Effect of team training on improving MRI study completion rates and no-show rates.

PURPOSE: Magnetic resonance imaging (MRI) is a high-cost imaging modality, and an optimized encounter ideally provides high-quality care, patient satisfaction, and capacity utilization. Our purpose was to assess the effectiveness of team training and its impact on patient show-up and completion rates for their MRI examinations. MATERIALS AND METHODS: A total of 97,712 patient visits from three tertiary academic medical centers over 1-year intervals were evaluated, totaling 49,733 visits at baseline and 47,979 after training. Each center's MRI team received team training skill training including advanced communication and team training techniques training. This training included onsite instruction including case simulation with scenarios requiring appropriate behavioral and communicative interventions. Orientation and training also utilized customized online tools and proctoring. The study completion rate and patient show-up rate during consecutive year-long intervals before and after team training were compared to assess its effectiveness. Two-sided chi-square tests for proportions using were applied at a 0.05 significance level. RESULTS: Despite differing no-show rates (5-22.2%) and study incompletion rates (0.7-3.7%) at the three academic centers, the combined patients' data showed significant (P < 0.0001) improvement in the patients' no-show rates (combined decreases from 11.2% to 8.7%) and incompletion rates (combined decreases from 2.3% to 1.4%). CONCLUSION: Our preliminary results suggest training of the imaging team can improve the no-show and incompletion rates of the MRI service, positively affecting throughput and utilization. Team training can be readily implemented and may help address the needs of the current cost-conscious and consumer-sensitive healthcare environment. J. MAGN. RESON. IMAGING 2016;44:1040-1047.

Radiology Resident Remediation: Five Important Questions to Ask.

OBJECTIVE: Residents needing remediation are difficult to recognize, assess, and address. The purposes of this article are to review common signs that a resident needs remediation and the causes of the deficiencies and to detail a checklist for preparing to approach the resident. CONCLUSION: Radiology residents who need remediation generally have either academic or professionalism deficits, and their remediation programs should be tailored to the deficit. Having a clear definition of the problem while eliciting the resident's thoughts on the nature of and solution to the problem are instrumental in the solution.

Medicare's national coverage determinations in diagnostic radiology: examining evidence and setting limits.

OBJECTIVE: To systematically review and summarize the Center for Medicare and Medicaid Services (CMS) national coverage determination (NCDs) pertaining diagnostic imaging technologies from 1999 through 2010. METHODS: All NCDs pertaining to diagnostic imaging were identified from the Tufts Medical Center NCD database. The variables under study included the quality of the clinical evidence and the final coverage determination. The types of restrictions were categorized. We also categorized the final decisions as "positive coverage" or "no positive/no change in coverage" and assessed the correlation between positive coverage and other variables using Fisher exact test. RESULTS: Twenty-two of 152 (15%) NCDs pertained to diagnostic imaging technologies. The supporting evidence was judge to be good, fair, and poor in 5, 6, and 11 cases, respectively. Eleven technologies (50%) were covered with conditions, four (18%) deferred the coverage decision to local level, and two (9%) were completely not covered. In five instances there was no change to the prior coverage status. Of the 11 decisions resulting in positive coverage, 8 (73%) restricted use to specific population subgroups, 5 (46%) applied restrictions related to treatment, 4 were covered with evidence development, and 2 were restricted to care in specific settings. A significantly higher rate of positive coverage decisions was achieved if the available evidence was good (100% 5/5) or fair (83% 5/6) compared to technologies with poor evidence (10% 1/10) (P < .01). CONCLUSION: CMS has demonstrated a propensity to limit the use of advanced diagnostic imaging to scenarios in which appropriateness is supported by adequate evidence of clinical utility and improved outcomes with the quality of evidence being a significant factor on final decisions. Understanding the need for high-quality evidence and the types of limitations placed on coverage allows for appropriate planning for the incorporation of diagnostic imaging technologies into clinical practice.

Primary and metastatic vascular neoplasms: imaging findings.

OBJECTIVE: The purpose of this article is to review the imaging findings of vascular tumors. CONCLUSION: Tumors of the vasculature are a pervasive disease entity consisting of both primary and metastatic lesions. Cross-sectional imaging plays a pivotal role in the diagnosis and delineation of the extent of this entity. Recognition of the characteristic imaging presentation of each tumor at CT and MRI can facilitate prompt diagnosis and accurate staging.

Cost impact of diagnostic imaging for lower extremity peripheral vascular occlusive disease.

OBJECTIVE: The evaluation of peripheral vascular disease in the primary care setting is routinely performed by contrast-enhanced magnetic resonance angiography (CE-MRA) and digital subtraction angiography (DSA). However, limited data are available on the relative costs and clinical outcomes following these diagnostic procedures. The objective of this study is to assess and compare costs associated with diagnostic imaging in peripheral vascular occlusive disease (PAOD). METHODS: US veterans (n = 19,209) with CE-MRA or DSA for the assessment of PAOD from fiscal year (FY) 1999 to FY 2004. Main outcome measure(s) using the Department of Veterans Affairs' (VA) costing algorithms, cost, and log-cost of interventions (e.g., revascularization, stent, angioplasty), amputations or mortality rates within 30/90 days and 1 year of DSA or CE-MRA were compared, and adjusted for patient characteristics and disease severity using multivariate regression. Imaging modality selection bias was evaluated with propensity score, instrumental variables, and Heckman methods using untransformed costs and log-costs with smearing retransformation. RESULTS: Initial CE-MRA imaging was significantly more likely among patients with prior renal disease or bypass surgery [odds ratio (OR) > 2; P < 0.001], and less likely among patients with prior amputation, peripheral vascular disease (PVD), claudication, or other cardiovascular disease (OR < 0.7; P < 0.001). After adjusting for endogenous choice of initial imaging modality, 30-day treatment costs were US$3500-$4300 lower (P < 0.001) for patients with initial CE-MRA. Eighty-two percent of DSA imaging patients had no additional procedures or events within 30 days, and 65% at 90 days. Less than 3.2% (3.6%) of patients had any repeat imaging within 30 (90) days of initial imaging. CONCLUSIONS: Relative to DSA, CE-MRA imaging was associated with substantial treatment episode savings, beyond the US$950 direct savings in imaging cost per procedure. Substituting CE-MRA for DSA among those not planning or requiring any follow-up procedures within 30 days, could have reduced outpatient imaging costs by up to 55%, and reduced VA system costs by US$13.2 million over the six-year period.

A six-year study of diagnostic lower extremity imaging practice patterns and outcomes in the Veterans Affairs health care system.

BACKGROUND: The use of diagnostic imaging in the United States continues to increase, while investigations of the clinical implications following testing are lacking. The objectives of the present study are to describe the practice patterns and clinical outcomes that follow lower extremity diagnostic imaging. This is a retrospective cohort study with six years of data (1999 to 2004). METHODS: The sources of data for the present study were Veterans Affairs Hospital administrative and clinical databases. The study population included 19,209 American veterans who had either contrast-enhanced magnetic resonance angiography (MRA) or digital subtraction angiography (DSA) for the assessment of peripheral artery occlusive disease. Descriptive statistics of the characteristics were provided, as well as adjusted ORs for having interventions or complications following an imaging procedure. RESULTS: The number of patients initially imaged with a contrast-enhanced MRA increased from 1999 to 2004, while those imaged with DSA decreased. The overall imaging rate remained relatively constant. In the multivariate model adjusted for the risk of complications within 30 days of the initial imaging procedure, the risk of complications following DSA increased 2.29-fold (95% CI 1.60 to 3.30). More patients had an intervention following DSA (DSA 41% versus MRA 23%, P<0.0001) but were also twice as likely to have an intervention with an amputation (adjusted OR 2.36, 95% CI 1.79 to 3.12). CONCLUSIONS: The present study illustrates the need for prospective evaluation of diagnostic imaging to determine how best to employ screening strategies that will optimize diagnostic imaging and treatment in patients diagnosed with peripheral artery occlusive disease.

Three dimensional computed tomographic imaging in planning the surgical approach for redo cardiac surgery after coronary revascularization.

OBJECTIVE: Reoperative cardiac surgery after previous coronary artery bypass grafting represents a surgical challenge due to the potential for injury to patent coronary grafts, aorta or right ventricle. Standard preoperative imaging using a coronary angiogram and chest radiograph (CXR) often results in inaccurate assessment of mediastinal anatomy. We aimed to evaluate 3D volume rendered computed tomographic imaging as an adjunct to standard preoperative assessment of patients requiring cardiac surgery in whom coronary artery revascularization had been performed in the past. METHODS: Between January 2003 and January 2004, 33 patients with previous coronary revascularization referred for reoperative cardiac surgery underwent preoperative 3D CT imaging in order to optimize the surgical approach. The mean age in this patient population was 72+/-8 years. The combined evaluation of CXR and conventional angiography offered incomplete insight into pertinent mediastinal topography in 85% of patients (28/33). RESULTS: The correlations for distances of the left internal mammary artery (LIMA) to left anterior descending artery (LAD) graft from the midline and posterior sternum obtained by CT angiography (CTA) and CXR were poor, R=0.56 and 0.49, respectively. The correlation coefficients for distances between the right ventricle and the aorta to the sternum obtained by the same methods were similarly marginal, 0.58 and 0.48, respectively. The correlation coefficients for distances between the LIMA to LAD, circumflex and right coronary artery grafts from the midline obtained by CTA and conventional angiography were 0.54, -0.13 and 0.43, respectively. In seven patients (21%) the surgical strategy was modified based on the location of patent grafts in the mediastinum. The hospital mortality was 17% (5/29). Intraoperative injuries to vital structures were encountered in two patients (7%). No injuries to patent LIMA or the aorta were encountered. CONCLUSIONS: The 3D CT imaging technique is useful in defining the optimal surgical strategy for reoperative cardiac surgery. We found that CTA is superior to CXR and conventional angiography in defining the position of patent grafts and vital structures in relation to the midline and posterior sternum. Preoperative mapping of patent coronary grafts and other vital mediastinal structures reduces the morbidity of the reoperation through modification of surgical approaches.

Comparative study with a moving heart phantom of the impact of temporal resolution on image quality with two multidetector electrocardiography-gated computed tomography units.

OBJECTIVE: The objective of this study was to compare the temporal resolution-related image quality of electrocardiography-gated images acquired with two multidetector computed tomography (CT) units with a moving heart phantom, at similar fixed heart rates, using half-scan and multisector acquisition modes. METHODS: An adjustable moving heart phantom (Limbsandthings, Horfield, Bristol, UK) was used. Specific heart rates (47, 55, 64, 66, 69, and 73 beats per minute [bpm]) were chosen. On a General Electric CT unit (LightSpeed Plus; General Electric Medical Systems, Milwaukee, WI), retrospective half-scan and multisector mode protocols were performed. On a Siemens CT unit (Somatom Volume Zoom; Siemens, Forchheim, Germany), a retrospective half-scan mode was performed at 47, 55, and 64 bpm, and a two-sector mode was performed at 66, 69, and 73 bpm. Reformatted maximum intensity projection images were qualitatively compared and related to their temporal resolution. RESULTS: Half-scan mode protocols provided similar good results with both CT units up to 55 bpm. The two-sector mode improved image quality compared with the half-scan mode. High temporal resolution with the multisector mode provided the best results. CONCLUSION: For coronary artery imaging, acquisition protocols that provide the highest temporal resolution are mandatory. The multisector mode is one technique that allows high temporal resolution but may be clinically inappropriate at heart rates below 65 bpm or when heart rate variation is observed during scan time.