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.

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

A CNN investigation, “Prescription for Cheating,” has targeted the practice of sharing recall exams – questions and answers to old tests – in preparation for American Board of Radiology exams.

 on the practice on its website, and will air the program at 8 p.m. ET tonight on “AC360” as well as on "CNN Presents" this Saturday and Sunday, January 14 and 15, at 8 p.m. and 11 p.m. ET.

“The recalls obtained by CNN show at least 15 years' worth of test questions and answers, some prepared as PowerPoint presentations. The tests were available on a radiology residents' website as well as a shared military computer server,” according to the story by CNN reporters Scott Zamost, Drew Griffin and Azadeh Ansari.

"It's been going on a long time, I know, but I can't give you a date," Gary Becker, MD, executive director of the American Board of Radiology (ABR), which oversees the exam that certifies radiologists, told CNN.

Asked if this were considered cheating, Becker told CNN, "We would call it cheating, and our exam security policy would call it cheating, yes."

The network’s reporting included interviews with a military radiologist who spoke out about the practice of using recalls, as well as interviews conducted at the recent RSNA 2011 conference in Chicago. Some radiologists there considered using the recalls as a study guide to be a gray area, given that details such as the orders of answers differ from those on the real exams. The nature of the exams also adds pressure to check out recalls.

“If they had a test where you could study relevant radiology knowledge and they tested on it, that would be fine,” radiologist Joseph Dieber, MD, told CNN. “Part of the problem is the test and the questions that they ask. Because some of the questions are so obscure, that unless you know that they like to ask questions about that topic, you're not going to study it because some of them are completely irrelevant to the modern practice of radiology.”

CNN Investigation Targets Radiology Board Exam Cheating

In the emergency department, those lacking health insurance receive less imaging than those covered. But once admitted as inpatients, they’re treated equally from the diagnostic imaging perspective, according to two studies published in the January 2012 edition of the 

Kimberly Applegate, MD, an Emory University Medical Center radiologist, and James Moser, PhD, of Econometrica, delivered both studies.

radiology orders from emergency departments

 (ED), the researchers used 2004 National Hospital Ambulatory Medical Care Survey as input. They found that, compared with insured persons, nonelderly uninsured ED patients received 8 percent fewer services and Medicaid ED patients received 10 percent fewer services. They found similar results for the value of imaging services received (13 percent and 19 percent less, respectively).

“These results suggest that insurance status influences how much imaging and the intensity of imaging patients receive,” said Applegate. “Whether insured patients receive unnecessary imaging or uninsured and Medicaid patients receive too little imaging is not clear.”

, considering radiology use in the inpatient setting, was based on 2003 National Hospital Discharge Survey data.

Just over 9 percent of inpatients were uninsured, according to the data, and those who underwent imaging received the same average number of imaging services (1.51) of the same average value as those for comparable insured persons. The uninsured received fewer interventional and image-guided procedures, but more CT studies than insured patients, Applegate and Moser found.

“Because insurance status does not seem to significantly influence the quantity or value of imaging services received by hospital inpatients, efforts to assist uninsured patients with imaging needs would be better directed elsewhere than the hospital inpatient setting,” Applegate said.

In the emergency department, those lacking health insurance receive less imaging than those covered. But once admitted as inpatients, they’re treated equally from the diagnostic imaging perspective, according to two studies published in the January 2012 edition of the Journal of the American College of Radiology.

Uninsured Receive Less ED Imaging, Similar Inpatient Imaging

Cardiovascular MRI beats SPECT in diagnosing heart disease, according to the authors of a major British study 

A team led by John Greenwood, MD, of the Leeds General Infirmary recruited 752 patients at two British hospitals from March 2006 through August 2009 in a $2 million study funded by the British Health Foundation.

In the prospective trial, called CE-MARK, patients with suspected heart disease and at least one cardiovascular risk factor were given cardiovascular MRI, SPECT, and invasive x-ray coronary angiography.

The researchers considered the relative sensitivity, specificity, and predictive value (positive as well as negative) of MRI and SPECT. Coronary angiography showed significant coronary heart disease in 39 percent of the cohort.

The sensitivity of MRI (86.5 percent) was higher than that of SPECT (66.5 percent). Specificity (83.4 percent for MRI versus 82.6 percent for SPECT) and positive predictive value (77.2 percent for MRI vs. 71.4 percent for SPECT) were comparable. MRI outperformed SPECT in negative predictive value (90.5 percent vs. 79.1 percent).

In view of what they described as cardiovascular MRI’s “superiority over SPECT,” Greenwood and colleagues concluded that cardiovascular MRI “should be adopted more widely than at present for the investigation of coronary heart disease.”
 

Cardiovascular MRI beats SPECT in diagnosing heart disease, according to the authors of a major British study published online on Dec. 23 in The Lancet.

Study: MRI Superior to SPECT for Heart Disease

Had the 1986 Forrest Report – which led to widespread mammography screening in Great Britain – included the harms of screening for breast cancer, it might never have become standard practice, according to a new

. The American College of Radiology (ACR) promptly 

 as flawed, being based on “discredited and obsolete data.”

James Raftery, PhD, and Maria Chorozoglou of Wessex University considered the studies used as the basis for the Forrest Report, adding harms associated with mammography-driven biopsies and other effects into a life-table model based on data from systematic reviews, trials, and other models. The work was sparked by their desire to flesh out the contentions of a 2009 Gotzsche and 

 article concluding that it was “not clear whether screening does more good than harm.”

The American College of Obstetricians and Gynecologists, the National Comprehensive Cancer network, the American College of Radiology, and the American Cancer Society all back annual screening for women ages 40 and older; the National Cancer Institute recommends screening biannually starting at age 40; and the U.S. Preventive Services Task Force, recommends biannual screens starting at age 50. Several studie have found mammography to cut breast cancer mortality around 25 percent.

The researchers considered women aged 50 and over who were invited for breast cancer screening. Including harms reduced the estimate of net cumulative quality-adjusted life years (QALYs) gained after 20 years from 3,301 to 1,536 – or by more than half.

The ACR asserts that Raferty and Chorozoglou’s data underestimate the lives saves by mammography screening by half.

“The bottom line is that we know that discontinuing regular mammograms will result in thousands more breast cancer deaths each year. That human cost would be too high,” said Barbara Monsees, MD, chair of the American College of Radiology Breast Imaging Commission.

The best estimates from the Cochrane review generated negative QALYs for the first seven years of screening, 70 QALYs after 10 years, and 834 QALYs after 20 years, Raferty and Chorozoglou wrote.
“This analysis supports the claim that the introduction of breast cancer screening might have caused net harm for up to 10 years after the start of screening,” they concluded.
 

Had the 1986 Forrest Report – which led to widespread mammography screening in Great Britain – included the harms of screening for breast cancer, it might never have become standard practice, according to a new British Medical Journal report.

Fuel to the Fire? BMJ Review Questions Mammography Benefits

Magnetic resonance imaging’s accuracy in detecting cancer in the lymph nodes of newly diagnosed breast cancer patients is nothing to sniff at – 80 percent with diffusion-weighted MRI and 85 percent with axial T1-weighted MRI, Canadian researchers have reported. But it’s not quite high enough to skip a lymph node dissection, according to a 

University of Toronto researchers chose 61 women (average age 53) with invasive breast cancer to undergo preoperative breast MRI. Axial T1-weighted MRI without fat saturation and diffusion-weighted (DW) MR images were analyzed by two experienced radiologists uninformed of the pathology findings.

They found the sensitivity, specificity, and accuracy to be 88 percent, 82 percent, and 85 percent, respectively, for axial T1-weighted MR imaging and 84 percent, 77 percent, and 80 percent for diffusion-weighted (DW) imaging. Apparent diffusion coefficients (ADCs) were significantly lower in the malignant group.

The team concluded that unenhanced MRI techniques showed high accuracy in the preoperative evaluation of patients with invasive breast cancer, and that, while the results indicated reliable and reproducible assessment with DW imaging, “it is unlikely to be useful in clinical practice.”

Magnetic resonance imaging’s accuracy in detecting cancer in the lymph nodes of newly diagnosed breast cancer patients is nothing to sniff at – 80 percent with diffusion-weighted MRI and 85 percent with axial T1-weighted MRI, Canadian researchers have reported. But it’s not quite high enough to skip a lymph node dissection, according to a study published online Dec. 5 in the journal Radiology.

MRI Not Quite There for Lymph Node Diagnosis in Breast Cancer

CHICAGO - The woman and her husband sat in silence. A surgeon had recently biopsied her breast lump and found cancer.

Joseph Tasjian, MD, of St. Paul Radiology, cleared his throat. The lump had shown up on a mammogram two years before. But in 2009, the films had been displayed in reverse order, deceiving Tasjian into concluding the lump had been shrinking. It was clear-cut medical error. The woman before him has lost two years of treatment – and, possibly, her chances of beating the disease, because of it.

Fortunately for Tasjian and the couple he uncomfortably addressed, this was a simulation. The woman and her agitated husband were actors. Tasjian had volunteered to play this role for an audience at an RSNA 2011 session on the topic of disclosing medical error in radiology.

“When I looked at your mammograms, I made an error,” he told the woman and the man playing her husband.

It’s the right thing to do, for one, Tasjian said after the vignette wound down. Plus, he said, “You’ve got an obvious malpractice case. You can’t do any worse.”

The point, in a case like this, is to help the patient understand that the two-year delay in diagnosis isn’t necessarily a death sentence, he added.

Despite concerns among radiologists that range from lawsuits to the loss of professional standing, Tasjian’s take on disclosure is increasingly mainstream, said David M. Browning, senior scholar at the Institute for Professionalism in Medical Practice in Boston.

“We are seeing a lot of insurers strongly supportive of this,” Browning said. “When there’s a clear-cut error, early disclosure is beneficial to the legal process. It’s not a silver bullet, but I do think insurers are coming along.”

Still, added Thomas Gallagher, MD, a general internist at the University of Washington with a research focus in patient disclosure, the notion of disclosing errors is much more accepted than the actual practice of disclosure. There are a few reasons for this “disclosure gap” to narrow, he said.

First, 2007-2009 data from COPIC, a Colorado malpractice insurer, showed that, while physicians believe they’re doing a good job disclosing medical errors, patients don’t generally feel that way, Gallagher said.

Second, he said, hospitals and other healthcare organizations are beginning to use quality-improvement tools to improve disclosure processes. The concern that bringing up disclosure will spark patient awareness of malpractice suits – and trigger more of them – appears unfounded, the COPIC study found.

Third, institutions are tying disclosure to patient compensation. One approach is to pay out-of-pocket expenses regardless of fault, Gallagher said. Another is an “early settlement model,” in which, after the disclosure of an error, the institution reaches out and tries to make an early and full offer to the patient. The University of Michigan does this, Gallagher said. There, legal expenses and claims have been cut in half; malpractice costs have dropped and time to settlement shortened, he said.

“Most of the benefit is not in the claims process itself, but in an improving culture of openness and transparency,” Gallagher said.

Admitting errors should not be done haphazardly, though, Gallagher and the other panelists agreed. “

Guidelines for Disclosure after an Adverse Event

,” by the Institute for Professionalism in Medical Practice and CRICO/RMF, the Harvard system’s malpractice insurance program, is one place to start.

An individual may be the one admitting to a medical error, but the effects reverberate across an organization. Proper disclosure requires policies, that procedures and support mechanisms are in place, Gallagher said. Many institutions employ “disclosure coaches” to provide just-in-time advice with disclosure, “so at 3 a.m., you can pick up the phone and they’ll help you with the disclosure process.”

Constance Lehman, MD, PhD, director of cancer care with the Seattle Cancer Care Alliance, said showing empathy and thinking about the patient’s experience is vital in these sorts of difficult conversations. Lehman said when she talks with a woman concerned with a delayed diagnosis, sometimes it helps to subtly guide the discussion, asking things like, “If I were you, this is what I’d be worried about. Is this what’s worrying you?”
 

CHICAGO - If you make a mistake, should you tell the patient or does that open you up to a malpractice suit? The rules seem to be changing – a little –  according to a malpractice and medical error panel discussion at RSNA 2011.