Diagnostic Imaging brings you daily coverage of the RSNA 2020 virtual annual meeting.

RSNA 2020: Nov. 30-Dec. 5

Case submitted by Elie Goulding, M.D., radiologist, to

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A young child presents with shortness of breath and distress. The chest X-Ray (CXR) demonstrates large left-sided lucency relative to right hemithorax. Deep sulcus sign is also demonstrated on the left side. There is also slight rightward mediastinal shift. Splaying of ribs is not definite, but there is suggestion of possible splaying at certain levels.

Evaluation for tension pneumothorax would be critical which would include mediastinal shift, splaying of ribs, for instance. Serial imaging would also be important to assess if the pneumothorax is worsening.

Articles

What is your diagnosis of a young child who presents with shortness of breath and distress? 

Image IQ Quiz: Patient Presents with Shortness of Breath and Distress

The number of CT and MRI cardiovascular images is rising in tandem with the number of radiologists who perform them. But, the number still remains small.

, investigators from St. Francis Hospital and Heart Center in New York laid out the details of cardiac imaging usage. This information, they said, could be used to set better reimbursement levels and design optimal training protocols.

With interest growing around implementing both cardiovascular CT and MRI for standard exams, there is a need for greater information about how these studies are being used and which providers are conducting them, they added.

“A clear understanding of the current state of cardiovascular MRI and CT in the United States would guide training recommendations and reimbursement and, in the future, affect clinical practice and use,” said James Goldfarb, Ph.D., cardiovascular imaging scientist, and Jonathan Weber, MPH, research analyst.

For their study, the co-authors pulled 2012 to 2017 data from Medicare Part B physician payments in the Provider Utilization and Payment Data Physician and Other Supplier Public Use Files. In addition to focusing on the number of CT and MRI exams, as well as the number of providers conducting them, Goldfarb and Weber also examined reimbursement and provider sex and location.

Based on their analysis, they determined that use of cardiovascular CT and MRI climbed during the six-year period by 75.5 percent for MRI and 97.4 percent for CT. However, these studies were overshadowed by nuclear medicine and echocardiography.

In addition, they identified changes among providers. By 2017, 582 physicians provided MRI, an 84.8-percent increase. For CT, the number of physicians was 1,645 -- an increase of 77.3 percent. The majority of providers were men, they said, and most were cardiologists or radiologists. Only 18 percent of providers offering MRI were women, as were 13.3 percent of those offering CT.

But, even though use climbed during the study, the amount of reimbursement reflected the lower implementation rates compared to other cardiovascular imaging tests. From 2012 to 2017, MRI and CT payments were $16.2 million and $55.8 million, respectively. However, reimbursement for echocardiography and nuclear medicine was much more substantial -- $5.9 billion and $4.2 billion, respectively.

Despite the lower use and reimbursement rates, radiologists still need to have these studies in their arsenal, and they must be ready to offer them when requested, said another industry expert in an 

. It is incumbent upon the radiologist to be prepared as these scans grow in popularity, said Andrew J. Bierhals, M.D., MPH, associate professor of radiology at Washington University in St. Louis and radiologist at Mallinckrodt Institute of Radiology.

“How does this impact the radiology profession?” he wrote. “First and foremost, there will need to be enough radiologists to ensure timely care as these services are increasingly being demanded by referring physicians. Second, radiologists, including those in general practice, will need understanding and training in cardiac CT and MRI.”

More radiologists are providing CT and MRI services, but these studies still fall behind echocardiography and nuclear medicine.

Cardiac CT and MRI Use Are Up, But Still Lagging Behind Other Heart Studies

In this week’s preview, here are some highlights of what you can expect to see coming soon:

It is no secret that screening mammography has a beneficial impact on reducing deaths related to breast cancer. But, what does that effect really look like – how significant can it be? This week, look for coverage of how participating in routine screening mammography actually impacts mortality rates.

Later this week, the European Congress of Radiology (ECR) will host its 2021 virtual annual meeting. 

 will bring you the latest news across all the modalities, as well as the details you need for greater workflow productivity and improved facility management. Watch for coverage to begin mid-week.

Recent research revealed that transgender patients have had mixed results – at best – with their radiology encounters. Nearly 75 percent of these patients have reported at least one negative experience with an imaging provider. This week, 

will publish coverage of a study published in the 

Journal of the American College of Radiology 

about best practices for radiologists to provide the highest level of care possible for transgender patients.

For additional coverage on imaging transgender patients

Here's what to expect this week on Diagnostic Imaging.

Diagnostic Imaging's A Look Ahead: March 1, 2021, to March 5, 2021

I’ve previously mentioned how this column prompts people to seek my thoughts on matters teleradiological. Go figure: Write a few hundred pages on a subject, and you’ll at least appear to know something about it.

As stated in the past, I find it gratifying and flattering when I get these inquiries. They also have an interesting side-effect, a la “you cannot touch without being touched.” When someone reaches out to me like this, they invariably bring me info I didn’t have. Even if all they have to offer is their personal experience, the sharing of wisdom is a two-way street. I gain a greater understanding of what’s doing out there in the radiology world with each of these interactions.

Most frequently, these folks are trying to learn the lay of the telerad-land: How do the various players differ? Compensation is, of course, a major interest, but not the only one. Other variables include hours needing coverage, available work volume, and less readily quantified things like the infrastructure or “personality” of a given telerad entity.

It might be interesting to puzzle at how/why such an information void exists, but most people contemplating a new gig in telerad—whether changing from a previous one or leaving a more conventional brick-n-mortar job—really just want answers to their questions. And, there isn’t any one place they can go to find it all.

Regularly perusing job listings, online forums, and social media turns up details here or there. Perhaps you’re lucky and know a savvy colleague who has good nuggets of info to share. You can try contacting each of the telerad entities – or recruiters – directly, but that can be a lot of legwork, and you wind up on a bunch of mailing-lists. You also only find out about the ones who made themselves visible in the places you thought to look.

So, it occurred to me that an awful lot of rads are going it alone—fumbling around in the dark with barely a candle’s worth of light to show them the way—when a shared approach could be far more effective for everyone involved. Multiple candles = greater illumination.

Some might not need this. Their Google-fu is strong, and/or they have the time and temperament to leave no stone unturned as they gather all of the details they could want. They might prefer to hoard their information; they found it all, why let someone else benefit? (Although I suggest that, once you’ve landed the best gig you could find, you have nothing to lose by sharing its details with others.)

For everyone else, I propose the Teleradiology Information Exchange (TIE, if you like). A central clearinghouse where rads can go to share their intel. A capable programmer or someone with money to throw at the situation might create an actual webpage for the purpose; for the time being, I simply offer my 

. There’s pretty much no traffic there other than what I post myself. If that ever changed, I could always make a new page exclusively for the TIE…but let’s not prematurely create a second page for me to monitor, shall we?

A simple format lends itself most easily to browsing and comparison, so I’d suggest a brief snapshot for any given telerad entity, easily fitting in a Tweet. Something like:

Obviously, real life isn’t so cut-and-dried. Tidy little templates like these leave out plenty of details in which devils may dwell. Fortunately, Twitter allows for those to be filled in via comments: A given rad would post his XYZ Telerad snapshot, for instance, and might make the first comment in the ensuing thread: “I work in XYZ right now, and here’s what I think of it…” or “I’m thinking of applying to ABC, and this is what they’re telling me.”

Others could, then, chime in with suggested corrections, additional salient details they happen to know about the telerad entity in question, or questions if they want to know more about it. The thread for a given entity could get as lengthy/detailed as participants made it…but, the tidy snapshot would never get “buried” by the chatter.

However, times do change, and next year XYZ might not match its current snapshot. It cuts the per-RVU rate to $19, for instance, or it now offers a W2-with-benefits option. Such changes would warrant someone making a new posting for it. Rather than deleting the previous one, I’d be inclined to leave it, maybe with the first comment in the new posting advising readers that this is an update, so they could see what had been said before and keep tabs on how XYZ is changing over time.

Twitter allows a page-owner to remove comments and even block visitors, so I’d definitely take action against folks displaying sufficiently trollish behavior (including repeated posting of disinformation to wrongly smear or hype telerad entities). However, the main idea is to share information, and people do develop justified strong opinions for or against rad groups. I would, thus, try to keep my moderation to minimal intrusiveness.

A benefit to all of this, beyond simply sharing information with colleagues: As things stand, with rads largely acting in an information vacuum, telerad companies have a huge advantage when it comes to setting terms. The companies know what’s doing in the field, with employees or consultants to advise them on the matter. A lone rad does not.

Thus, an outfit like XYZ Telerad can offer per-RVU rates below what the rest of the industry is paying: They have a strong recruitment machine to make more noise than the competitors, and they know that there are enough telerads out there who won’t know that there are better deals to be had. This goes away in a hurry if the vast majority of telerads have somewhere to go and see that XYZ has a bunch of competitors who are hiring with better terms.

Net result: A lot of rads wind up with better gigs, and outfits like XYZ are forced to improve their offerings if they still want to fill their virtual seats. The balance of power shifts in favor of working rads.

Follow Editorial Board member Eric Postal, M.D., on Twitter:

Sharing the details of teleradiology companies can level the playing field for all.

The Teleradiology Information Exchange

African American women have significantly less access to digital breast tomosynthesis (DBT) that do their white counterparts, according a study published recently in the 

Journal of the American College of Radiology

Even though DBT improves cancer detection and reduces recall rates, researchers from PennMedicine found that, based on their study population of more than 385,000 women, only 44 percent of African American women undergo DBT. Among Asian and white women, the rates of 63 percent and 61 percent, respectively.

This inequity in access presents a significant problem because African American women are more likely to be diagnosed with more aggressive forms of breast cancer at younger ages. Having easier, more consistent access to could greatly improve their outcomes.

Although radiologists and mammographers do not order DBT exams for these women, they do have a role to play in improve access and reducing the inequity, said Linda Blount, MPH, president and chief executive officer for Black Women’s Health Imperative, a non-profit organization dedicated to improving health and wellbeing for African American women and girls.

Videos

Radiologists may not order a DBT exam for African American patients, but they can participate in improving access to the screening.

The Radiologist's Role in Improving DBT Access Equity

Focused ultrasound may be used to ignite an immunological healing response in patients with Alzheimer’s disease – and MRI can help providers see the results.

Based on the results of a first-in-kind clinical trial from West Virginia University (WVU), investigators from WVU School of Medicine and the Rockefeller Neuroscience Institute (RNI) showed that ultrasound can effectively cross the blood-brain barrier to target the hippocampus. They published their results recently in 

“The blood-brain barrier has long presented a challenge in treating the most pressing neurological disorders,” said Ali Rezai, M.D., RNI executive director and principal investigator of the clinical trial. “The ability to non-invasively and reversibly open the blood-brain barrier in deep brain areas, such as the hippocampus, offers a new potential in developing treatments for Alzheimer’s disease.”

This is where focused ultrasound comes in, said Rashi Mehta, M.D., associate professor of neuroradiology at WVU.

“Focused ultrasound is an innovative technique and new way of approaching brain diseases, including Alzheimer’s disease,” she said. “Novel technique are needed for Alzheimer’s disease since traditional approaches have not proven effective.”

In this trial, Mehta’s team used ultrasound to target the hippocampus because of the integral role it plays in learning and memory. They enrolled three women – ages 61, 72, and 73 – who had early-stage Alzheimer’s disease and underwent three ultrasound treatments. Each therapy session, conducted at two-week intervals, used a 220-kHz transducer to open the blood-brain barrier and administer a micro-bubble contrast agent that focused on the hippocampus and entorhinal cortex.

Using 3.0T MRI with gadolinium-enhancement dye, the team saw the changes that took place post-treatment in each patient’s brain. The images revealed the dye moving along the course of draining veins after each procedure. According to their analysis, the MRI images clearly showed the post-procedure contrast enhancement within the targeted brain volumes, indicating treatment had created an immediate, precise blood-brain barrier opening. In addition, they said, parenchymal enhancement was resolved within 24 hours after treatment, confirming that the blood-brain barrier had re-sealed.

It is important to note, she said, that the treatment produced no negative effects. Additionally, the team did not use any medication in this clinical trial – the ultrasound treatment was enough, by itself, to prompt a possible immunological response.

“This imaging pattern was unexpected and enhances our understanding of brain physiology,” Mehta explained. “The glymphatic system, which is a fluid-movement and waste-clearance system that’s unique to the brain, has been studied in animals, but there is controversy about whether this system truly exists.”

The imaging pattern they discovered, she said, not only supports the contention that the system exists in humans, but also that focused ultrasound may be able to modulate the system’s fluid movement patterns and immunological responses. Their evaluation of the MRI findings also points to a possible immunological healing response around the draining veins after the procedure.

“This observation may be an important clue in understanding the physiological mechanism by which the focused ultrasound procedure modifies brain amyloid levels and might be used to treat patients with Alzheimer’s disease and other brain disorders,” she added.

Work within the trial is still ongoing. Ultimately, Mehta said, the team wants to be able to assess whether focused ultrasound can reduce amyloid plaque build-up in patients with Alzheimer’s disease. The next step is to enroll more participants and look at the treatment’s long-term effects, examining its safety and efficacy for slowing – or potentially reversing – the progression of the disease.

Images reveal ultrasound therapy can effectively open and close the blood-brain barrier, opening the door for potential new Alzheimer’s treatments. 

MRI Shows Focused Ultrasound May Induce Immunological Response in Alzheimer’s Patients

Radiologists can classify breast lesions more accurately if they use artificial intelligence algorithms fueled by 4D data captured with dynamic contrasted-enhanced MRI (DCE-MRI), new research has found.

investigators from the University of Chicago outlined their method for fusing the 4D volumetric and temporal details gleaned from DCE-MRI with 2D deep-learning breast lesions analysis. Using maximum intensity projection (MIP) of lesion features that are pulled from four dynamic time points during a DCE-MRI via a deep-learning algorithm can provide better lesion classification, they said.

“Incorporating 4D information in DCE-MRI by feature MIP in deep transfer learning demonstrated superior classification performance compared with using MIP images as input in the task of distinguishing between benign and malignant breast lesions,” said the team led by doctoral student Qiyuan Hu, noting that their method outperforms the existing MIP strategy that only uses one post-contrast subtraction image.

This new method is the second attempt by University of Chicago researchers to use 4D information from DCE-MRI. The first iteration, dubbed image MIP, collapsed suspicious 4D DCE-MRI areas of interest from second post-contrast subtraction images down into 2D MIP, and, its results were better than those rendered by 3D-based methods.

“Instead of collapsing the volumetric information at the image level to form MIP images, we do so at the feature level by taking the maximum of CNN features along the axial dimension for a given lesion directly within the deep neural network architecture,” they said.

To gather more substantive temporal information, this method – called feature MIP – incorporates subtraction images from four dynamic points in the DCE sequence that are, then, put into red, green, and blue CNN channels. The team postulated that this new method might perform better in distinguishing between benign and malignant breast lesions because it might better leverage DCE-MRI’s volumetric information.

They set out to prove their hypothesis by using a retrospective dataset of 1,990 distinct lesions – 1,494 malignant and 496 benign – from 1,979 women. With a training and validation set of 1,455 lesions gathered between 2015 and 2016, Hu’s team trained linear support vector machine classifiers to characterize lesions as benign or malignant based on features extracted from the CNN.

Based on their analysis, the team determined that, on an independent 535-lesion test set, image MIP and feature MIP produce areas under the curve of 0.91 and 0.93, respectively, with the feature MIP method outperforming image MIP.

The team said they plan to expand this method to T2-weighted and diffusion-weighted MRI sequences in multi-parametric MRI, using images gathered from other medical centers and groups. Doing so, they concluded, will allow them to evaluate how their method performs across manufacturers, protocols, and patient groups.

New method can help providers distinguish between benign and malignant breast lesions.

4D-Fueled AI with DCE-MRI Improves Breast Lesion Characterization

Welcome to Diagnostic Imaging’s Weekly Scan. I’m senior editor, Whitney Palmer.

Before we get to our featured interview with Linda Blount, MPH, president and chief executive officer for Black Women’s Health Imperative about the inequities of access to digital breast tomosynthesis, here are the top stories of the week.

Adding a radiomics-based machine learning algorithm to CT colonography allows for the differentiation between benign and pre-cancerous polyps picked up on colorectal cancer screening. To date, radiologists have not been able to make that determination using CT colonography, but thanks to work from German 

, it is possible to do so with high sensitivity and specificity. They built a machine algorithm that uses radiomics to extract quantitative image features that predict whether a polyp will develop into cancer. They trained the algorithm on 169 CT segmentations from 107 colorectal polyps from 63 patients and tested it on 118 segmentations from 77 polyps from 59 patients. Using random forest analysis, they determined their algorithm could accurately differentiate benign and pre-malignant polyps with 82-percent sensitivity and 85-percent specificity with an area under the curve of 0.91. Ultimately, the team said, incorporating a machine learning-derived algorithm into CT colonography can make it an even better colorectal cancer screening tool.

New brain MRI images have shown that COVID-19 can create leukoencephalopathy, a rare condition that affects white brain matter. Currently, the industry does not have defining criteria for COVID-19 disseminated leukoencephalopathy (CRDL), so researchers from the University of Pennsylvania investigated whether identifying signs was possible, and they published their findings in the 

. After examining 2,820 COVID-19-positive patients who were hospitalized between March 2020 and June 2020, they determined 59 patients underwent brain MRI. Those scans revealed six patients (10.2 percent) had findings that suggested CRDL, such as extensive confluent or multifocal white matter lesions, micro-hemorrhages, diffusion restriction, and enhancement. Other patients also had evidence of multiple sclerosis and small vessel ischemic disease white matter lesions; acute, subacute, and chronic infarcts; abnormal basal ganglia signal from hypoxemia; and micro-hemorrhage associated with acute, subacute, and chronic infarcts. The team did note that their findings could overlap with findings for other conditions, but they maintained that radiologists must remain alert to potential presentations of CRDL.

While CT is typically used in the angiography suite, new research published in 

 shows that using MRI instead can help providers determine whether to continue to thrombectomy, the place stents, or to administer anti-thrombotic medications with patients who have suffered acute ischemic stroke. In a retrospective study of patients who received endovascular intervention for acute ischemic stroke between July 2019 and May 2020, a team from the University of California at San Francisco determined that of 47 patients who underwent stroke intervention, 12 had X-ray angiography with MRI. Based on their analysis, including MRI directly impacted treatment decision for all 12, including whether to proceed with mechanical thrombectomy, to place intracranial stents, or whether to administer antithrombotic medication. But, while these advancements show promise, other experts said that streamlining workflow to reduce transfer time between the angiography unit and the MRI is critical because, with stroke, “time in brain.”

 spoke with Linda Blount, MPH, president and chief executive officer for Black Women’s Health Imperative about recent 

 that reveals black women do not have equal access to digital breast tomosynthesis despite better cancer detection and lower recall rates associated with the screening. She discussed what these inequities mean for this patient group and what can be done to alleviate the disparities. Here’s what she had to say.

CT Colonography & Tumor Differentiation; COVID-19 & Leukoencephalopathy; MRI, the Angiography Suite, and Acute Ischemic Stroke; Plus, DBT, African American Women, & Decreased Access

Diagnostic Imaging's Weekly Scan: Feb. 22, 2021, to Feb. 26, 2021

The statistics speak volumes. Approximately 30.3 million American adults have been diagnosed with heart disease, according to the Centers for Disease Control and Prevention (CDC). Moreover, cardiovascular disease is the No. 1 cause of death in the United States — responsible for taking the lives of 659,041 people in 2019 alone.

U.S. cardiologists have their work cut out for them. The specialty ranks among the busiest and most demanding, with a large volume of cases, as well as the need to respond to emergencies quickly. Experts say the challenges of the next decades will be many as the prevalence of various heart diseases will remain high due to a range of factors. These include family history of heart disease, poor diet, physical inactivity, obesity, and smoking, for example.

With such a pressing task, cardiologists are seeking the best possible medical technologies to help them properly diagnose and treat patients and improve overall outcomes. Medical imaging has come a long way. Today’s cardiologists have cutting edge diagnostic imaging tools at their disposal, and that’s an important first step.

But, imaging is only as good as its availability or accessibility. Workflow challenges are among the biggest hurdles for today’s cardiologists. The inability for a clinician to see the studies he or she needs at any given moment can literally mean the difference between life and death for a patient.

Fortunately, there is a solution to the myriad of workflow obstacles in the cardiac care space. A robust enterprise imaging technology can offer speedy access to images. But, it can do a whole lot more, too, like increase efficiencies, enhance collaboration, boost patient engagement, and help drive better outcomes.

Cardiology Challenges Demand an Enterprise Solution

A specialty that currently treats more than 92 million Americans conducts an enormous amount of testing and imaging. Providing anywhere, anytime access to growing cardiology datasets is a tall order, and organizations are under pressure to make data secure and readily available, both inside and outside the organization.

Disparate imaging and reporting systems in various departments is often a challenge, too. To enhance collaborative care, cardiologists need to share images with radiologists and other specialists, but very often their viewing tools are different, impeding this process.

Add to this the fact that we live in an era of mergers and acquisitions, where uniting hospitals often brings legacy systems that don't connect with one another—making the sharing of images a cumbersome process.

Finally, in the cardiac care space, reporting can be burdensome. The need to manually populate increasing volumes of clinical information into reports creates a bottleneck on cardiologists’ clinical workflows.

The upshot: The traditional Cardiology PACS is no longer a sustainable tool. To enable the best possible cardiac care and support the entire healthcare organization, Cardiology PACS solutions must evolve to function as a comprehensive enterprise imaging system.

, a next-generation PACS visualization platform that unites radiology, cardiology, and enterprise imaging through a single, zero-footprint PACS viewer.

This best-in-breed technology supports interoperability and access to the whole patient record—and that’s making a difference in patient care. For cardio teams, it enables on-demand, secure access to the holistic patient record which is having a positive impact on both workflow efficiencies and clinical outcomes.

Minnesota-based North Memorial Health is one of the top-rated hospitals in the nation for cardiovascular care. North Memorial’s Heart & Vascular group is led by a distinguished team of cardiologists and cardiothoracic surgeons, ensuring professional expertise of the highest standard.

When it came to medical imaging and reporting efficiencies, the cardiac group struggled. As a large, multi-site health system, North Memorial’s workflow issues and pain points were many.

For starters, various departments were using disparate solutions—impeding smooth and speedy workflow. For example, the health system’s cath lab, echo lab, vascular lab and nuclear medicine department all connected to different imaging and reporting systems. In addition, the organization’s legacy application lacked reporting customization capabilities.

North Memorial knew it was time for a more modern solution, including enterprise imaging. The team opted to install Fujifilm’s 

, a next-generation server-side rendering solution designed specifically to help streamline image review and reporting across cardiovascular modalities.

Synapse Cardiology PACS was designed to improve cardiology PACS workflow. It was built with cardiologists—and cardiac patients—in mind. It includes a secure image management and reporting platform that meets the needs of busy cardiologists’ caseloads, affording them proper and efficient reporting to continuously advance the quality of patient care.

This powerful technology simultaneously streamlines cardiologists’ workflow, image review, and advanced reporting, eliminating bottlenecks and allowing more efficient care to flourish.

Enhanced Efficiencies, Collaboration, Patient Engagement

Addressing workflow problems with enterprise imaging technology really does have a direct link to improving cardiac care. The North Memorial team is experiencing many benefits thanks to Synapse Cardiology PACS.

The consolidation of all diagnostic cardiology images and data means cardiologists work more efficiently by having all relevant information on one platform at the time of reporting.

Advanced reporting templates are improving workflow, too. North Memorial physicians actually helped design templates that maximize efficiencies while they're reading—freeing up valuable time that can now be spent focusing on patient care.

And the server-side technology is exceptionally speedy. That means physicians can have their procedure report into the North Memorial Health EHR almost instantaneously.

Perhaps one of the greatest benefits is that Synapse Cardiology PACS displays the complete patient record and provides access across cardiology and radiology PACS—a merge of cardiology and radiology imaging designed to improve clinical care. In fact, this dual ability is one of the things that makes the system so unique.

For example, cardiologists can evaluate a patient’s ECG in Synapse Cardiology alongside a chest X-ray in Synapse Radiology PACS—leading to quicker treatment decisions.

Clinicians can work anywhere, anytime and immediately see images they need to interpret. Instead of being limited to the cath lab, for example, they can access images and create reports from home.

Equally noteworthy, this enterprise solution enhances collaboration in cardiac care. With a single viewer, all providers have access to and view the same holistic patient picture. This makes it easier for physicians to work together, no matter where they are located.

Finally, the North Memorial team says Synapse Cardiology PACS lets them connect better and deeper with their patients.

As soon as it was installed, the technology led to improvements in patient communication and engagement. High-quality images can be printed, accessed, and shared on the spot with the patient. That helps patients to better understand their treatment plan and be more involved in their own wellness journey.

For example, showing a patient ‘before’ and ‘after’ images after a stent placement or other procedure can help encourage them to do their part to maintain their heart health with proper lifestyle changes.

From atherosclerosis to arrhythmia, heart failure to heart attack, cardiovascular diseases are on the rise in the United States. By 2035, more than 130 million adults—or 45.1 percent of the U.S. population—are projected to have some form of cardiovascular disease, according to the American Heart Association.

Clearly, cardiology is a specialty that will continue to be in high demand. As cardiologists contend with growing caseloads they will also encounter greater workflow challenges. Simply put, the Cardiology PACS of the past is limited and inflexible. The specialty requires a more robust, flexible, and secure workflow solution so cardiologists are freed up to do what they do best—care for patients.

Now is the time for providers to be proactive and seek out enterprise imaging technology that enables greater efficiencies, boosts collaborative care, and ultimately, drives better patient outcomes.

For better cardiology services, providers must look beyond the existing cardiology PACS.

Enabling Better Cardiac Care with Robust Enterprise Imaging

Case submitted by Kay Ogenda, M.D., radiologist, to

A 45-year-old female presents with an increasing growth on the right neck. A CT scan revealed an extremely large heterogeneous mass in the right supraclavicular region. Findings are consistent with a high grade sarcoma of the sternocleidomastoid muscle. Specifically, this lesion is consistent with rhabdomyosarcoma of muscular origin.

 Soft-tissue sarcomas are malignant lesions that originate from soft tissues. Rhabdomyosarcomas arise from muscle cells and are most commonly found in children. They account for up to 10 percent of childhood malignancies and 20 percent of all pediatric soft tissue sarcomas. 

There is a slight male predominance of incidence of sarcomas. Clinical presentation will vary on the location of a tumor. In this case, rhabdomyosarcomas are rapidly growing masses with mass effect on neurovascular structures, as well as with extensive infiltration often seen of adjacent structures, including bones and adjacent organs. Rhabdomyosarcomas can occur anywhere, but they particularly develop where skeletal muscle is located. The most common locations include the head, neck, and pelvis.

What is your diagnosis for a patient who presents with increasing size of neck and shoulder region?

Image IQ Quiz (Video): Patient Presents with Enlarging Neck and Shoulder Region

Radiology practices have a tremendous opportunity in 2021 to grow and invest in their businesses, and most importantly, to drive meaningful cost and quality improvement to the broader health care industry and to be a leader in providing value-based care.

2020 was a challenging year, with the healthcare industry fundamentally altered by the COVID-19 pandemic, forcing radiology practices to quickly adapt. The pandemic served as a wake-up call for radiology leaders to innovate and evolve how they operate to build stronger and more resilient models. In many cases, groups were able to identify opportunities for cost efficiencies that will serve to reduce unnecessary overhead and infrastructure.

What considerations should radiologist practice leaders be making in order to position their practices optimally in 2021 and for the future?

Radiology leaders have a sizable opportunity to drive value-based care into the 21st century, but that value creation will not happen overnight. Practices must be proactive and make critical platform investments to capture forthcoming opportunities.

A proactive mindset must consider key factors affecting the radiology and healthcare landscape today. Here is an overview of today’s radiology practice landscape, outlining the top considerations, opportunities and factors all radiologists must understand in order to be best positioned for success:

Today’s Radiology Landscape: Critical Factors

As practices adjust to 2021, here are the top themes affecting radiology practices in the upcoming year:

Federal Government Healthcare Policy Changes

Center for Medicare & Medicaid Services (CMS) announced the new Medicare 

, which was finalized on Dec. 1, 2020, and projects to cut Medicare reimbursement for radiology practices by approximately 7 percent over the next two years. The reimbursement cut will be phased over two years, which helps lessen the burden on practices. Groups with a higher Medicare patient concentration will most likely see a more profound impact than groups that are predominantly focused on commercial patients. Regardless of reimbursement mix, radiology groups need to be proactive in planning for and investing in new sources of revenue and cost efficiencies to help offset these future cuts.

RadPartner’s $885-million acquisition of Mednax Radiology adds 800 radiologists, bringing the company’s total enterprise to more than 2,400 radiologists nationally. This consolidation continues a recent consolidation trend in radiology: there were 23 practice transactions in 2018, followed by a record-high 25 in 2019, and, then, 11 in 2020. While the pandemic reduced the amount of consolidations in the first three quarters of 2020, we saw activity in Q4 2020 returning back to 2019 levels.

Groups of all sizes should pay close attention to increasing consolidation and the possible benefits that come with greater scale, including clinical research, technology, expanded services and greater geographic reach. While joining a larger national platform may not be ideal for every group, those that wish to remain independent should certainly make investments today to bolster potential gaps and increase competitiveness in the market.

Push to Outpatient Services and Consumerization

In 2020, outpatient volume increased about 10.5 percent, and early trends show this shift continuing in 2021. Patients prefer to visit outpatient environments and managed care is certainly aligned in steering patients to lower-cost outpatient imaging centers over higher cost hospital sites.

COVID-19 has certainly driven a higher “retail” consumption of healthcare with patients being accustomed to services being offered in a much more convenient fashion. Gone are the days of waiting for hours for care in a crowded waiting room or filling out paper forms. Even after the COVID-19 recovery, patients will continue to demand a higher touch, more digital and streamlined experience.

Private practices need to re-evaluate their outpatient and broader consumer strategy, and if one does not exist, they should quickly create and implement one. Radiology groups that are 100 percent dependent on hospital revenue should assume that volume will continue shifting away from hospitals, in favor of free-standing outpatient centers. Groups should also understand that their long-term success is increasingly driven by innovative marketing departments that bolster consumer recognition in the market. Forward-thinking radiology groups are investing in digital marketing, building app-based scheduling capabilities, embracing telemedicine, and driving towards a modern consumer experience.

COVID-19’s continued spread and lasting impact has created an avalanche of challenges for the U.S. healthcare system. There have been massive reductions in elective procedures and operational changes required to deliver care safely. Many Americans have lost their health insurance as a result of job loss.

A ramification of CMS’ specialty practice ruling is the reallocation of Medicare payments that benefits general practitioners, family practice providers and nurse practitioners. This reallocation comes at the expense of specialty practices like radiology groups.

Payors are also incentivizing patients to opt for care in lower-cost settings, away from hospitals, and hospitals are responding by increasing their outpatient footprint. Lastly, payors are moving deeper into primary care, imaging, and urgent care as a means to exert greater influence in the overall flow of care across their ecosystem.

In light of these issues and challenges facing our healthcare system, radiology practice leaders must recognize that they are at a critical crossroads and must think strategically about how to position themselves optimally for the future.

As radiology practices consider how to best strengthen their positioning for the future, Ziegler recommends conducting a SWOT analysis to identify areas for investment and fortification.

Once a SWOT analysis and strategic plan is formalized, it is vital to execute on that plan and make the necessary investments in a prudent fashion. The success of that plan is however dependent the success of its execution.Ziegler has outlined below a six-step process to ensuring the greatest degree of success in the execution of any strategic plan.

While coping with external pressures, such as COVID-19, reimbursement pressures, and industry consolidation can be daunting, creating a long-term strategic plan that deepens competitive differentiation and builds scale is critical for ensuring long-term sustainability and maximizing shareholder value.

It is not practical to make all investments at once, but the key is to outline a one-year, five-year and 10-year investment plan and to stick to it. Incremental growth is best as it is most manageable, demonstrates practice momentum and helps ensure your practice is nimble and agile to adjust for previously unforeseen events, such as COVID-19 or abrupt market changes.

The physician practices that will fare best in 2021 and beyond will undoubtedly be those that have made strategic investments in their platforms, bolstering their ability to scale and ready to address whatever challenges the future might bring.

Source: Banthin et al,, “Changes in Health Insurance Coverage Due to the COVID-19 Recession: Preliminary Estimates Using Microsimulation,” Urban Institute, July 2020.

— Andrew Colbert is a senior managing director and founding member of Ziegler's Healthcare Investment Banking practice. Andrew has represented more than 20 radiology groups on innovative transactions. He specializes in advising physician groups on strategic and financing alternatives including merger and acquisitions, joint ventures, capital raising transactions, and partnership development. More information is available at www.ziegler.com/radiology.

Ziegler is a privately held, national boutique investment bank, capital markets and proprietary investments firm. It has a unique focus on healthcare, senior living and education sectors, as well as general municipal and structured finance. Headquartered in Chicago with regional and branch offices throughout the U.S., Ziegler provides its clients with capital raising, strategic advisory services, fixed income sales, underwriting and trading as well as Ziegler Credit, Surveillance and Analytics. To learn more, visit 

Information contained or referenced in this document is for informational purposes only and is not intended to be a solicitation of any security or services.” “B.C. Ziegler and Company | Member SIPC & FINRA.

The top considerations for radiology practices.



Achieving Success in a Turbulent Healthcare Landscape

Across the United States, 1.4 million individuals identify as being transgender. Although that accounts for only 0.6 percent of adults, these individuals frequently need imaging services, particularly if they opt to pursue gender affirmation surgery, referred to as transitioning.

 revealed that 71 percent of transgender patients have experienced at least one negative encounter with an imaging provider. There is currently a lack of information about data-driven practices that can improve the care these patients receive, so a multi-institutional team, led by Hannah Perry, M.D., a diagnostic radiologist with the University of Vermont Medical Center, published six steps in the 

to help radiologists provide the best care possible to this group.

Take a quick look at their recommendations:

6 Steps to Better Imaging for Transgender Patients

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Radiologists can play an active role in improving the healthcare experience for transgender patients, most of whom have had a negative imaging encounter.

Skipping an appointment for a screening mammography – even for one year – can put a woman at significantly higher risk for dying from breast cancer. A new study shows that, for women who come in for their routine exams, that risk drops by half.

 on March 2, a multi-national team of investigators showed that, based on an observational study of more than half a million women, keeping up with scheduled mammograms can go a long way toward preventing an avoidable death.

“Regular participation in all scheduled screens confers the greatest reduction in your risk of dying from best cancer,” said lead study author Stephen W. Duffy, M.Sc., professor of cancer screening at Queen Mary University of London. “While we suspected that regular participation would confer a reduction greater than that with irregular participation, I think it is fair to say that we were slightly surprised by the size of the effect.”

Better Understanding of Screening Mammography Cuts Imaging Rates Among Older Women

Even though screening mammography is widely heralded as the best line of defense in catching breast cancers and reducing mortality, a significant number of women still avoid the exam. According to 2018 data from the Centers for Disease Control & Prevention, only 65.3 percent of women in the United States over age 40 go in for routine screening mammograms. The findings from this study, Duffy said, underscore the importance of these exams in helping to stop cancer before it has a chance to grow.

“Missing even one screening examination confers a significant increase in risk,” he said. “This is an important message for women in the screening age groups, their referring physicians, and public health decision makers.”

For their study, the team, led by László Tabár, M.D., professor of radiology at Falun Central Hospital in Sweden, analyzed screening mammography rates for 549,091 women from nine Swedish counties. During the study period from 1992 to 2016, Swedish policy offered women between ages 40 and 54 mammography screening every 18 months; the policy for women between ages 55 and 69 was screening every 24 months.

Race-Related Cancer Disparities Fall with Screening Mammography

The women enrolled in the study averaged 58.9 years, and they were divided into four groups. The team categorized them as: serial participants who underwent two consecutive screenings (392,135 women), intermittent participants who had their last – but not next-to-last mammogram (41,746 women), lapsed participants who had their next-to-last – but not most previous – mammogram (30,945 women), and non-serial participants who had neither scheduled exam (84,265 women).

The team identified 3,995 breast cancer deaths across the four groups. Based on their analysis, serial participants had much better outcomes than women who passed by both screening mammograms. Not only did serial participants have a 49 percent lower risk of breast cancer mortality, the team said, but they also 50 percent less likely to die from breast cancer within 10 years. The intermitted and lapsed groups also saw risk reductions of 33 percent and 28 percent, respectively.

When looking at the 2,589 breast cancers that proved fatal within a decade, the 50-percent reduction among serial screeners outpaced the small drops for women in the intermittent and lapsed groups. Those women experienced a 36 percent and 25 percent decrease, respectively.

After adjusting for potential self-selection bias and lead time, the team said, they calculated breast cancer incidence reductions for disease fatal at 10 years. The relative risks were: 0.56 for serial participants, 0.71 for intermittent participants, and 0.81 for lapsed participants.

While these findings do shed light on the benefit provided by screening mammography, the team said they are continuing their work to better understand how the exam affects the interval cancers that pop up in between screenings.

“We are planning further prognostic research into the mechanism of this effect,” Duffy said. “For example, we plan to investigate whether and – if so – to what extent regular attendance improves the prognosis of interval cancers, as well as screen-detected cancers. Estimation of this by time since last screen may have implications for policy on screening frequency.”

Women who do not miss their screening mammography appointments are far less likely to die from breast cancer than women who either forego one – or all – exams.

Achieving Success in a Turbulent Healthcare Landscape

6 Steps to Better Imaging for Transgender Patients

A Good Habit: Consecutive Screening Mammograms Drop Breast Cancer Mortality by Half