David J. Seidenwurm

ACR Appropriateness Criteria® on Low Back Pain

Acute low back pain with or without radiculopathy is one of the most common health problems in the United States, with high annual costs of evaluation and treatment, not including lost productivity. Multiple reports show that uncomplicated acute low back pain or radiculopathy is a benign, self-limited condition that does not warrant any imaging studies. Guidelines for recognition of patients with more complicated status can be used to identify those who require further evaluation for suspicion of more serious problems and contribute to appropriate imaging utilization.

Magnetic resonance imaging of brain herniation into the middle ear

Four patients with cholesteatoma were shown to have a large area of eroded tegmen tympani on computed tomography (CT). Magnetic resonance imaging (MRI) in the coronal and sagittal plane showed temporal lobe herniation in three cases and cholesteatoma with abscess elevating the dura in one case. In the patient with a cholesteatoma and an eroded tegmen tympani on CT, MRI is indicated to rule out brain herniation into the middle ear.

ACR Appropriateness Criteria Sinonasal Disease

Imaging of sinonasal pathology may occur for assessment of rhinosinusitis or mass lesions. Rhinosinusitis is prevalent in up to 16% of the US population with annual economic burdens estimated at 22 billion dollars. Rhinosinusitis is characterized as acute or chronic based on symptom duration; if four or more episodes occur annually, the term recurrent acute rhinosinusitis (RARS) is used. In acute uncomplicated rhinosinusitis when inflammatory change remains in the paranasal sinuses and nasal cavity, imaging may not be required. Distinction between viral or bacterial rhinosinusitis is a clinical diagnosis, and imaging should be interpreted in conjunction with clinical and endoscopic findings. Sinus CT imaging is appropriate per clinical judgment in associated complications including headache, facial pain, swelling, orbital proptosis, or cranial nerve palsies. In maxillary sinusitis, teeth may require assessment because 20% may be odontogenic in origin. MRI may be complementary in aggressive infections with intraocular/intracranial complications, invasive fungal sinusitis, or sinonasal masses. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR White Paper: Task Force to Evaluate the Value Add Impact on Business Models

Radiology practices are seeing both evolutionary and revolutionary changes in their business models. The Task Force to Evaluate the Value Add Impact on Business Models was charged with considering how radiologists and their practices add value in these novel settings. Both traditional and novel forms of added value were considered. Types of new business models that were evaluated included hybrid groups of radiologists and other practitioners, regional or national megagroups, and novel services both within and beyond the traditional purview of radiology practice. Recommendations for both how to measure and how to capture this value were considered at both the practice and national levels.

MRI of the Knee and Shoulder Performed Before Radiography

PURPOSE Available data are limited on the level of adherence to established guidelines for appropriate utilization of MR in musculoskeletal imaging. This study estimates the percentage of MRI examinations for knee and shoulder pain or tendonitis performed without prior radiography, which thus may fall outside the ACR Appropriateness Criteria for the Medicare and commercially insured populations. METHODS The percentage of MRI examinations for knee and shoulder pain or tendonitis performed without prior radiography was estimated among patients in the Medicare 5% carrier claims limited data set and among commercially insured patients in the Truven Marketscan Treatment Pathways database in 2010. RESULTS Approximately 28% of all knee MRIs, and 35%-37% of all shoulder MRIs were performed without recent prior radiographs. The extrapolated expense of these potentially unwarranted MRIs in the entire fee-for-service Medicare population was between

Developing Quality Measures for Diagnostic Radiologists: Part 2

20 and

Report of the ACR’s Economics Committee on Value-Based Payment Models

35 million. Between 20% and 23% of patients undergoing knee MRI, and 27%-32% undergoing shoulder MRI, did not have radiographic examination at any point before the MRI in the same calendar year. CONCLUSIONS MRI performed without prior radiography represents a potential gap in care and should be considered as an area for establishment of performance measures.

A Radiologist’s Primer on Bundles and Care Episodes

The ACR convened a cross-specialty, multidisciplinary technical expert panel to identify and define new measures for quality improvement. These measures can be included in the ACRs National Radiology Data Registry and potentially used in the CMS quality reporting programs. The technical expert panel was tasked with developing measures that reflect the most rigorous clinical evidence and address areas most in need of performance improvement. The measures described in these articles represent a new phase in the ACRs efforts to develop meaningful measures for radiologists that promote population health through diagnostic accuracy, clinical effectiveness, and care coordination.