Arvind Vijayasarathi

How Much Do Common Imaging Studies Cost? A Nationwide Survey of Radiology Trainees.

OBJECTIVE The objective of this study was to gauge the knowledge of radiology trainees regarding the costs of common imaging services and to assess their perceptions of current relevant education. SUBJECTS AND METHODS During mid-2014, an online survey of 5325 U.S. residents and fellows who were members of the American College of Radiology was conducted. Respondents were asked to provide information about year of training, relevant advanced degrees (e.g., Master of Business Administration or Master of Public Health), number of hours of formal education in health care economics provided annually by their training program, self-perception of knowledge of health care economics, and desire to learn more about the costs of imaging. Respondents were asked to estimate Medicare-allowable fees for five commonly performed imaging examinations: two-view chest radiography, contrast-enhanced CT of the abdomen and pelvis, unenhanced MRI of the lumbar spine, complete abdominal ultrasound, and unenhanced CT of the brain. Responses within ± 25% of published allowable amounts in the Medicare fee schedule were deemed correct. RESULTS A total of 1066 of 5325 trainees (20.0%) returned surveys that were sufficiently complete for analysis. Only 17.1% of all responses were correct; 65.3% of responses were overestimations of actual costs, and 17.6% were underestimations. Almost half of the trainees (45.1%) incorrectly estimated the cost of every examination. Overall, knowledge of costs of examinations did not improve with advancing years of training, hours of education in health care economics, or attainment of a relevant advanced degree. Only 9.3% of trainees considered their knowledge of imaging costs to be adequate. An overwhelming 89.7% of trainees desired more focused education. CONCLUSION Radiology trainees have limited knowledge of the costs of commonly performed imaging studies. Effective training program curricula currently appear to be lacking. Targeted education and integration of cost information into clinical decision support tools are probably warranted.

JOURNAL CLUB: Radiologists' Online Identities: What Patients Find When They Search Radiologists by Name

OBJECTIVE Patients are increasingly seeking online information regarding their health and their health care providers. Concurrently, more patients are accessing their electronic medical records, including their radiology reports, via online portals. Thus, this study aims to characterize what patients find when they search for radiologists online. MATERIALS AND METHODS All Medicare-participating U.S. radiologists were identified using the Physician Compare National Downloadable File dataset obtained from the Centers for Medicare & Medicaid Services (CMS). Using a custom application, the top 10 Google search results for each radiologist in the national dataset were retrieved, and 90.5% of website domains with more than one occurrence were categorized as follows: physician or institution controlled, third party-controlled physician information systems, social media, or other. Aggregate and subgroup analyses were performed. RESULTS Of all U.S. health care providers recognized by CMS, 30,601 self-identified as radiologists. There was at least one search result for 30,600 radiologists (99.997%), for a total of 305,795 websites. Of all the domains, 69.8% were third party-controlled physician information systems, 17.7% were physician or institution controlled, 1.0% were social media platforms, 2.1% were other, and 9.5% were not classified. Nine of the top 10 most commonly encountered domains were commercially controlled third-party physician information systems. CONCLUSION Most U.S. radiologists lack self-controlled online content within the first page of Google search results. Opportunities exist for individual radiologists, radiology groups, academic departments, and professional societies to amend their online presence, control the content patients discover, and improve the visibility of the field at large.

Imaging of vascular pseudoaneurysms in the thorax and abdomen.

INTRODUCTION This review article illustrates a spectrum of arterial pseudoaneurysms that may occur in various locations throughout the thoracoabdominal region. This article discusses the common etiologies and typical clinical presentations of arterial pseudoaneurysms as well as the imaging modalities employed in their diagnosis and potential treatment options. OBJECTIVE The goal of this review article is to familiarize radiologists with the diagnosis of thoracoabdominal arterial pseudoaneurysms, the prompt identification and treatment of which are crucial in this patient population. CONCLUSION In summary, a thorough understanding of the etiologies, imaging characteristics, and clinical implications of pseudoaneurysms can help optimize identification and management of this spectrum of disease.

The Use of Facial CT for the Evaluation of a Suspected Simple Dentoalveolar Abscess in the Emergency Department

Introduction Facial computed tomography (CT) is often performed in the emergency department as a part of the diagnostic workup for patients presenting with the signs and symptoms of dentoalveolar abscess (DA). This investigation evaluated the diagnostic yield of the facial CT and its effects on management change in patients suspected of DA. Furthermore, we assessed secondary consequences of routine facial CT use in this population by using turn-around time (TAT), cost, and radiation exposure as the key parameters. Material and Methods We retrospectively reviewed records of suspected DA patients over a 5-year period, from June 2008 to June 2013. TAT was calculated for patients from the time the examination was ordered by the emergency department physician, to the time the report was finalized by the attending radiologist. Effective radiation dose for facial CT was calculated by multiplying dose length product by the standard conversion coefficient K (K = 0.0021 mSv/mGy x cm). CT cost was included for reference but was not analyzed extensively due to the lack of standardization of costs across the various institutions. Results Our investigation consisted of 117 patients; 75 males of average age 41 (±12) years and 42 females of average age 44 (±17) years. Out of the total 117 patients that underwent CT for the suspicion of a simple DA, only a single individual (0.85%) underwent a management change. Mean TAT of facial CT was 110 (±63) minutes, and a median TAT was 87 (±71) minutes. Average effective radiation dose for a facial CT was 2.4 (±0.4) mSv. Approximate estimated cost of a contrast enhanced facial CT was

24/7/365 Neuroradiologist Coverage Improves Resident Perception of Educational Experience, Referring Physician Satisfaction, and Turnaround Time

253 and non-contrast facial CT was

Trainee Knowledge of Imaging Appropriateness and Safety: Results of a Series of Surveys From a Large Academic Medical Center

209. Conclusion Our study shows that routine use of facial CT has a very limited diagnostic value in the workup of simple DA and rarely results in management change. The overall impact on patient management is miniscule in the context of prolonged TAT, radiation exposure, and adding to the rising medical costs.

What caused this patient's chest pain and refractory hypotension?

PURPOSE To quantitatively and qualitatively assess the impact of attending neuroradiology coverage on radiology resident perceptions of the on-call experience, referring physician satisfaction, and final report turnaround times. MATERIALS AND METHODS 24/7/365 attending neuroradiologist coverage began in October 2016 at our institution. In March 2017, an online survey of referring physicians, (emergency medicine, neurosurgery, and stroke neurology) and radiology residents was administered at a large academic medical center. Referring physicians were queried regarding their perceptions of patient care, report accuracy, timeliness, and availability of attending radiologists before and after the implementation of overnight neuroradiology coverage. Radiology residents were asked about their level of independence, workload, and education while on-call. Turnaround time (TAT) was measured over a 5-month period before and after the implementation of overnight neuroradiology coverage. RESULTS A total of 28 of 64 referring physicians surveyed responded, for a response rate of 67%. Specifically, 19 of 23 second (junior resident on-call) and third year radiology residents (senior resident on-call) replied, 4 of 4 stroke neurology fellows replied, 8 of 21 neurosurgery residents, and 16 of 39 emergency medicine residents replied. Ninety-five percent of radiology residents stated they had adequate independence on call, 100% felt they have enough faculty support while on call, and 84% reported that overnight attending coverage has improved the educational value of their on-call experience. Residents who were present both before and after the implementation of TAT metrics thought their education, and independence had been positively affected. After overnight neuroradiology coverage, 85% of emergency physicians perceived improved accuracy of reports, 69% noted improved timeliness, and 77% found that attending radiologists were more accessible for consultation. The surveyed stroke neurology fellows and neurosurgery residents reported positive perception of the TAT, report quality, and availability of accessibility of attending radiologist. CONCLUSIONS In concordance with prior results, overnight attending coverage significantly reduced turnaround time. As expected, referring physicians report increased satisfaction with overnight attending coverage, particularly with respect to patient care and report accuracy. In contrast to some prior studies, radiology residents reported both improved educational value of the on-call shifts and preserved independence. This may be due to the tasking the overnight neuroradiology attending with dual goals of optimized TAT, and trainee growth. Unique implementation including subspecialty trained attendings may facilitate radiology resident independence and educational experience with improved finalized report turnaround.

Coronary anomalies encountered in the acute setting: an imaging review

OBJECTIVE In order to provide high quality care to their patients and utilize imaging most judiciously, physician trainees should possess a working knowledge of appropriate use, radiation dose, and safety. Prior work has suggested knowledge gaps in similar areas. We aimed to evaluate the knowledge of imaging appropriateness, radiation dose, and MRI and contrast safety of physician trainees across a variety of specialties. METHODS Between May 2016 and January 2017, three online surveys were distributed to all interns, residents, and fellows in ACGME accredited training programs at a large academic institution over two academic years. RESULTS Response rates to three surveys ranged from 17.2% (218 of 1266) for MRI and contrast material safety, 19.1% (242 of 1266) for imaging appropriateness, to19.9% (246 of 1238) for radiation dose. Overall 72% (509 of 706) of survey respondents reported regularly ordering diagnostic imaging examinations, but fewer than half (47.8%; 470 of 984) could correctly estimate radiation dose across four commonly performed imaging studies. Only one third (34%; 167 of 488) of trainees chose appropriate imaging in scenarios involving pregnant patients. Trainee post-graduate year was not significantly correlated with overall radiation safety scores, and no significant difference was found between radiation safety or appropriate imaging scores of those who participated in a medical school radiology elective vs. those who did not. A total of 84% (57 of 68) of radiology trainees and 43% (269 of 630) of non-radiology trainees considered their knowledge adequate but that correlated only weakly correlated to actual knowledge scores (p<0.001). Most trainees (73%, 518 of 706) agreed that more training in these areas would have beneficial effects on patient care. CONCLUSIONS Knowledge gaps pertaining to appropriateness and imaging safety exist among many trainees. In order to enhance the value of imaging at the population level, further work is needed to assess the most appropriate method and stage of training to address these knowledge gaps.

The diagnostic utility of rib series in assessing rib fractures

CASE A 66-year-old man was found unconscious at home by his son, who called 911. The patient was unresponsive without a palpable pulse and was resuscitated and intubated by emergency medical technicians. He was taken to the hospital, where he underwent aggressive fl uid resuscitation and vasopressor therapy. He subsequently regained a palpable pulse. According to his son, the patient had complained of chest and back pain the previous day. The patient is an ex-smoker and has a long-standing history of chronic obstructive pulmonary disease (COPD) and poorly controlled hypertension. He lives alone. His family history is positive for hypertension and heart disease. In the ED, physical examination revealed an intubated, unresponsive patient with a Glasgow Coma Scale score of 3 out of 15, and persistent hypotension (systolic BP of 80 to 90 mm Hg despite vasopressors). He has present but feeble brachial and radial pulses; femoral and pedal pulses cannot be palpated bilaterally. His skin is diffusely mottled and cool to touch. An ECG and chest radiograph were taken emergently (Figure 1). Which imaging study would help to defi ne the exact cause of the fi ndings on the chest radiographs of this patient? • transesophageal echocardiogram • transthoracic echocardiogram • digital subtraction angiography of the lower extremities • contrast-enhanced CT • MRI of the chest

Knowledge of the Costs of Diagnostic Imaging: A Survey of Physician Trainees at a Large Academic Medical Center

A broad spectrum of congenital coronary anomalies may be discovered on imaging and sometimes in the emergency setting on computed tomography (CT). Most coronary artery anomalies are of academic interest; however, a minority can cause morbidity and mortality and symptoms such as angina, myocardial infarction, or arrhythmias. These anomalies are usually discovered as an incidental finding on CT examinations as part of the diagnostic workup for other pathology or on dedicated coronary computed tomography angiography (CCTA) as part of the evaluation for a coronary cause of chest pain. The purpose of this pictorial review is to demonstrate the types of coronary anomalies and to enhance the clinicians’ understanding of the imaging classifications and clinical implications.