An Empirical Framework for Breast Screening Bundled Payments.

PURPOSE: In an effort to curb health care costs and improve the quality of care, bundled payment models are becoming increasingly adopted, but to date, they have focused primarily on treatment episodes and primary care providers. To achieve current Medicare goals of transitioning fee-for-service payments to alternative payment models, however, a broader range of patient episodes and specialty physicians will need opportunities to participate. The authors explore breast cancer screening episodes as one such opportunity. METHODS: The authors developed a bundled payment model for breast cancer screening and calibrated it using both a national sample of retrospective Medicare claims data and data from a private health system. The model includes alternative screening episode definitions, methods for calibrating prices, and an examination of risk and can serve as a general framework on which other cancer screening bundles could be crafted. RESULTS: The utilization of services associated with breast cancer screening and diagnosis is stable over time. The inclusion of high-risk patients in breast screening bundles did not cause substantial changes in estimated bundle prices. However, prices are sensitive to the choice of services included in the bundle. CONCLUSIONS: Breast cancer screening may provide a mechanism to expand the use of bundled payments in radiology and could serve as a framework for other episodic specialty bundles. Because screening bundles include costs for follow-up diagnostic imaging in addition to the initial screening mammographic examination, patient adherence to screening guidelines may improve, which may have profound effects on public health.

Spectrum and detection of musculoskeletal findings on trauma-related CT torso examinations.

This study aims (1) to evaluate the spectrum of musculoskeletal (MSK) findings detected on trauma-related torso CT exams performed in the emergency department and (2) to identify the findings of high clinical importance that are underreported. Following IRB approval, two fellowship-trained MSK radiologists independently reviewed 200 consecutive trauma CT torso examinations performed at a level 1 trauma center, focusing on MSK findings. Discrepancies were resolved by consensus. Findings were categorized as of high, moderate, or low clinical importance based on criteria established with an orthopedic trauma surgeon. Findings evident on only one series (scout, axial, or sagittal/coronal reformations) were documented. The consensus reading was compared to the final report. Unreported findings of high clinical importance were entered into our departmental QA system. Eighty-two percent (164/200) of the studies had at least one MSK finding. There were 433 total findings of varying importance and the overall detection rate was 61 % (266/433). The detection rate for high importance findings was 80 % (177/221) with the majority representing acute fractures (99 %). For findings of high clinical importance, the lowest detection rates were for fractures of the sternum, proximal humerus, and forearm. Of the high severity findings, 6.3 % (14/221) were detected only on sagittal or coronal reformatted or scout images. Twenty percent of musculoskeletal findings of high clinical importance on trauma-related CT torso exams were not reported. Fractures of the sternum, proximal humerus, and forearm were the most commonly missed fractures and review of scout and multiplanar reformations can increase detection.

A review of Charcot neuroarthropathy of the midfoot and hindfoot: what every radiologist needs to know.

Charcot neuroarthropathy (CN) occurs commonly in diabetic patients in the joints of the foot and ankle. Radiologists may be the first to suggest the diagnosis of CN and can facilitate prompt intervention and treatment if they are aware of the radiographic manifestations of CN and the signs of progression of disease. Radiologists should also become aware of the evolving treatment of the disease as focus is shifting toward early surgical intervention and limb salvage rather than amputation. Knowledge of preoperative assessment, the types of surgeries performed, and some of the encountered postoperative complications enable the radiologist to facilitate timely intervention by our surgical colleagues and be a valuable member of the management team.

Case report: Longitudinal stress fracture of the humerus: imaging features and pitfalls.

Longitudinal stress fractures are an uncommon injury in which a diaphyseal fracture line occurs parallel to the long axis of a bone in the absence of direct trauma. They have been described in the tibia and less commonly in the femur but apparently not in the upper limb. We report a longitudinal stress fracture occurring in the humerus of a 62-year-old woman who had a history of osteoporosis and had undergone recent surgery of the contralateral wrist. We present the radiographic, MRI, and CT features of the case and emphasize the difficulties in diagnosis caused by negative findings on early radiographs and by nonspecific bone marrow edema pattern on MRI. The risk of a contralateral upper extremity stress fracture from activities of daily living in a patient with osteoporosis whose other upper extremity is immobilized also is highlighted.

Bone and soft-tissue lesions: what factors affect diagnostic yield of image-guided core-needle biopsy?

PURPOSE: To assess lesion-related and technical factors that affect diagnostic yield in image-guided core-needle biopsy (CNB) of bone and soft-tissue lesions. MATERIALS AND METHODS: Institutional review board approval and verbal informed consent were obtained for a HIPAA-compliant prospective study of 151 consecutive CNBs of bone (n = 88) and soft-tissue (n = 63) lesions. Each CNB specimen was reported separately in the final pathology report. Diagnostic yield (total number of biopsies that yield a diagnosis divided by total number of biopsies) was calculated for all lesions and subgroups on the basis of lesion composition (lytic, sclerotic, soft tissue), lesion size (< or = 2, > 2 to 5, or > 5 cm), biopsy needle gauge, image guidance modality, number of specimens obtained, and specimen length (< 5, 5-10, or > 10 mm). The minimum number of specimens required to obtain a diagnosis was determined on the basis of the specimen number at which the diagnostic yield reached a plateau. Chi(2) And Wilcoxon rank-sum tests were performed in bivariate analyses to evaluate associations between each factor and diagnostic yield. Significant factors were evaluated with multivariate logistic regression. RESULTS: Diagnostic yield was 77% for all lesions. Yield was 87% for lytic bone lesions and 57% for sclerotic bone lesions (P = .002). Diagnostic yield increased with larger lesions (54% for lesions < or = 2 cm, 75% for lesions > 2 to 5 cm, and 86% for lesions > 5 cm [P = .006]). There was no difference in diagnostic yield for bone versus soft-tissue lesions or according to needle gauge or image guidance modality. Diagnostic yield was 77% for bone lesions and 76% for soft-tissue lesions (P = .88). Yield was 83%, 72%, 77%, and 83% for biopsies performed with 14-, 15-, 16-, and 18-gauge needles, respectively (P = .57). Yield was 77% with computed tomographic guidance and 78% with ultrasonographic guidance (P = .99). Diagnostic yield increased with number of specimens obtained and with longer specimen length; it reached a plateau at three specimens for bone lesions and four specimens for soft-tissue lesions. CONCLUSION: Diagnostic yield is higher in lytic than in sclerotic bone lesions, in larger lesions, and for longer specimens. Obtaining a minimum of three specimens in bone lesions and four specimens in soft-tissue lesions optimizes diagnostic yield.

Improved detection and characterization of adrenal disease with PET-CT.

Positron emission tomography (PET)-computed tomography (CT) combines complementary modalities, thereby providing useful structural and functional information for the detection and characterization of a variety of conditions affecting the adrenal gland. The coregistered information provided by PET-CT is often superior to that provided by CT or PET owing to a variety of pitfalls inherent in the use of either modality alone. In addition, PET-CT can prove invaluable in the differentiation between benign and malignant adrenal disease. However, this combined modality also has certain limitations. Benign entities such as lipid-poor adenomas may demonstrate increased uptake at 2-[fluorine 18]fluoro-2-deoxy-d-glucose PET while being indeterminate at standard CT. Moreover, the combined information from PET-CT will not always obviate additional studies or biopsy. Nevertheless, radiologists and nuclear physicians should be familiar with the common as well as the atypical manifestations of adrenal disease at PET and CT. They should also be meticulous in the performance and interpretation of PET-CT, which is crucial for optimal diagnosis and treatment.

Delayed gadolinium-enhanced magnetic resonance imaging of the meniscus: an index of meniscal tissue degeneration?

OBJECTIVE: Much attention has been focused recently on the need for a better understanding of the mechanisms and natural progression of knee osteoarthritis (OA), particularly in its early stages. One technique that has been used to investigate early OA is delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC), where T1(Gd) (T1 value after penetration of the MRI contrast agent gadopentate dimeglumine [Gd-DTPA(2-)]) is used as an index of the molecular status of articular cartilage. The goal of this study was to explore T1(Gd) in the meniscus and its relationship with articular cartilage T1(Gd) in knee dGEMRIC image data sets. METHODS: T1(Gd) maps of the meniscus and articular cartilage were made from knee dGEMRIC images obtained from prior studies of dGEMRIC of the knee in 21 asymptomatic subjects and 9 patients with self-reported OA. RESULTS: T1(Gd) of the meniscus covered a range of values (247-515 msec) and patterns (homogeneous and focal variations). In addition, T1(Gd) of the meniscus correlated with that of articular cartilage (R = 0.38, P = 0.037; R = 0.57, P = 0.001 for correlations of the medial posterior meniscus with the medial femoral and tibial cartilage, respectively; T1[Gd] of the anterior meniscus and lateral compartments also correlated, with R > 0.38 and P < 0.037), potentially demonstrating parallel degradative processes in the knee. CONCLUSION: While the biophysical basis for the T1(Gd) results relative to meniscus molecular structure needs investigation, these findings introduce a potential means of examining the time course of meniscal tissue change in the development and progression of arthritis.

Use of gadolinium chelate to confirm epidural needle placement in patients with an iodinated contrast reaction.

OBJECTIVE: When performing epidural steroid injections for the management of chronic back pain, imaging guidance and a limited epidurogram improve accuracy of needle placement and ensure appropriate delivery of the injectate into the epidural space. We describe our experience using a gadolinium chelate as an alternative contrast agent for limited epidurography in patients with a history of an iodinated contrast reaction. DESIGN: Thirty-eight of 2,067 (1.8%) epidural steroid injections performed in our department over a 25-month period (December 2003-January 2006) employed gadolinium. All injections were performed in the lumbar spine employing a paramedian interlaminar approach. Procedural notes and patient charts were reviewed to evaluate for immediate or delayed complications related to incorrect intrathecal or intravascular needle placement. A retrospective analysis of selected fluoroscopic spot images was performed to evaluate confidence of epidural needle placement; this analysis compared these spot images against those obtained from age- and gender-matched control patients in whom iodinated contrast was used to confirm needle placement. RESULTS: Real-time fluoroscopic guidance permitted confident visualization of an epidurogram at the time of procedure in all 38 cases as documented in the procedural report, and no procedure resulted in a complication due to incorrect needle placement. Retrospective review of fluoroscopic spot images revealed at least moderate confidence of epidural needle placement by both readers in 29/38 cases (76.3%). Fluoroscopic spot images obtained using gadolinium yielded significantly less confidence than images obtained in control patients whose procedures were performed using iodinated contrast (P < 0.01). However, operators were sufficiently confident in needle placement based on real-time fluoroscopic images (not available in our subsequent review) to inject anesthestic in all 38 cases, despite the immediate consequences that could result from intrathecal administration. During the same time period, there were 11/2,067 (0.5%) instances of intrathecal needle placement discovered during attempted epidurography despite the use of fluoroscopy for needle guidance and reliance on loss-of-resistance technique. CONCLUSION: Gadolinium chelate represents a safe and useful alternative contrast agent for confirmation of epidural needle placement in patients with an iodinated contrast allergy.

Significance of incidental thyroid lesions detected on CT: correlation among CT, sonography, and pathology.

OBJECTIVE: The purpose of our study was to determine the prevalence of malignancy in incidental abnormalities of the thyroid gland detected on CT and to determine the relative accuracy of characterizing these abnormalities on CT as compared with sonography and pathology. MATERIALS AND METHODS: We searched our department's computerized clinical database for all thoracic and cervical CT scans in which a new abnormality was incidentally identified in the thyroid gland from 1998-2001. Two hundred thirty patients with abnormal findings in the gland on CT subsequently underwent thyroid sonography, and 118 of the 230 patients underwent a diagnostic biopsy or resection. CT and sonographic images were directly reviewed to identify imaging features of each thyroid abnormality, including the location, size, appearance, and presence or absence of calcifications. Associations were evaluated using Fisher's exact test of significance and the Student's t test. The overall rate of malignant and potentially malignant lesions among these incidental abnormalities of the thyroid gland was calculated. RESULTS: CT findings matched the sonographic characterization in 122 patients (53.0%), correctly identified the dominant nodule but missed multinodularity in 69 (30.0%) patients, and underestimated the number of nodules in 24 (10.4%) patients. CT overestimated the number of nodules in 5 (2.2%) patients and was false-positive for lesions in 10 patients (4.3%). Ninety-one patients with a single or dominant nodule on CT had pathologic correlation: 7 nodules were malignant, 17 showed malignant potential, and 67 were benign. Of 27 patients with multinodular or enlarged thyroid glands on CT and histopathologic correlation, 2 lesions were malignant and 25 benign. The presence of punctate calcifications on CT significantly correlated to the presence of microcalcifications on sonography (p < 0.02). Benign nodules were significantly smaller (mean, 2.16 +/- 1.01 cm; range, 0.6-4.5 cm) than malignant and potentially malignant nodules (mean, 2.79 +/- 0.99 cm; range, 0.7-4.6 cm) (p = 0.01). Patients 35 years or younger who had a thyroid lesion on CT were more likely to have malignancy (p < 0.01). Overall, among incidentally detected lesions of the thyroid gland, there was at least a 3.9% rate of malignancy (95% CI: 1.8-7.3%) and 7.4% rate of malignant potential (95% CI: 4.4-11.6%). CONCLUSION: There is at least an 11.3% prevalence of malignant or potentially malignant lesions among incidental thyroid abnormalities detected on CT. Patients 35 years or younger who have incidental abnormalities have a significantly greater rate of malignancy. No CT feature reliably distinguishes benign from malignant lesions in the thyroid gland. CT underestimates the number of nodules relative to sonography, which suggests that sonography is a useful adjunctive test after the incidental detection of a thyroid abnormality on CT.

Fellowship directors' perceptions of the 2005 NRMP Radiology Fellowship Match.

RATIONALE AND OBJECTIVES: The aim of the study is to gauge radiology fellowship directors' experiences with the fellowship application process and perceptions of the National Resident Matching Program Radiology Fellowship Match, as well as compare these perceptions with those of senior residents. METHODS AND MATERIALS: An electronic survey was sent to 291 members of the Association of Program Directors in Radiology. Responses were compared directly with an earlier survey of senior residents who participated in the same cycle of the Fellowship Match. RESULTS: Sixty-seven respondents participated in the survey. Based on our estimates of the total number of US-based radiology subspecialty fellowship programs, this represents between 15.3% (67/438) and 24.2% (67/277) of all fellowship directors. Approximately three quarters (52/76 directors; 77.6%) participated in the Fellowship Match. Respondents believe that the match process makes the process fairer for all applicants (31/43 respondents; 70.5%) and primarily benefits residents (30/76 respondents; 60.0%), a significant difference compared with senior residents (P < .01). The majority of fellowship directors favor the current calendar and the ability to select internal candidates outside the Match. The majority of respondents believe that programs generally are not abiding by the rules of the Match (22/43 respondents; 51.2%), and at least 15 instances of rule violations were reported. A majority of fellowship directors favor continuing the Match in some form (26/42 respondents; 61.9%). CONCLUSION: Although there are significant differences in perception of the Match process between fellowship directors and senior residents, the majority of fellowship directors favor continuing the Match in some form. Several potential solutions, including explicit declaration of the number of available positions and strict enforcement of Match rules, may help improve the process in the future.

The impact of professional turf battles on radiology resident education: perspectives from the radiology class of 2005.

PURPOSES: To assess residents' exposure to professional turf battles, via a survey of the radiology residency class of 2005, and to assess perceptions about the causes, solutions, and impact of turf battles on resident education. METHODS: An electronic survey composed by the ACR Resident and Fellow Section was completed by 168 senior residents (a 18.9% response rate) enrolled in allopathic radiology residency programs from across the United States. RESULTS: The majority of respondents (153 of 168, 91.1%) perceive a loss of professional turf from nonradiologists. Areas most often perceived as being affected by lost professional turf were interventional radiology (136/168, 81.0%), cardiothoracic imaging (106 of 168, 63.1%), and ultrasound (88 of 168, 52.4%). The sense of lost professional turf was most often attributed to inadequate residency training in the affected subspecialities (87 of 168, 51.8%). The most commonly cited motivation for ongoing turf battles was reimbursement for diagnostic imaging and image-guided procedures as a motivator for nonradiologists. The majority of residents feel that the most effective ways to counter professional turf battles include the promotion of national physician-training standards for diagnostic imaging and image-guided therapies, the mandatory accreditation of all imaging facilities, and the development of performance standards that providers of imaging services must meet to qualify for reimbursement. CONCLUSIONS: The majority of resident respondents feel that professional turf battles have had a significant impact on their education. Methods recommended to counter professional turf battles mirror recent proposals by the ACR to support mandatory national quality, safety, and training standards for providers of diagnostic imaging.

CT perfusion in acute stroke.

As new treatments are developed for stroke, the potential clinical applications of CT perfusion (CTP) imaging in the diagnosis, triage, and therapeutic monitoring of these diseases are certain to increase. Technical advances in scanner hardware and software should no doubt continue to increase the speed, coverage, and resolution of CTP imaging. CTP offers the promise of efficient use of imaging resources and, potentially, of decreased morbidity. Most importantly, current CT technology already permits the incorporation of CTP as part of an all-in-one acute stroke examination to answer the four fundamental questions of stroke triage quickly and accurately, further increasing the contribution of imaging to the diagnosis and treatment of acute stroke.

The radiology class of 2005: postresidency plans.

PURPOSE: To examine the postresidency plans of the radiology residency class of 2005, including influences on and trends in the decision to pursue subspecialty fellowship training after residency. METHODS: An electronic survey composed by the ACR Resident and Fellow Section was completed by 416 senior residents (a 46.9% response rate) enrolled in allopathic radiology residency programs from across the United States, representing approximately 41.2% of the entire residency class. RESULTS: Eighty-seven percent (95% confidence interval 83.8% to 90.2%) of respondents plan to do fellowships immediately after residency, representing an increasing number, compared with published figures from the 1990s. Increasing age at the completion of residency was independently and significantly correlated with the decision not to pursue a fellowship. There has been a shift in the most popular fellowships, with an increased interest in musculoskeletal radiology fellowships and decreased interest in interventional radiology. Among residents not pursuing immediate fellowship training, the most common plans were private practice positions (48.1%), military obligations (22.2%), and nighthawk positions (9.3%). CONCLUSION: An increasing number of residents are electing to pursue subspecialty training after the completion of residency. Close monitoring of the postresidency plans of current residents may portend important trends in education, residency training, and changes in the radiology workforce.

The radiology class of 2005: the fellowship application process and perceptions of the NRMP fellowship match.

PURPOSE: To assess experiences and perceptions of the fellowship application process of the radiology residency class of 2005, including the 2005 National Resident Matching Program (NRMP) Radiology Fellowship Match. METHODS: An electronic survey composed by the ACR Resident and Fellow Section was completed by 416 senior residents (a 46.9% response rate) enrolled in allopathic radiology residency programs from across the United States. RESULTS: Residents generally agree with the timing of the current fellowship application calendar in the spring of the third year of residency. Respondents were divided over the issue of permitting internal candidates to fill positions outside of the match, although the majority felt that the process influences both applicants and programs to favor their own institutions to avoid the match process. Residents support requiring fellowship programs to declare the number of positions being filled through the match before applications are due (72.6%) or before rank lists are due (79.8%). Residents noted match rule violations, which threaten to undermine residents' confidence in the process. Residents were split over the future of the match: 23.1% favored continuing the match in its current form, 28.8% favored continuing the match with modifications, and 34.4% favored discontinuing the match entirely. CONCLUSION: Although the NRMP Fellowship Match was created to improve and standardize the fellowship application process, and although a majority of residents support continuing the match in some form, there are areas of concern, including adherence to the letter and spirit of the match rules, which must be addressed to galvanize support among residents in the future and ensure a fair process for fellowship applicants.