Abdominal aortic aneurysms revisited: MDCT with multiplanar reconstructions for identifying indicators of instability in the pre- and postoperative patient.

Rupture of an abdominal aortic aneurysm is commonly a fatal event. Multidetector computed tomographic (CT) signs of frank aortic rupture are usually readily apparent and widely understood. However, diagnosing an impending aortic rupture on the basis of imaging findings can prove more difficult. CT is the primary modality used for serial imaging in patients with aortic aneurysm and may show findings indicative of aortic instability. Therefore, it is critical that radiologists be familiar with the CT findings of aortic instability to avert the potential complications of hemorrhage, end organ or limb ischemia, and death. Various preoperative CT indicators have been previously described in both research investigations and review articles. A large baseline aneurysm size and a rapid increase in size over time are associated with a higher risk for rupture. The importance of obtaining accurate measurements with multiplanar reconstructions and the role of new semiautomated tools for obtaining accurate, reproducible measurements are discussed. Additional CT findings that reflect aortic aneurysm instability include luminal expansion with lysis of thrombus, intramural hemorrhage (ie, the crescent sign), periaortic hemorrhage, a penetrating atherosclerotic ulcer, and contained rupture (ie, the draped aorta sign). After open or endovascular aneurysm repair, CT is routinely used to monitor for graft complications. In this setting, radiologists should understand that the presence of an endoluminal stent or surgical graft does not preclude aortic rupture. Online supplemental material is available for this article.

Physician tiering by health plans in Massachusetts.

BACKGROUND: Physician tiering is an emerging health-care strategy that purports to grade physicians on the basis of cost-efficiency and quality-performance measures. We investigated the consistency of tiering of orthopaedic surgeons by examining tier agreement between health plans and physician factors associated with top-tier ranking. METHODS: Health plan tier, demographic, and training data were collected on 615 licensed orthopaedic surgeons who accepted one or more of three health plans and practiced in Massachusetts. We then computed the concordance of physician tier rankings between the health plans. We further examined the factors associated with top-tier ranking, such as malpractice claims and socioeconomic conditions of the practice area. RESULTS: The concordance of physician tiering between health plans was poor to fair (range, 8% to 28%, κ = 0.06 to 0.25). The percentage of physicians ranked as top-tier varied widely among the health plans, from 21% to 62%. Thirty-eight percent of physicians were not rated top-tier by any of the health plans, whereas only 5.2% of physicians were rated top-tier by all three health plans. Multivariate analysis showed that board certification, accepting Medicaid, and practicing in a suburban location were the independent factors associated with being ranked in the top tier. More years in practice or fewer malpractice claims were not related to tier. CONCLUSIONS: Current methods of physician tiering have low consistency and manifest evidence of geographic and demographic biases.