Howard P. Forman

National Trends in CT Use in the Emergency Department: 1995-2007

PURPOSE To identify nationwide trends and factors associated with the use of computed tomography (CT) in the emergency department (ED). MATERIALS AND METHODS This study was exempt from institutional review board approval. Data from the 1995-2007 National Hospital Ambulatory Medical Care Survey were used to evaluate the numbers and percentages of ED visits associated with CT. A mean of 30 044 visits were sampled each year. Data were also subcategorized according to multiple patient and hospital characteristics. The Rao-Scott χ(2) test was performed to determine whether CT use was similar across subpopulations. Data were evaluated according to exponential and logistic growth models. RESULTS From 1995 to 2007, the number of ED visits that included a CT examination increased from 2.7 million to 16.2 million, constituting a 5.9-fold increase and a compound annual growth rate of 16.0%. The percentage of visits associated with CT increased from 2.8% to 13.9%, constituting a 4.9-fold increase and a compound annual growth rate of 14.2%. The exponential growth model provided the best fit for the trend in CT use. CT use was greater in older patients, white patients, patients admitted to the hospital, and patients at facilities in metropolitan regions. By the end of the study period, the top chief complaints among those who underwent CT were abdominal pain, headache, and chest pain. The percentage of patient visits associated with CT for all evaluated chief complaints increased-most substantially among those who underwent CT for flank, abdominal, or chest pain. CONCLUSION Use of CT has increased at a higher rate in the ED than in other settings. The overall use of CT had not begun to taper by 2007.

Rising Use of CT in Child Visits to the Emergency Department in the United States, 1995–2008

PURPOSE To describe nationwide trends and factors associated with the use of computed tomography (CT) in children visiting emergency departments (EDs) in the United States between 1995 and 2008. MATERIALS AND METHODS This study was exempt from institutional review board oversight. Data from the 1995-2008 National Hospital Ambulatory Medical Care Survey were used to evaluate the number and percentage of visits associated with CT for patients younger than 18 years. A mean of 7375 visits were sampled each year. Data were subcategorized according to multiple patient and hospital characteristics. The Rao-Scott χ(2) test was performed to determine whether CT use was similar across subpopulations. RESULTS From 1995 to 2008, the number of pediatric ED visits that included CT examination increased from 0.33 to 1.65 million, a fivefold increase, with a compound annual growth rate of 13.2%. The percentage of visits associated with CT increased from 1.2% to 5.9%, a 4.8-fold increase, with a compound annual growth rate of 12.8%. The number of visits associated with CT at pediatric-focused and non-pediatric-focused EDs increased from 14,895 and 316,133, respectively, in 1995 to 212,716 and 1,438,413, respectively, in 2008. By the end of the study period, top chief complaints among those undergoing CT included head injury, abdominal pain, and headache. CONCLUSION Use of CT in children who visit the ED has increased substantially and occurs primarily at non-pediatric-focused facilities. This underscores the need for special attention to this vulnerable population to ensure that imaging is appropriately ordered, performed, and interpreted.

Radiation Dose Associated with Unenhanced CT for Suspected Renal Colic: Impact of Repetitive Studies

OBJECTIVE The purpose of our study was to assess the dose of ionizing radiation delivered through the use of unenhanced CT for suspected renal colic by determining the incidence of repeated unenhanced CT examinations and the cumulative radiation dose delivered. MATERIALS AND METHODS All unenhanced CT examinations for suspected renal colic performed at our institution over a 6-year period were included, and patient age, sex, and multiplicity of examinations were determined. For the adult patient, this protocol prescribes a fixed tube current of 200 mA, 140 kVp, and a nominal slice width of 5 mm. The dose-length product (DLP) was estimated for 15 randomly chosen single-detector CT (SDCT) and MDCT adult flank pain examinations using manufacturers software. The mean DLPs for SDCT and MDCT were computed and converted to effective doses. Total effective doses were calculated for patients who underwent more than three examinations, and values were compared with established standards. RESULTS A total of 5,564 examinations were performed on 4,562 patients. Of these patients, 2,795 (61%) were women (mean age, 45.5 +/- 16.2 [SD] years) and 1,731 (38%) were men (mean age, 44.7 +/- 16.4 years), with 144 patients (3%) of pediatric age. The mean effective doses for a single study were 6.5 mSv for SDCT and 8.5 mSv for MDCT. A subset of 176 patients (4%) had three or more examinations, with estimated effective doses ranging from 19.5 to 153.7 mSv. All patients with multiple examinations had a known history of nephrolithiasis. CONCLUSION Patients with a history of nephrolithiasis and flank pain are at increased risk for serial CT with potentially high cumulative effective doses.

Diagnostic CT Scans: Institutional Informed Consent Guidelines and Practices at Academic Medical Centers

OBJECTIVE The purpose of this article is to characterize current informed consent practices for diagnostic CT scans at U.S. academic medical centers. MATERIALS AND METHODS We surveyed 113 radiology chairpersons associated with U.S. academic medical centers using a survey approved by our institutional review board. The need for informed consent for this study was waived. Chairpersons were asked if their institutions have guidelines for nonemergent CT scans (by whom; oral and/or written), if patients are informed of the purpose of their scans (by whom), what specific risks are outlined (allergic reaction, radiation risk and dose, others; by whom), and if patients are informed of alternatives to CT. RESULTS The study response rate was 81% (91/113). Of the respondents, two thirds (60/90) currently have guidelines for informed consent regarding CT scans. Radiology technologists were most likely to inform patients about CT (38/60, 63%) and possible risks (52/91, 57%), whereas ordering physicians were most likely to inform patients about CTs purpose (37/66, 56%). Fifty-two percent (30/58) of sites provided verbal information and 5% (3/58) provided information in written form. Possible allergic reaction to dye was explained at 84% (76/91) of sites, and possible radiation risk was explained at 15% (14/91) of sites. Nine percent (8/88) of sites informed patients of alternatives to CT. CONCLUSION Radiology technologists are more likely to inform patients about CT and associated risks than their physician counterparts. Although most academic medical centers currently have guidelines for informed consent regarding CT, only a minority of institutions inform patients about possible radiation risks and alternatives to CT.

MD/MBA programs in the United States: evidence of a change in health care leadership.

Purpose Managerial sciences are playing an increasingly prominent role in the organization and delivery of health care. Despite popular media reports that a rising number of physicians are acquiring a background in this discipline through MD/MBA (medical and master of business administration) programs, no recent study has verified this. This study measured changes in the number and nature of the affiliations between management and medicine in the form of MD/MBA programs in the United States. Method Surveys of admission officers of 125 U.S. allopathic medical schools and of the overseers of each joint MD/MBA degree program were administered in May–October 2001. Main outcome measures included program growth, curriculum and degree requirements, application and admission requirements, and program leadership and organization. Results The number of MD/MBA programs grew from six to 33 between 1993 and 2001, and 17 more medical schools were considering establishing the joint-degree program. Ten, 15, and 20 programs produced 27, 42, and 61 graduates in 1999, 2000, and 2001, respectively, and over 100 students were expected to graduate per year when all 33 programs matured. Program structures and oversight indicate a spectrum of philosophies regarding the appropriate level of integration of the two degrees. MD/MBA programs apparently attempt to complement medical education with management education rather than the converse. Conclusions The growth in the numbers of MD/MBA programs and participants indicates rising cooperation between medical and business schools and increasing interest in management education early in the careers of graduating physicians.

The State of Teleradiology in 2003 and Changes Since 1999

OBJECTIVE The purpose of our study is to describe in detail the use of teleradiology in 2003 and to report on changes since 1999 in this rapidly evolving field. MATERIALS AND METHODS We analyze non-individually identified data from the American College of Radiologys 2003 Survey of Radiologists, a stratified random sample mail survey that achieved a response rate of 63%, and data from the American College of Radiologys 1999 Survey of Practices. Responses were weighted to represent the distribution of individual radiologists and radiology practices nationwide. We present descriptive statistics and multivariable regression analysis results on the prevalence and uses of teleradiology in 2003 and comparisons with 1999. RESULTS Overall, 67% of all radiology practices in the United States, which included 78% of all U.S. radiologists, reported using teleradiology. A significant increase (p < 0.05) was seen in the prevalence of teleradiology or PACS, from 58% of practices in 1999 to 73% in 2003. Regression results indicate that, other practice characteristics being equal, in 2003, primarily academic practices were less likely to use teleradiology than private radiology practices, and medium-sized practices (5-14 radiologists) were more likely to have teleradiology than larger ones. In practices using teleradiology, home was the most frequent receiving site in both 1999 (81%) and 2003 (75%), the percentages being not significantly different. CONCLUSION Already a fixture of radiology practice in 1999, teleradiology increased in prevalence substantially by 2003. The primary use of teleradiology, transmission of images to home, did not change, suggesting that easing the burden of call remains the main use of teleradiology.

Communicating Potential Radiation-Induced Cancer Risks From Medical Imaging Directly to Patients

OBJECTIVE Over the past decade, efforts have increasingly been made to decrease radiation dose from medical imaging. However, there remain varied opinions about whether, for whom, by whom, and how these potential risks should be discussed with patients. We aimed to provide a review of the literature regarding awareness and communication of potential radiation-induced cancer risks from medical imaging procedures in hopes of providing guidance for communicating these potential risks with patients. MATERIALS AND METHODS We performed a systematic literature review on the topics of radiation dose and radiation-induced cancer risk awareness, informed consent regarding radiation dose, and communication of radiation-induced cancer risks with patients undergoing medical imaging. We included original research articles from North America and Europe published between 1995 and 2014. RESULTS From more than 1200 identified references, a total of 22 original research articles met our inclusion criteria. Overall, we found that there is insufficient knowledge regarding radiation-induced cancer risks and the magnitude of radiation dose associated with CT examinations among patients and physicians. Moreover, there is minimal sharing of information before nonacute imaging studies between patients and physicians about potential long-term radiation risks. CONCLUSION Despite growing concerns regarding medical radiation exposure, there is still limited awareness of radiation-induced cancer risks among patients and physicians. There is also no consensus regarding who should provide patients with relevant information, as well as in what specific situations and exactly what information should be communicated. Radiologists should prioritize development of consensus statements and novel educational initiatives with regard to radiation-induced cancer risk awareness and communication.

Renal Ultrasonography in the Evaluation of Acute Kidney Injury Developing a Risk Stratification Framework

BACKGROUND In adult inpatients with acute kidney injury (AKI), clinicians routinely order a renal ultrasonography (RUS) study. It is unclear how often this test provides clinically useful information. METHODS Cross-sectional study, including derivation and validation samples, of 997 US adults admitted to Yale-New Haven Hospital from January 2005 to May 2009, who were diagnosed as having AKI and who underwent RUS to evaluate elevated creatinine level. Pregnant women, renal transplant recipients, and patients with recently diagnosed hydronephrosis (HN) were excluded. Demographic and clinical characteristics were abstracted from the medical records. A multivariable logistic regression model was developed to create risk strata for HN and HN requiring an intervention (HNRI); a separate sample was used for validation. The frequency of incidental findings on RUS was assessed for each stratum. RESULTS In a derivation sample of 200 patients, 7 factors were found to be associated with HN: history of HN; recurrent urinary tract infections; diagnosis consistent with obstruction; nonblack race; and absence of the following: exposure to nephrotoxic medications, congestive heart failure, or prerenal AKI. Among 797 patients in the validation sample (mean age, 65.6 years), 10.6% had HN and 3.3% had HNRI. Of 223 patients in the low-risk group, 7 (3.1%) had HN and 1 (0.4%) had HNRI (223 patients needed to be screened to find 1 case of HNRI). In this group, there were 0 incidental findings on RUS unknown to the clinical team. In the higher-risk group, 15.7% had HN and 4.7% had HNRI. CONCLUSION In adult inpatients with AKI, specific factors can identify patients unlikely to have HN or HNRI on RUS.

Gender Trends in Radiology Authorship: A 35-Year Analysis

OBJECTIVE The purpose of this study was to describe trends over time in female authorship in the radiology literature and to investigate the tendency of female first authors to publish with female senior authors. MATERIALS AND METHODS Data on the gender of academic physician authors based in the United States for all major articles published in three general radiology journals--Radiology, AJR, and Academic Radiology--were collected and analyzed for the years 1978, 1988, 1998, 2008, and 2013. Multivariate logistic regression was used to identify significant trends over time, and a chi-square test of independence was performed to determine significant relations between the genders of first and senior authors. RESULTS The gender of 4182 of 4217 (99.17%) authors with MD degrees was determined. The proportion of original research articles published by women as first authors increased from 8.33% in 1978 to 32.35% in 2013 (p < 0.001). The proportion of original research articles with women as senior authors increased from 6.75% in 1978 to 21.90% in 2013 (p < 0.001). Female first and senior authorship increased significantly over time (first author, p < 0.001; senior author, p < 0.001). There was a statistically significant relation between the genders of first and senior authors of original research articles and guest editorials (p < 0.001). CONCLUSION Over 35 years, there was a statistically significant upward linear trend of female physician participation in authorship of academic radiology literature. Female first authors were more likely to publish with female senior authors.

Masters of Radiology Panel Discussion: Women in Radiology— How Can We Encourage More Women to Join the Field and Become Leaders?

145 outside my domain of expertise, and I will keep my comments brief to hear more from our women on the panel. The sex imbalance in radiology concerns me on a number of levels but perhaps most because of its implications that, as a specialty, we may not be equally welcoming to all. In a time when women are at least equally represented in other medical specialties, it is not due to a sex imbalance in medical students. I do not know exactly what the reasons are, but it is worth assessing women medical students’ perceptions of the nature of the work, career opportunities, role models, work-life balance, etc., and then working to improve where we can. Norbash: To have increasing numbers of women join radiology, it would be helpful to create an atmosphere where women fundamentally are appreciated and valued, given parity where leadership and research positions are concerned, and given the autonomy and resources to create appropriate mentoring and support services. Simultaneously, there will need to be attention paid to resources and need to establish the appropriate environment to secure work-life balance. Specific actions should include formulating match lists to ultimately yield 50% of matched women in each department, formulating policies to ease women residents’ desire to start a family, and balancing faculty to promote and celebrate the advancement of women radiologists to positions of responsibility and leadership. Beauchamp: We also should keep in mind that diversity is an opportunity not an obligation. Extensive research shows that as you increase the diversity of your groups, productivity, creativity, innovation, and problem solving also increase. Also relative to this conversation is the case of diversity in terms of getting more women in medicine. We are missing an opportunity, given the Masters of Radiology Panel Discussion: Women in Radiology— How Can We Encourage More Women to Join the Field and Become Leaders?