American College of Radiology blog

Is Radiology Recession-Proof?

As more Americans are feeling the effects of the economy, it should come as no surprise that people are opting out of health care. The primary reason? Costs.

A survey of 12,000 Americans released last week found that about 20 percent of Americans have skipped medical care. About the same percentage thought they would have a difficult time paying for medical care in the future. However, only about 8 percent of those surveyed indicated skipping some form of medical imaging. More than half said they skipped a doctor’s visit.

Does that mean that Americans value medical imaging over a visit to their primary care doctor? That would be hard to determine from this one study. But it is something to think about.

The College is interested in knowing what you think.

• Has your practice or hospital experienced any effects from the economy?

• Or, have patients cancelled any imaging studies due to costs?

I look forward to hearing your thoughts.

ACR, Patient Groups, Industry Make Case for CTC Coverage

Despite significant evidence of CT colonography’s effectiveness as a screening tool for colorectal cancer, on Feb. 11, the Centers for Medicare and Medicaid Services (CMS) announced a proposed decision not to cover the exam, stating that the evidence was inadequate to conclude that CTC would provide health benefits to the average Medicare beneficiary.

In the CMS proposed decision memo, opponents to coverage cited unknown effects from radiation exposure associated with the exam, questions as to the amount of training necessary to properly read the exam, and concern that it would be difficult to generalize the results of the ACRIN CT Colonography Trial to the average practice setting and specifically to the Medicare population.

The ACR and other societies have been working together to reverse CMS’s proposal by educating members of Congress that using CTC as a screening method for colorectal cancer will help more people to get screened, aid in early detection and ultimately help save lives.

At a Capitol Hill briefing last Monday, Elizabeth McFarland, M.D., chair of the ACR Colon Cancer Committee, made a presentation to congressional and regulatory staff members on behalf of the College as to the effectiveness and importance of this exam. In response to these efforts, several lawmakers have signed on to letters written to CMS urging them to cover CTC.

In a letter to the editor published in Saturday’s New York Times, Andrew R. Spiegel, chief executive of the Colon Cancer Alliance, Ilyse Schuman, managing director of the Medical Imaging and Technology Alliance, and myself, reinforced the proven cost-effectiveness of CTC as well as its “potential to enhance colon cancer screening compliance.”

The 30-day public comment period for the proposal ended on Friday, CMS is expected to make a final (at least for the immediate future) decision on coverage by May 12.

For those of you who currently offer/perform CTC:

• Has your practice seen an increase in CTC volume since the results of the ACRIN study were published in the New England Journal of Medicine last fall or a decrease since CMS proposed not to cover the exam?

And if you do not currently offer/perform CTC:

• Will Medicare’s final coverage decision determine whether or not you add this exam to your practice or seek out training?
  
  

I look forward to your thoughts.

Radiation Exposure Back in the News

As you may know, on Tuesday, the National Council for Radiation Protection and Measurement (NCRP) issued a report stating that Americans were exposed to seven times more radiation from medical imaging exams in 2006 than they were in 1980.

Radiation exposure is always a hot topic and has garnered a significant amount of media attention over the past several years. Some of this attention can alarm patients, as did the November 2007 NEJM study which claimed that up to 2 percent of all cancers can be attributed to radiation received from CT scans.

The College immediately issued a response to the latest NCRP report advising patients to consider the information within the report in its proper context and to discuss any concerns about radiation exposure with their doctor. It is important for people to understand the undeniable benefits of medical imaging in early detection and staging of diseases, and not to forgo testing out of fear.

Although the NCRP report did not go into causes of the dramatic increase in dose, the NCRP’s executive director did, at a recent international conference, identify self-referral as a primary driver of the trend.

The ACR response and statements by College spokespersons made clear the tie between self-referral and increased imaging in a resulting Reuters Health article and in other print and broadcast news reports.

The NCRP study also served as an opportunity for the to College to publicize what steps have been done thus far to lower dose, like the adoption of principles such as ALARA (as low as reasonably achievable), the Image Gently^SM campaign (www.imagegently.org), and ACR Appropriateness Criteria® (www.acr.org/ac) which can help physicians prescribe the most appropriate imaging exam for more than 200 clinical conditions.

I would like to know:

• What are your overall thoughts on this NCRP report?

• Have you had patients ask you about radiation risk as a result of the report and the associated media coverage?

• What do you tell them?

*Note: Keep in mind your comments will be in the public domain.

Savings Through Spending: Obama’s Budget Announced

On Thursday, President Obama announced his $3.6 trillion budget plan for the 2010 fiscal year. The plan would create a “health care reserve” costing $634 billion over 10 years, in an effort to provide universal health coverage. Tax increases and cuts to Medicare and Medicaid would fund the reserve.

According to the plan, increased spending on insuring all Americans upfront will save money in the long run, because patients will seek out care and engage in preventative measures to reduce the occurrence of chronic (and often costly) diseases.

The proposed plan would seek to control imaging costs through the use of radiology benefit management companies in the Medicare program. The ACR, however, has argued that the use of Appropriateness Criteria in an order entry system is a better way to monitor imaging, and ensures that patients receive the best study for their condition in a timely manner.

Other health care measures in the plan include:

• $1 billion to the FDA to improve food safety
• $6 billion for cancer research
• $76.8 billion toward EMR adoption and medical treatment comparison
• $330 million toward addressing doctor and nurse shortages

What do you think about the budget plan in terms of health care reform?

What do you think are the strengths and shortcomings of the plan?

I look forward to your comments.

Good, Better and Best Practices

My column in this month’s ACR Bulletin focuses on how collaborating with others on best practices can lead to quality improvement and overall patient satisfaction. Focusing on improvement doesn’t necessarily mean that your practice is sub-par or not meeting certain standards of care; it simply means that we as physicians recognize that in this ever-changing health care arena, there are bound to be new ideas or solutions for things we do every day.

This being said, I’d like to hear what best practices you’ve adopted and made part of your daily routine. How did you identify the need for a change? What has worked and what hasn’t? Perhaps it was as simple as providing patients with educational materials before an exam. Or, maybe you invested in new imaging equipment, or learned a cutting-edge technique. Feel free to leave details in the comments section to share with other members.

I’m looking forward to your responses. And, be sure to read the articles in this month’s Bulletin for more ideas, tips, and testimonials from your colleagues on implementing best practices.

Image Gently Campaign Reaches Out to Parents

In January 2008, the Alliance for Radiation Safety in Pediatric Imaging launched the Image Gently campaign, to bring attention to the opportunities for medical imaging professionals to lower or optimize the radiation dose when performing imaging studies on children.

This month, the campaign is introducing new materials to educate parents about medical imaging.

The first item is an imaging record card — parents are encouraged to use this record as they do the widely-used vaccination record. It will allow parents to keep track of pertinent information related to their child’s exams — where and when the study was performed as well as the type of exam. Tracking the number of radiologic studies children have received helps inform treating physicians of recent similar exams, helping to decide if an exam is truly necessary.

Also created were two pamphlets which explain the various imaging exams with a focus on CT scans and radiation safety. Potential risks involved with imaging are discussed as well as estimated effective doses. These tools are available now to download from the Image Gently Web site (www.imagegently.org).

We encourage you to make these available in your patient waiting areas and offices, and inform the parents of your pediatric patients that these resources have been created for them.

Additionally, information brochures are now also available on the American Academy of Pediatrics Web site for parents and pediatricians.

If you haven’t done so already, please take the Image Gently pledge to show your commitment to “child-sizing” the radiation dose used in children’s imaging.

I would also be interested in knowing:

• Do you typically get questions from parents regarding radiation dose used in pediatric imaging?

• Do you think these materials will help you answer them?

• What do you typically say to patients with questions regarding dose?
  
  

I look forward to your feedback.

How We’ll Tackle 2009

Get organized …
Lend a hand …
Listen more …

These may seem like your basic list of New Year’s resolutions, but they’re actually taken straight from our colleagues in the field.

In the latest edition of ADVANCE for Imaging and Radiation Therapy Professionals, I offered my vision for what the ACR would put forward in 2009. You can read what I (and others) had to say here.

It’s no secret that we will face another round of hard issues in the year ahead. With the Obama Administration taking office in just a few days, there are already items on the table that will affect us. Prior authorization is one of them; changes to how Medicare reimburses for the technical component of imaging exams is another.

Education and advocacy remain at the heart of the College’s mission, and we will continue to strengthen our presence in the face of the forthcoming health care legislation.

There are a great many items on the agenda for 2009. New courses will be added to the ACR Education Center over the next few months. ACR staff is working to tailor your membership to your needs, using the newly launched Practice of Radiology Environment Database (PRED), and much more.

Despite any challenges we encounter this year (and there will be challenges), the ACR will remain at the forefront to lead the way. Please write in with what you think radiology’s biggest challenges are for the coming year and how you think the ACR can help.

I very much look forward to your input.

Unnecessary Invasive Breast Biopsies

In case you missed it, CBS News recently aired a story regarding a study which showed that approximately 600,000 women each year receive invasive breast biopsies performed by surgeons when referring them to a radiologist for a needle/stereotactic biopsy would be just as effective at confirming or ruling out cancer, would be less costly, less invasive, and would leave the patient with a far smaller scar.

If you are having trouble viewing the video below, it can also be viewed on the CBS Web site (a short commercial will air before the segment begins).

I am not a breast imager by subspecialty, but would be interested to know whether this is a pattern of referral behavior that you are seeing in your market (without mentioning specific names).

If so — what do you think radiologists can and/or should do to counter this trend?

What would you recommend that patients ask their referring physicians regarding this process?

I look forward to hearing from you.

Increased CT Ownership in Nonradiologists

An interesting trend was examined in the December issue of JACR — CT ownership in nonradiologist specialties.

When we hear about anything related to equipment ownership, imaging growth, or self-referral, primary care is typically not top of mind. But according to the study authors from Thomas Jefferson University, the nonradiologist specialty with the highest growth in CT procedures in 2006 was, in fact, primary care. Moreover, nonradiologist ownership of CT increased by 263 percent from 2001-2006.

There are of course many implications for radiologists. For one, market share — and the rapid pace at which nonradiologists are gaining it. Also, rising opportunities for self-referral, radiation safety concerns, and costs to the health care system.

The full article which appears in the December issue of JACR can be read online by clicking here and downloading the PDF.

What are your thoughts about this study and the results? What ownership/leasing arrangements have you seen that support these findings? I look forward to your comments.

Side Note 1: The JACR Editorial Board is excited about a new member benefit coming to the journal. Look for the CME icon next to the JACR cover on the ACR Web site starting with the January 2009 issue and claim CME for reading JACR. The Web site www.jacr.org is also going through a redesign so be sure to visit the site in January to see what’s new.

Side Note 2: There is a link on the left-hand side of this page to “Contact a Blog Contributor.” We want to talk about issues you are facing, so please don’t hesitate to contact us about topics of importance to you. We are also looking for some guest bloggers to weigh in every now and then; so let us know if you’re interested and we’ll talk. Thanks for reading.

How Will the ABR’s Changes to Diagnostic Radiology Boards’ Structure and Timing Affect You?

We are all well aware that the American Board of Radiology (ABR) has planned changes to future certification exams in radiology. This will affect residents beginning in 2010, and will not alter the training of those already in residency. The last time this topic was discussed on the blog, many of you voiced your concerns over the decision to delay the certifying exam to 15 months out of residency, and how the changes may create too strong an emphasis on subspecialization.

These changes have been in deliberation for years — those who agree with the changes believe fourth-year residents should concentrate on their responsibilities, and not have to balance studying at the same time; those on the other side believe that residents in their fourth year are best suited to handle the core competency-based format and therefore the exam should remain static.

In response to the many questions ACR members had regarding these changes — rather than deliberate the pros and cons to each side of the debate — the College created a task force to consider the potential impact of changes in the diagnostic radiology boards’ structure and timing. I served as chair, and my fellow members included a mix resident physicians, and private and academic practice members.

So, what will these changes mean for those of us at present — those already in practice?

We realized that there would be no easy solution to this question, and we immediately determined a need to create two subcommittees — one to examine the impact of the ABR’s decision on the future practice of radiology and the ACR, and the other to focus on how the change might affect residency training programs and trainees. Our discussions are summarized at length in a white paper in the November issue of the Journal of the American College of Radiology (JACR). To read the paper in its entirety, login to the ACR Web site and then click on the JACR links on the bottom left-hand side of the page.

Was the task force successful at addressing your questions and concerns about this major change in radiology?

How do you think the number of individuals choosing to complete fellowships immediately after residency will change?

And, what other issues, if any, do you foresee?

I look forward to your thoughts.

Scanning for Truth: New Opportunities for fMRI

Recently, the ACR Daily News Scan ran an original article about using MRI as a tool for truth detection.

We are accustomed to using MRI as a screening tool for diagnosing and treating disease — serving as the next-generation polygraph seems a bit far fetched. Or is it?

fMRI truth-testing analyzes blood flow and oxygen changes in the brain, whereas the polygraph focuses on the human stress-response. And, the polygraph is arguably only about 65 percent accurate. One San Diego, Calif.-based firm is currently conducting a large trial set for completion next year, which hopes to achieve upwards of 90 percent accuracy in determining who is telling the truth.

The ACR has not taken a formal position on fMRI for truth detection, nor whether it represents an appropriate use of a diagnostic study for medical-legal purposes. I urge you to read the article in its entirety, as it discusses the medical and legal implications, as well as the opportunities for fMRI use in pre-employment screenings and the criminal justice system.

How do you feel about MRI being used as truth screenings?

Do you think this technology could have real implications on our judicial system?

I look forward to your thoughts.