A detailed audit of reimbursement for abdominal CT in an academic practice.

RATIONALE AND OBJECTIVES: Declining fee schedules, decreasing operating margins, and increasingly stringent compliance regulations create a need for intense scrutiny and optimization of a radiology organization's billing and collection procedures. The authors' goal was to analyze the effectiveness of departmental professional billing procedures, identify controllable factors, and intervene when they could be improved. MATERIALS AND METHODS: A detailed audit of professional claims and payments was performed for all patients who underwent abdominal-pelvic computed tomography (CT) during July 1999 (n = 717). The adequacy of indication for the CT examination as given by the referring physician and modified by the radiology staff, the time required for claim generation, and the status of reimbursement within 120 days were assessed by an interdisciplinary team. After an intervention was performed to improve adequacy of the available clinical indication, the audit was repeated in December 1999 (n = 710). RESULTS: Despite a significant (P < .05) improvement in wording of clinical indications for billing purposes between July (68%) and December (85%), there was no significant change in reimbursement against gross charges. The vast majority of claims (97% in July, 99% in December) were generated in less than 30 days. At 120 days after the date of service, payments had been received that amounted to only 66% and 54% of discounted professional fees for July and December, respectively. For examinations performed in December, payment was delayed beyond contracted time periods in 138 cases (19%). CONCLUSION: Optimum billing and collection for imaging studies is an increasingly complex task. Even when substantial efforts are devoted to eliciting the proper indication for the study, reimbursement remains low primarily because of payer delays.

Radiology quality and performance metrics on the Web: a management information and communications tool.

RATIONALE AND OBJECTIVES: The purpose of this study was to demonstrate the feasibility of using the World Wide Web to communicate critical radiology quality and performance metrics to departmental and hospital management staff. MATERIALS AND METHODS: Data on report turnaround, appointment access, patient and physician satisfaction, and financial performance were harvested from a variety of sources. These were then standardized and condensed so they could be displayed electronically in a concise, information-dense fashion. RESULTS: The final product was a series of graphic materials on a single Web site. The most informative was a summary "spiderweb chart" that indicated the percentage of specified performance goals achieved for 12 operational parameters. These graphic materials were distributed to management staff monthly by means of e-mail. CONCLUSION: The use of simple Web-based technology facilitates the collection of key departmental performance data and the dissemination of these data to a wide audience.

Technical cost of radiologic examinations: analysis across imaging modalities.

PURPOSE: To determine the individual technical costs of general diagnostic radiographic, ultrasonographic (US), computed tomographic (CT), magnetic resonance (MR) imaging, and scintigraphic examinations and interventional radiology. MATERIALS AND METHODS: The Radiology Cost and Productivity Benchmarking Study method of the University HealthSystem Consortium, a cooperative group of academic medical centers, was modified and extended to the six imaging modalities in a tertiary care academic setting. Hospital billing and cost records were analyzed for fiscal year 1996. Costs were divided into labor and nonlabor categories and were allocated to individual imaging modalities on the basis of resources consumed. Physician cost and hospital overhead were not included. Unit costs were analyzed per technical relative value unit (RVU) and per examination. RESULTS: The costs per technical RVU for diagnostic radiography, US, CT, MR imaging, scintigraphy, and interventional radiology were $65. 06, $28.74, $20.95, $17.69, $42.19, and $89.03, respectively. The technical costs per examination for diagnostic radiography, US, CT, MR imaging, scintigraphy, and interventional radiology were $41.92, $50.28, $112.32, $266.96, $196.88, and $692.60, respectively. CONCLUSION: The method of unit cost analysis for individual imaging modalities was successfully tested in a tertiary care setting. The method should be adopted to allow cost comparison across many institutions, which will permit the promotion of best practices.

Modality interfacing: the impact of a relay station.

We evaluated the effect of a deploying a relay station on demographic discrepancies, image segmentation for routing, quality control (QC), and technologist workflow in a distributed architecture type picture archiving and communication system (PACS) environment. A currently existing PACS environment for computed tomography (CT) was evaluated before and after the implementation of a relay station for demographic error-rate and correct study routing to the workstations. Assessment of the technologists' perceptions with respect to numerous workflow factors was performed with a questionnaire. Statistical analysis was performed using a chi-square test. The demographic error rate for CT examinations was nearly abolished with relay station deployment (14.0% pre-Relay v 0.55% post-Relay, P < .001, chi2). The technologists' perception was favorable, with a substantial majority indicating that a positive impact is made on correcting demographic errors (90%), facilitating QC (67%), and ensuring proper routing (77%). A majority also felt the user interface was intuitive (93.3%) and preferred relay (90%) over film handling but that training should be provided both by didactic sessions and "hands on" time with a trainer. The times to perform tasks were favorable for the relay station (1 to 5 minutes) versus film production and handling (2 to 15 minutes). In conclusion, the relay station prospectively eliminates demographic errors, effectively segments images from the same study routing them to different workstations, and can be seamlessly integrated into the technologists' current workflow. This can be scalable and a lower cost solution as opposed to deploying dedicated PACS QC workstations.

Perceived features reported as nodules: interpretation of spiral chest CT scans.

RATIONALE AND OBJECTIVES: The purpose of this study was to evaluate nontarget locations identified in a study of lung nodule detection with spiral computed tomographic (CT) scans that compared cine and film presentations. MATERIALS AND METHODS: In a previous study of lung nodule detection, eight observers were asked to identify 10 nodule locations in each of five CT scans containing eight simulated nodules. In the current study, each nontarget location that was reported more than once in the previous study was inspected with a stack-mode display in both cine and static modes. The nontarget locations were evaluated for probable identity, shape, and distance from the peripheral lung surface. RESULTS: Fifty-two nontarget locations included clinically undetected pulmonary nodules (n = 12), lymph nodes (n = 2), unclassifiable structures (n = 2), pleural scars (n = 8), and vascular structures (n = 28). Five nontarget locations contained vessels with complex courses apparent only with cine mode. As a group, nontarget locations were significantly closer to the periphery than would be expected by chance (for all locations, P < .0001; for locations not touching the pleural surface, P = .013). CONCLUSION: The lower reporting threshold caused by the observer instructions to find 10 targets resulted in increased reporting of structure with a nodular appearance. The locations of these reports in the lung periphery can be attributed to the relationship between frequent disease and a nearly featureless background in the lung periphery.

Can academic radiology departments become more efficient and cost less?

PURPOSE: To determine how successful two large academic radiology departments have been in responding to market-driven pressures to reduce costs and improve productivity by downsizing their technical and support staffs while maintaining or increasing volume. MATERIALS AND METHODS: A longitudinal study was performed in which benchmarking techniques were used to assess the changes in cost and productivity of the two departments for 5 years (fiscal years 1992-1996). Cost per relative value unit and relative value units per full-time equivalent employee were tracked. RESULTS: Substantial cost reduction and productivity enhancement were realized as linear improvements in two key metrics, namely, cost per relative value unit (decline of 19.0% [decline of $7.60 on a base year cost of $40.00] to 28.8% [$12.18 of $42.21]; P < or = .001) and relative value unit per full-time equivalent employee (increase of 46.0% [increase of 759.55 units over a base year productivity of 1,651.45 units] to 55.8% [968.28 of 1,733.97 units]; P < .001), during the 5 years of study. CONCLUSION: Academic radiology departments have proved that they can "do more with less" over a sustained period.

Negative predictive value of imaging-guided abdominal biopsy results: cytologic classification and implications for patient management.

OBJECTIVE: Our purpose was to assess the negative predictive value of imaging-guided abdominal biopsy results and correlate it with cytology classification, lesion size, needle gauge, and cancer history. MATERIALS AND METHODS: A retrospective study was performed of 100 patients with proven diagnoses who had undergone imaging-guided abdominal biopsies showing no cells that were malignant or suspicious for malignancy. Specimens were classified as normal or benign, nondiagnostic, or atypical. Negative predictive value was calculated for each cytologic category, lesion size, needle gauge, and cancer history. Logistic regression analysis was performed to allow us to identify predictors of false-negative results. RESULTS: Overall negative predictive value was 67%. Other negative predictive values were normal or benign result, 78%; nondiagnostic result, 66%; and atypical result, 29%. Negative predictive value was greater when the lesion was large (> or =3 cm) (p = .031). Logistic regression analysis allowed us to predict a 9.3% chance of a false-negative result for a specimen of normal or benign cytology that was taken from a large lesion in a patient with no cancer history but an 87% chance of a false-negative when a specimen of atypical cytology was taken from a small (<3 cm) lesion in a patient with a cancer history. CONCLUSION: Imaging-guided abdominal biopsy specimens containing atypical cells should be viewed with caution. In patients without cancer, if a lesion is large and the specimen contains normal target organ or benign cells, the likelihood of a false-negative result may be low enough that imaging surveillance at appropriate intervals may be sufficient.

Web-based digital radiology teaching file: facilitating case input at time of interpretation.

OBJECTIVE: Our goal was to develop a software system that allows easy and rapid input of digital radiology images and text reports, at the time of interpretation, into an easily searchable electronic teaching file database using the Internet and the World-Wide Web protocols, servers, and browsers. CONCLUSION: Using the Internet, the World-Wide Web, and our software system, we can rapidly input digital radiology images and associated text reports into an easily searchable database accessed by privileged users. This inexpensive and simple method for building a digital teaching file database allows cross-platform access for users who have a Web browser.

Trends in the use of radiology with inpatients: what has changed in a decade?

OBJECTIVE: Our goal was to evaluate trends in the use of radiology with inpatients in the 10-year period of 1984-1993. MATERIALS AND METHODS: We retrospectively reviewed administrative data from a 751-bed, tertiary care hospital between October 1, 1983, and September 30, 1993 (Fiscal years 1984-1993). We coded each study by imaging technique: CT, MR imaging, sonography, nuclear medicine, or conventional studies (plain films and fluoroscopy). Echocardiography, cardiac catheterization, and angioplasty procedures were omitted. The number of admissions per year was adjusted for severity of disease (case-mix-adjusted admission [CMA]). We used relative value units to evaluate workload changes during the study period. We assessed significance of trends using linear regression analysis. RESULTS: The total number of imaging studies per CMA decreased during the study period (p = .0001). This was due to a decrease in the number of conventional studies (p = .0001) and sonograms per CMA (p = .02), despite significant increases in the numbers of CT (p = .005) and MR imaging (p = .0001) studies per CMA. No significant change existed in the number of nuclear medicine studies per CMA (p = .11). The global, professional, and technical relative value units per CMA rose during the latter half of the study. CONCLUSION: The overall number of imaging studies per CMA decreased during the decade, despite a significant rise in the use of CT and MR imaging, suggesting that these new imaging techniques are replacing older ones. To control further increases in overall imaging costs, priority should be placed on understanding the patterns of use for CT and MR imaging techniques and curbing their inappropriate use.

Influence of CT image size and format on accuracy of lung nodule detection.

PURPOSE: To evaluate the effect of reducing image size on observers' ability to detect lung nodules on computed tomographic (CT) scans. MATERIALS AND METHODS: Stimuli were 80 single sections from 13 normal chest CT studies. On half of the images, 3-5-mm-diameter nodules were superimposed electronically at random locations. Four observers viewed images in six formats and sizes that ranged from 6 on 1 (133 x 133 mm) to 80 on 1 (40 x 40 mm). The images were viewed at a fixed distance of 55 cm and at an unrestricted, variable distance. RESULTS: With the fixed viewing distance, nodule detection decreased with smaller image sizes. The area under the receiver operating characteristic curve (Az) decreased from 0.857 for the 6-on-1 format to 0.671 for the 80-on-1 format (P = .0001). With a variable viewing distance, Az decreased from 0.884 to 0.834 across all formats (difference not statistically significant). However, there was a significant drop in performance with the smallest images (P < .05). Overall, Az for the fixed and variable viewing distances was significantly different (P < .001). CONCLUSION: Reducing image size leads to decreased lung nodule detection on CT scans viewed at a fixed distance; however, the observer can compensate for the smaller image by adjusting the viewing distance.

Percutaneous abdominal biopsy: cost-identification analysis.

PURPOSE: To determine the difference in cost to providers of percutaneous abdominal biopsy as the first strategy versus surgical biopsy. MATERIALS AND METHODS: Cost of tissue diagnosis determination with percutaneous biopsy as the first strategy in 439 patients with an abdominal mass was estimated. Costs included direct hospital costs and professional costs of initial and repeat biopsy, follow-up imaging and clinic visits, surgical biopsy (when needed), and treatment of complications. The sum of these costs was compared with the estimated cost had the same patients undergone surgical biopsy instead, with no complications or need for follow-up or repeat biopsy. RESULTS: The total estimated cost of percutaneous biopsy as the first strategy ($543,245) was less than the cost had surgical biopsy been used alone ($1,919,867). The average per patient direct hospital cost of percutaneous biopsy ($800) was lower than that of surgical biopsy ($3,419). The average per patient professional cost of percutaneous biopsy ($438) was also lower than that of surgical biopsy ($955). Savings averaged $3,136 per patient, or $1,376,622 for the study period. CONCLUSION: Substantial health care cost savings may result by using a diagnostic algorithm in which percutaneous biopsy is the first strategy for establishment of a diagnosis in patients suspected of having abdominal malignancy.

Prostate cancer: relative effects of demographic, clinical, histologic, and MR imaging variables on the accuracy of staging.

PURPOSE: To determine the effects on the accuracy of staging prostate gland cancer of diagnostic prediction rules based on demographic, clinical, histologic, and magnetic resonance (MR) image variables. MATERIALS AND METHODS: A total of 200 cases from four medical centers were evaluated by nine radiologists experienced in MR imaging. The accuracies of the four diagnostic variables (age, prostate specific antigen level, Gleason tumor grade, and MR imaging findings) were measured, both singly and combined in a particular sequence, by calculating the area index of the receiver operating characteristic curve. RESULTS: The accuracy of staging with single variables (age, 0.58; prostate specific antigen level, 0.74; Gleason grade 0.73, MR image findings, 0.74) increased as the variables were optimally merged. The first two variables combined to yield an accuracy of 0.74; the first three combined to yield an accuracy of 0.81; and all four variables resulted in an accuracy of 0.86. In a clinically important subset of 69 cases for which antigen level and Gleason grade together were inconclusive for the purposes of staging, the addition of MR imaging findings resulted in an increase in accuracy from 0.55 to 0.73. CONCLUSION: Optimal merging of diagnostic test results yields an improvement in the accuracy of prostate cancer staging.

Spiral CT in the evaluation of flank pain: overall accuracy and feature analysis.

PURPOSE: Our goal was to assess test reliability and identify those features that have the strongest positive and negative predictive values in the diagnosis of renal colic using spiral CT. METHOD: Fifty non-contrast-enhanced CT scans (5 mm slice thickness) obtained in patients presenting with flank pain were reviewed by three radiologists blinded to the final diagnoses. The sensitivity, specificity, and positive and negative predictive values for nine pertinent findings were determined as compared to clinical follow-up. RESULTS: Twenty-nine cases had findings of ureteral obstruction. Findings with the strongest positive predictive values (> 0.90) were ureteral stone, hydronephrosis, hydroureter, periureteral stranding, and ureterovesical junction edema. Findings with the strongest negative predictive values (> 0.89) were absence of hydronephrosis and hydroureter. The areas under the receiver operating curves for Readers 1, 2, and 3 were 0.970 +/- 0.030, 0.942 +/- 0.036, and 0.982 +/- 0.020. CONCLUSION: Absence of hydroureter and hydronephrosis on spiral CT images should prompt a search for a diagnosis other than an obstructing ureteral stone.

Influence of visual distractors on detectability of liver nodules on contrast-enhanced spiral computed tomography scans.

RATIONALE AND OBJECTIVES: The authors evaluated the ability of observers to identify simulated nodules placed electronically on normal contrast material-enhanced computed tomography (CT) scans of the liver to assess the effect of nodule size and polarity on detection and localization. METHODS: Seven readers evaluated two sets of CT scans that contained 80 stimuli each. The simulated nodules were either darker or brighter than the contrast-enhanced liver and were 5.6-8.0 mm in diameter. Readers were asked to find the most suspicious-looking nodule on each section and rate the likelihood that the chosen location actually contained a nodule. RESULTS: The fraction of nodules found by each observer was substantially greater for dark nodules than for bright ones (0.679 +/- 0.03 vs 0.345 +/- 0.045, respectively [mean +/- standard error]). This difference was consistent for all nodule sizes. Additional analyses (including receiver operating characteristic curves of conditional responses) suggested that the presence of bright blood vessels distracted the readers and decreased their ability to find bright nodules. CONCLUSION: Normal vascular structures on contrast-enhanced CT scans of the liver impair an observer's ability to detect bright liver nodules.

Expediting the turnaround of radiology reports in a teaching hospital setting.

OBJECTIVE: The purpose of this study was to determine whether total quality management (TQM) techniques that had proved successful in a pilot study in one departmental section of a teaching hospital could be generalized for use by the entire radiology department. MATERIALS AND METHODS: Each departmental section developed interventions to improve its report turnaround time. These interventions were tailored to practice style and habits of each section. Commonly used interventions included electronic signature from the radiologist's home, a report-signing buddy system, elimination of a trainee signature requirement, accelerated transcription, structured reports, faster film delivery to reading desks, and training about the importance of radiology reports for clinical decision making. Specialized programs included computerized form-driven reporting and reports generated directly by computer voice recognition of radiologists' dictation. Our radiology information system provided data on each step in the reporting process. RESULTS: The TQM approach produced significant improvements in departmental total report turnaround time (-55%; p = .001), transcription time (-80%; p = .003), and signature time (-68%; p = .0004). Each section achieved significant gains. The sonography section initiated a computerized, form-driven reporting system and outperformed the rest of the department. CONCLUSIONS: TQM techniques can be expanded and generalized for department-wide projects in teaching hospitals.

A contrast agent delivery nomogram for hepatic spiral CT.

PURPOSE: A nomogram for hepatic spiral CT (SCT) was constructed based on randomization of patients into a prospective study using four different injection protocols. Its utility in a separate prospective randomized trial was subsequently evaluated in a new group of patients. METHODS: Thirty-nine patients randomized into four groups underwent SCT (Somatom-Plus S; 24 s exposure, 10 mm collimation, 10 mm/s) using 90 ml Omnipaque 240 (22 g I) at 2.5, 4, 5, or 6 ml/s. Peak and mean aortic and liver enhancement and time to peaks were measured and correlated with patients' age, weight, dose, rate, and contrast agent concentration, and a nomogram was constructed. In the validation experiment, 20 new patients were randomized to nomogram-guided and control groups for contrast dose administration during SCT. All patients underwent SCT (Somatom-Plus S; 32 s exposure, 10 mm collimation, 10 mm/s) using 90 ml Omnipaque 240 or 140 ml Hypaque 60 at 1.5-6 ml/s. Peak and mean aortic and liver enhancement and time to peaks were measured and correlated with patients' age, weight, dose, rate, and contrast agent concentration. Mean and peak aortic and hepatic enhancements were measured and rated by three blinded reviewers. RESULTS: Peak hepatic enhancement occurred 32 s after termination of contrast bolus administration in all groups. Correlation between the predicted and actual enhancement was very good (r = 0.7-0.9). Ninety-eight percent of the nomogram-guided group had optimal timing and utilized 10% less contrast agent than the control group. CONCLUSION: The phenomenon of peak hepatic enhancement occurring 32 s after the termination of contrast bolus regardless of injection rate may be of use in a nomogram for optimal contrast delivery for hepatic SCT.

Achievement of substantial cost reduction through joint purchasing by the radiology departments of a large vertically integrated health care system.

RATIONALE AND OBJECTIVES: The authors sought to lower costs by coordinating the purchase of equipment, supplies, and services in the radiology departments of a vertically integrated health system formed by the merger of two of the largest academic medical centers in New England. METHODS: The radiology departments at Massachusetts General Hospital and Brigham & Women's Hospital formed a cost-reduction task force to explore opportunities to jointly decrease costs. Data from the operating budgets of both institutions were collected and analyzed to find specific items within the budgets that could yield substantial cost savings. RESULTS: The project's first phase yielded over $810,000 in reduced costs from a system-wide annual budget of only $7 million for film and contrast material. Ongoing additional projects suggest that longer term contracts that contain steeper discounts with a decreased number of vendors will result in further decreases in the cost of materials and supplies. CONCLUSION: Coordination of purchasing by the radiology members of an integrated delivery system can yield substantial savings.