Todd Neff

Medicare-paid musculoskeletal (MSK) ultrasound volume more than tripled from 2000 to 2009. But even that meteoric rise pales in comparison to the MSK 

 among nonradiologists - especially podiatrists.

That’s according to an article published February 1 in the 

Journal of the American College of Radiology

 by Richard E. Sharpe, MD, MBA, of Thomas Jefferson University Hospital in Philadelphia, Penn.

MSK ultrasound provides a less-expensive alternative to 

 (MRI) for imaging muscles, tendons, ligaments, joints and soft tissue throughout the body. But some insurance providers have expressed concern about increased MSK ultrasound use, possibly facilitated by the low cost and ready availability of the technology.

The study’s data seems to back them up. Data was obtained from the CMS Physician/Supplier Procedure Summary Master Files from 2000 to 2009, and records were extracted for procedures for extremity non-vascular ultrasound. Researchers analyzed annual volume by provider type using specialties, practice settings and geographic regions where the studies were performed.

In 2000, Medicare reimbursed 56,254 MSK ultrasound studies, which increased to 233,964 in 2009. That’s a rise of 316 percent. Radiologists performed the largest number of MSK ultrasound studies in 2009 - 91,022 - an increase from 40,877 in 2000. But podiatrists were close behind, doing 76,332 studies, up from just 3,920 in 2000. That’s a more than 18-fold increase. By 2009, podiatrists performed 32.6 percent of all MSK ultrasounds, up from 7 percent of them in 2000, the researchers found.

Overall, private office MSK ultrasound procedures increased from 19,372 in 2000 to 158,351 in 2009 (up 717 percent). In 2009, podiatrists performed the largest number of private office procedures (75,544) and accounted for 51.5 percent of the total private office growth from 2000 to 2009. Radiologist private office procedures totaled 19,894 in 2009, accounting for 9.2 percent of the total private office MSK ultrasound growth.

Rheumatologists accounted for 22,581 procedures in 2009, compared with 176 in 2000 (up 12,730 percent). Primary care physicians accounted for 13,271 procedures in 2009 and 4,675 in 2000 (up 184 percent). All other providers accounted for 30,758 procedures in 2009, up from 7,606 in 2000 (a 304 percent increase).

“It is possible, particularly in a slow economy, that MSK ultrasound examinations are being performed more frequently to subsidize ultrasound equipment that has already been procured,” the authors wrote. “When imaging equipment has already been purchased and is idle in practice settings, it may become used for situations and indications for which it was not previously perceived as necessary. These situations may not necessarily yield a patient benefit but do increase the costs of delivering health care.”
 

Articles

Study seems to support concern about increased MSK ultrasound use, possibly facilitated by the low cost and ready availability of the technology.

Nonradiologists Have Binged on Musculoskeletal Ultrasound

A new magnetic resonance spectroscopy (MRS) technique provides a definitive diagnosis of brain cancer based on imaging of a protein associated with a mutated gene found in 80 percent of low- and intermediate-grade gliomas, according to a 

.

Researchers at the University of Texas Southwestern Medical Center say theirs is the first clinical application of a new imaging technique to diagnose brain tumors. The test could preclude the need for surgery in patients whose tumors are located in areas of the brain too dangerous to biopsy, they say.

“To our knowledge, this is the only direct metabolic consequence of a genetic mutation in a cancer cell that can be identified through noninvasive imaging,” said Elizabeth Maher, MD, associate professor of internal medicine and neurology at UT Southwestern and senior author of the study “This is a major breakthrough for brain tumor patients.”

The team developed the test by modifying the settings of an MRI scanner to track levels of protein 2-hydroxyglutarate (2HG) in brain tumors. The protein’s accumulation is associated with mutations in isocitrate dehydrogenases 1 and 2 (IDH1 and IDH2) in most grade 2 and grade 3 gliomas in adults.

The data acquisition and analysis was developed by lead author and UT Southwestern radiologist Changho Choi, MD.

To confirm the MRI test, the team analyzed biopsy samples from 30 glioma patients enrolled in the a clinical trial. Half had the mutation and high levels of the protein. MRS imaging of these patients done before surgery predicted which patients had the mutation with 100 percent accuracy. 
 

A new magnetic resonance spectroscopy technique provides a definitive diagnosis of brain cancer based on imaging of a protein associated with a mutated gene.

New MRI Technique Helps Diagnose Gliomas

A follow-on CT scan can help lower risks of brain hemorrhage for patients with minor head injuries who are taking the anticoagulant warfarin, according to a study 

Italian researchers enrolled 97 patients receiving warfarin and showing no intracranial lesions on a first CT scan after minor head injury treated at a level 2 trauma center in Ancona, Italy. After 24 hours of observation, they performed a pre-discharge CT-scan follow up, evaluating the frequency of death, admission, neurosurgery, and delayed intracranial hemorrhage.

Of the 87 patients agreed to the second scan, the follow-on radiology consult revealed a new hemorrhage lesion in five patients (6 percent), with three patients being hospitalized. One received a craniotomy for subdural hematoma.

In addition, two patients discharged after completing the study with two negative CT scan results were readmitted within days with symptomatic subdural hematomas; neither received surgery. Two of the five patients with delayed bleeding at 24 hours had an initial international normalized ratio (INR value) greater than 3.0, as did both patients with delayed bleeding beyond 24 hours. Patients with initial INR value greater than 3.0 were 14 times more likely to have delayed hemorrhage, the researchers found.

Guidelines from the European Federation of Neurological Societies guidelines recommend follow-on CT scans strategy for all patients on blood thinners with minor head injury.

“For patients receiving warfarin who experience minor head injury and have a negative initial head CT scan result, a protocol of 24-hour observation followed by a second CT scan will identify most occurrences of delayed bleeding,” the researchers concluded.
 

A follow-on CT scan can help lower risks of brain hemorrhage for patients with minor head injuries who are taking the anticoagulant warfarin, according to a study published online this week in the Annals of Emergency Medicine.

Follow-on Brain CT Key for those on Blood Thinners

The ‘strontium breakthrough’ problems leading to unexpectedly high patient radiation exposure and the July 2011 voluntary recall of Bracco Diagnostics’ CardioGen-82 PET imaging agent were probably the result of user error, the 

FDA officials say the nationwide study Bracco is conducting has found that, of 375 patients surveyed at 43 clinical sites, 54 patients were planned for further radiation testing because of abnormal screening test results. All 54 patients were from two clinical sites. Both sites appear to have had insufficient documentation of compliance with the CardioGen-82 labeling recommendations for strontium breakthrough testing, the agency said.

The FDA said it’s working with the manufacturer to revise the CardioGen-82 labeling to better describe how to use the generator and to implement a plan for the return of CardioGen-82 to the market. The agency added that the apparent deficiencies in Bracco’s manufacturing process identified in its July 26, 2011, 

 were unrelated to the patient radiation exposure problem.

“The recalled CardioGen-82 generators that were functional following shipping were tested by the manufacturer to identify potential structural or functional causes of strontium breakthrough,” FDA officials said in the statement. “None of the tested generators showed signs of breakthrough.”

 the rubidium-82 generator in July 2011 when the FDA recommended its 

 because of possible strontium isotopes “breaking through” in the generation process. The recall came in the wake of excessive radiation being detected in two patients.

The patients’ exposure came to light when they traveled to the United States and set off airport radiation alarms despite having had PET scans two and four months earlier. Rb-82 has a half-life of 75 seconds; strontium’s is 25 days.

The FDA said in July 2011 that it believed the risk of harm to be minimal, with the estimated amount of excess radiation the two patients received being similar to that of exposure to certain other types of heart scans.

 it suspected user error to have played a role and the company expected a “limited and progressive reintroduction” of CardioGen-82 PET tracer in the first or second quarter of 2012.
 

The problems lead to unexpectedly high patient radiation exposure and voluntary recall of the PET imaging agent.

Todd Neff

Articles

Nonradiologists Have Binged on Musculoskeletal Ultrasound

New MRI Technique Helps Diagnose Gliomas

Follow-on Brain CT Key for those on Blood Thinners

FDA: Bracco CardioGen ‘Strontium Breakthrough’ Caused by User Error