters continuous improvement initiatives (523 of 610 [86%]). Users of PL are more likely than nonusers to identify learning opportunities from routine clinical practice (83% vs 50%, P < .00001), engage in programming inclusive of more team members, and implement more practice improvement projects (P < .00001). PL users' net promoter score of 65% strongly suggests that users of PL are highly likely to recommend the program to colleagues. CONCLUSIONS: Radiologists across a breadth of radiology practices are engaged in PL activities, which are perceived to align with emerging principles of improving health care and enhance culture, quality, and engagement.

Current Controversies in Radiology on Cost, Reimbursement, and Price Transparency: AJR Expert Panel Narrative Review.

Many believe that fundamental reform of the U.S. health care system is overdue and necessary given rising national health care expenditures, poor performance on key population health metrics, meaningful health disparities, concerns about potential financial toxicity of care, inadequate price transparency, pending insolvency of Medicare Part A, increasing commercial insurance premiums, and large uninsured and underinsured populations. The Medicare Payment Advisory Commission, an independent congressional agency, believes that part of this reform includes redistribution of reimbursements away from specialties such as radiology. Thus, despite an increase in the Medicare population and spending, Medicare payments for medical imaging have been decreasing for years. Further, the No Surprises Act, a federal law intended to curb the problem of surprise medical billing, was repurposed in federal rulemaking to reduce reimbursement from commercial payers to certain specialties, including radiology. In this article, we examine challenges facing the U.S. health care system, focusing on cost, reimbursement, and price transparency and the role of radiology in addressing such challenges. Medical imaging is a minor contributor to national health care expenditures but has an outsized impact on patient care. The radiology community should work together to reinforce the value of medical imaging and reduce inappropriate utilization of low-value care.

Transitioning From Peer Review to Peer Learning: Report of the 2020 Peer Learning Summit.

Since its introduction nearly 20 years ago, score-based peer review has not been shown to have meaningful impact on or be a valid measurement instrument of radiologist performance. A new paradigm has emerged, peer learning, which is a group activity in which expert professionals review one another's work, actively give and receive feedback in a constructive manner, teach and learn from one another, and mutually commit to improving performance as individuals, as a group, and as a system. Many radiology practices are beginning to transition from score-based peer review to peer learning. To address challenges faced by these practices, a 1-day summit was convened at Harvard Medical School in January 2020, sponsored by the ACR. Several important themes emerged. Elements considered key to a peer-learning program include broad group participation, active identification of learning opportunities, individual feedback, peer-learning conferences, link with process and system improvement activities, preservation of organizational culture, sequestration of peer-learning activities from evaluation mechanisms, and program management. Radiologists and practice leaders are encouraged to develop peer-learning programs tailored to their local practice environment and foster a positive organizational culture. Health system administrators should support active peer-learning programs in the place of score-based peer review. Accrediting organizations should formally recognize peer learning as an acceptable form of peer review and specify minimum criteria for peer-learning programs. IT system vendors should actively collaborate with radiology organizations to develop solutions that support the efficient and effective management of local peer-learning programs.

Do patients who undergo multiparametric MRI for prostate cancer benefit from additional staging imaging? Results from a statewide collaborative.

OBJECTIVES: Prostate cancer (CaP) staging traditionally includes computed tomography (CT) and technetium-99m bone scintigraphy (BS) for assessment of lymph node (LN) and bone metastases, respectively. In recent years, multiparametric magnetic resonance imaging (mpMRI) has been used in diagnostic assessment of CaP. We sought to compare the accuracy of mpMRI to CT and BS for pretreatment staging. MATERIALS AND METHODS: Using the Michigan Urological Surgery Improvement Collaborative registry, we identified men undergoing pretreatment mpMRI in addition to CT and/or BS in 2012 to 2018. Imaging reports were classified as positive, negative, or equivocal for detection of LN and bone metastases. A best value comparator (BVC) was used to adjudicate metastatic status in the absence of pathologic data. mpMRI accuracy was calculated using pessimistic (equivocal=positive) and optimistic (equivocal = negative) interpretations. We compared the diagnostic performance of mpMRI, CT, and BS in detecting metastases. RESULTS: In total, 364 men underwent CT and mpMRI, and 646 underwent BS and mpMRI. Based on the BVC, 52 men (14%) harbored LN metastases and 38 (5.9%) harbored bone metastases. Sensitivity of mpMRI for LN metastases was significantly higher than CT (65-73% vs 38%, P < 0.005), and specificity of mpMRI and CT were 97% to 99% and 99% (P = 0.2-0.4), respectively. For bone metastases, BS sensitivity was 68% as compared to 42% to 71% (P = 0.02-0.83) for mpMRI. Specificity for bone metastases was 95% to 99% across all modalities. CONCLUSIONS: Using statewide data, mpMRI appears superior to CT and comparable to BS for detection of LN and bone metastases, respectively. Pretreatment mpMRI may obviate the need for additional staging imaging.

Integration and Diagnostic Accuracy of 3T Nonendorectal coil Prostate Magnetic Resonance Imaging in the Context of Active Surveillance.

OBJECTIVE: To evaluate the integration of 3T nonendorectal coil multiparametric prostate magnetic resonance imaging (mpMRI) at 2 high-volume practices that routinely use mpMRI in the setting of active surveillance. MATERIALS AND METHODS: This was an institutional review board-approved, Health Insurance Portability and Accountability Act-compliant, and dual-institution retrospective cohort study. Subjects undergoing 3T mpMRI without endorectal coil at either study institution over a 13-month period (August 1, 2015-August 31, 2016) were selected based on predefined criteria: clinical T1/T2 Gleason 6 prostate cancer, prostate-specific antigen <15 ng/mL, ≥40 years old, mpMRI within 2 years of prostate biopsy, and Prostate Imaging Reporting and Data System (PI-RADS) v2 score assigned. Subjects surveilled for Gleason ≥3 + 4 prostate cancer were excluded. The primary outcome was detection of Gleason ≥3 + 4 prostate cancer on magnetic resonance-ultrasound fusion biopsy, standard biopsy, or prostatectomy within 6 months following mpMRI. Positive predictive values (PPVs) were calculated. RESULTS: A total of 286 subjects (N = 193 from institution 1, N = 93 from institution 2) met the criteria. Most (87% [90 of 104]) with maximum PI-RADS v2 scores of 1-2 did not receive immediate biopsy or treatment and remained on active surveillance. Incidence and PPVs for PI-RADS v2 scores of ≥3 were the following: PI-RADS 3 (n = 57 [20%], PPV 21% [6 of 29]), PI-RADS 4 (n = 96 [34%], PPV 51% [39 of 77]), and PI-RADS 5 (n = 29 [13%], PPV 71% [20 of 28]). No Gleason ≥4 + 3 prostate cancer was identified for PI-RADS v2 scores of 1-3 (0 of 43 with histology). Following mpMRI and subsequent biopsy, 21% (61 of 286) of subjects were removed from active surveillance and underwent definitive therapy. CONCLUSION: The 3T nonendorectal coil mpMRI has been integrated into the care of patients on active surveillance and effectively stratifies risk of Gleason ≥3 + 4 prostate cancer in this population.

Leveraging Twitter to Maximize the Radiology Meeting Experience.

Over recent years, social media engagement has proliferated among physicians, health care systems, scientific journals, professional societies, and patients. In radiology, Twitter (Twitter Inc, San Francisco, California) has rapidly become the preferred social media engagement tool and is now an essential activity at many large radiology society meetings. Twitter offers a versatile, albeit simple, platform for anyone interested in engaging with others, regardless of title, stature, or geography. In radiology and other medical specialties, year-after-year increases in Twitter engagement before, during, and after professional society meetings continue with widespread positive feedback. This short-form messaging tool also allows users to connect and interact with high-impact individuals and organizations on an ongoing basis (rather than once a year during large meetings). Through live-polling, Twitter also has the power to gather global opinions on issues highly relevant to radiology's future, such as the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) or breast cancer screening. Also increasingly popular is "live-tweeting" of curated meeting content, which makes information from the meeting accessible to a global audience. Despite the promise of growing professional networks and enabling discussions that cross geographic boundaries, the risks of Twitter use during radiology meetings must be recognized and mitigated. These include posting of unpublished data without consent (eg, slide content captured on camera phones), propagation of misinformation, and copyright infringement. Despite these issues and with an eye towards professionalism, Twitter can nonetheless be used effectively to increase engagement among radiologists, radiology societies, and patients.

Personal Branding: A Primer for Radiology Trainees and Radiologists.

A radiologist's personal brand is a composite of many parts in one's professional life. In an age where work quality and digital footprints are tracked and measured more than ever before, it behooves radiologists to develop and curate their own individual brands in effective ways. Personal branding consists of the decisions we make, both consciously and unconsciously, which affect our reputation and the likelihood of seeking our services in the future for both patients and referring providers. As hospital systems are increasingly adjusting their systems to cater to better patient experiences, it is imperative that radiologists similarly adjust our practice patterns to accommodate the needs of the new paradigm of value-based care. It is no longer sufficient to only practice excellent clinical radiology; one's service experience to clinical providers, report quality, and digital presence must all be robust and compelling. Defining your brand and promoting your vision and quality standards have become as important to radiologists' future as keeping up with advancements in radiologic technology. One must select the proper platforms and types of interactions in which to engage from available social media options. Developing a consistent brand and presence in the work setting, on social media accounts, and in professional organizations at the local, national, and international levels is the ultimate goal. At present, very little, if any, formal training is provided on personal branding skills such as these in current residency curricula, and it is critical for radiologists to fill their gaps in knowledge through additional means.

Evaluating the Effect of Unstructured Clinical Information on Clinical Decision Support Appropriateness Ratings.

OBJECTIVE: To determine the appropriateness rating (AR) of advanced inpatient imaging requests that were not rated by prospective, point-of-care clinical decision support (CDS) using computerized provider order entry. MATERIALS AND METHODS: During 30-day baseline and intervention periods, CDS generated an AR for advanced inpatient imaging requests (nuclear medicine, CT, and MRI) using provider-selected structured indications from pull-down menus in the computerized provider order entry portal. The AR was only displayed during the intervention, and providers were required to acknowledge the AR to finalize the request. Subsequently, the unstructured free text information accompanying all requests was reviewed, and the AR was revised when possible. The percentage of unrated requests and the overall AR, before and after radiologist review, were compared between periods and by provider type. RESULTS: CDS software prospectively generated an AR for only 25.4% and 28.4% of baseline and intervention imaging requests, respectively; however, radiologist review generated an AR for 82.4% and 93.6% of the same requests. During the respective periods, the percentage of baseline and intervention imaging requests considered appropriate was 18.7% and 22.9% by prospective CDS software rating and increased to 82.4% and 88.7% with radiologist review. CONCLUSION: Despite limited effective use of CDS software, the percentage of requests containing additional, relevant clinical information increased, and the majority of requests had overall high appropriateness when reviewed by a radiologist. Additional work is needed to improve the amount and quality of clinical information available to CDS software and to facilitate the entry of this information by appropriate end users.

Utilizing time-driven activity-based costing to understand the short- and long-term costs of treating localized, low-risk prostate cancer.

BACKGROUND: Given the costs of delivering care for men with prostate cancer remain poorly described, this article reports the results of time-driven activity-based costing (TDABC) for competing treatments of low-risk prostate cancer. METHODS: Process maps were developed for each phase of care from the initial urologic visit through 12 years of follow-up for robotic-assisted laparoscopic prostatectomy (RALP), cryotherapy, high-dose rate (HDR) and low-dose rate (LDR) brachytherapy, intensity-modulated radiation therapy (IMRT), stereotactic body radiation therapy (SBRT), and active surveillance (AS). The last modality incorporated both traditional transrectal ultrasound (TRUS) biopsy and multiparametric-MRI/TRUS fusion biopsy. The costs of materials, equipment, personnel, and space were calculated per unit of time and based on the relative proportion of capacity used. TDABC for each treatment was defined as the sum of its resources. RESULTS: Substantial cost variation was observed at 5 years, with costs ranging from $7,298 for AS to $23,565 for IMRT, and they remained consistent through 12 years of follow-up. LDR brachytherapy ($8,978) was notably cheaper than HDR brachytherapy ($11,448), and SBRT ($11,665) was notably cheaper than IMRT, with the cost savings attributable to shorter procedure times and fewer visits required for treatment. Both equipment costs and an inpatient stay ($2,306) contributed to the high cost of RALP ($16,946). Cryotherapy ($11,215) was more costly than LDR brachytherapy, largely because of increased single-use equipment costs ($6,292 vs $1,921). AS reached cost equivalence with LDR brachytherapy after 7 years of follow-up. CONCLUSIONS: The use of TDABC is feasible for analyzing cancer services and provides insights into cost-reduction tactics in an era focused on emphasizing value. By detailing all steps from diagnosis and treatment through 12 years of follow-up for low-risk prostate cancer, this study has demonstrated significant cost variation between competing treatments.

Meaningful Peer Review in Radiology: A Review of Current Practices and Potential Future Directions.

The current practice of peer review within radiology is well developed and widely implemented compared with other medical specialties. However, there are many factors that limit current peer review practices from reducing diagnostic errors and improving patient care. The development of "meaningful peer review" requires a transition away from compliance toward quality improvement, whereby the information and insights gained facilitate education and drive systematic improvements that reduce the frequency and impact of diagnostic error. The next generation of peer review requires significant improvements in IT functionality and integration, enabling features such as anonymization, adjudication by multiple specialists, categorization and analysis of errors, tracking, feedback, and easy export into teaching files and other media that require strong partnerships with vendors. In this article, the authors assess various peer review practices, with focused discussion on current limitations and future needs for meaningful peer review in radiology.

Safe Use of Contrast Media: What the Radiologist Needs to Know.

Iodinated and gadolinium-based contrast media are used on a daily basis in most radiology practices. These agents often are essential to providing accurate diagnoses, and are nearly always safe and effective when administered correctly. However, reactions to contrast media do occur and can be life threatening. Therefore, it is critical for faculty and staff to know how reactions to contrast agents manifest and how to treat them promptly. The decline in renal function seen occasionally after intravenous administration of iodinated contrast agents is poorly understood and likely multifactorial, and its association with the contrast medium may be overemphasized. However, it is important that radiologists be aware of current understanding and strategies to decrease the incidence of renal dysfunction. Nephrogenic systemic fibrosis, a skin disease, is an adverse reaction related to use of some gadolinium-based contrast agents in patients with chronic renal failure. The types of gadolinium most often associated with this condition and the indications for withholding gadolinium are important and are discussed in this article. The use of enteric contrast agents and contrast agents during pregnancy and nursing are reviewed briefly. Current knowledge for safe use of contrast media and key concepts that all radiologists should know are summarized in this review.

The disruptive radiologist.

Radiologists interact with many individuals during daily practice, including patients, technologists, and other physicians. Some interactions may potentially negatively affect patient care and are termed "disruptive" behaviors. These actions are not uncommon and may begin during training, long before a radiologist enters clinical practice. The causes of disruptive behavior are multifactorial, and it is important that educators and radiologists in practice alike be able to identify them and respond accordingly. An escalated approach for both trainees and practicing radiologists is recommended, with substantial penalties after each incident that can include termination of employment. Training programs and practices must have clearly defined methods for confronting this potentially time-consuming and difficult issue.

The effect of clinical decision support for advanced inpatient imaging.

PURPOSE: To examine the effect of integrating point-of-care clinical decision support (CDS) using the ACR Appropriateness Criteria (AC) into an inpatient computerized provider order entry (CPOE) system for advanced imaging requests. METHODS: Over 12 months, inpatient CPOE requests for nuclear medicine, CT, and MRI were processed by CDS to generate an AC score using provider-selected data from pull-down menus. During the second 6-month period, AC scores were displayed to ordering providers, and acknowledgement was required to finalize a request. Request AC scores and percentages of requests not scored by CDS were compared among primary care providers (PCPs) and specialists, and by years in practice of the responsible physician of record. RESULTS: CDS prospectively generated a score for 26.0% and 30.3% of baseline and intervention requests, respectively. The average AC score increased slightly for all requests (7.2 ± 1.6 versus 7.4 ± 1.5; P < .001), for PCPs (6.9 ± 1.9 versus 7.4 ± 1.6; P < .001), and minimally for specialists (7.3 ± 1.6 versus 7.4 ± 1.5; P < .001). The percentage of requests lacking sufficient structured clinical information to generate an AC score decreased for all requests (73.1% versus 68.9%; P < .001), for PCPs (78.0% versus 71.7%; P < .001), and for specialists (72.9% versus 69.1%; P < .001). CONCLUSIONS: Integrating CDS into inpatient CPOE slightly increased the overall AC score of advanced imaging requests as well as the provision of sufficient structured data to automatically generate AC scores. Both effects were more pronounced in PCPs compared with specialists.