Vijay M. Rao

Musculoskeletal imaging: medicare use, costs, and potential for cost substitution.

PURPOSE The current study explores the substitution of ultrasound (US) for magnetic resonance imaging (MRI) of musculoskeletal (MSK) disorders by describing the recent use and costs of MSK imaging in the Medicare population, projecting these trends from 2006 to 2020, and estimating cost-savings involved in substituting MSK US for MSK MRI, when appropriate. METHODS The study used government-published data sets and de-identified Radiology Information System records exempt from institutional review board approval. From 1 years MSK MRI records (n = 3,621), the proportion of cases in which US could be substituted for MRI was estimated. The use rates for 4 modalities of MSK imaging and average costs were determined from government Medicare data sets from 1996 to 2005. Regression analysis was used to project use rates from 2006 to 2020. The effect on costs of substitution was calculated. RESULTS For the Medicare population, although there has been a moderate overall increase (25.7%) in MSK imaging, MSK MRI has increased 353.5% from 1996 to 2005. Projected MSK imaging costs in 2020 are

Bending the Curve: The Recent Marked Slowdown in Growth of Noninvasive Diagnostic Imaging

3.6 billion, of which

The Overuse of Diagnostic Imaging and the Choosing Wisely Initiative

2.0 billion will be for MRI. A study of 3,621 MSK MRI reports indicates that 45.4% of primary diagnoses and 30.6% of all diagnoses could have been made with MSK US. The substitution of MSK US for MSK MRI, when appropriate, would lead to savings of more than

Placement and Removal of Inferior Vena Cava Filters: National Trends in the Medicare Population

6.9 billion in the period from 2006 to 2020. CONCLUSION MRI MSK use has grown substantially from 1996 to 2005. The substitution of MSK US, when appropriate, would lead to large cost-savings for Medicare.

Magnetic Resonance Imaging of the Ischemic Hip: Alterations Within the Osteonecrotic, Viable, and Reactive Zones

OBJECTIVE The purpose of this article is to determine whether there has been any change in the rapid growth pattern that has characterized noninvasive diagnostic imaging in recent years. MATERIALS AND METHODS The annual nationwide Medicare Part B databases were used. All Current Procedural Terminology codes for discretionary noninvasive diagnostic imaging were identified. The overall utilization rates per 1,000 fee-for-service beneficiaries were calculated from 1998 through 2008, as were rates by modality. Determination was made as to whether studies were interpreted by radiologists or nonradiologist physicians. RESULTS The total utilization rate of noninvasive diagnostic imaging grew at a compound annual growth rate of 4.1% from 1998 to 2005, but this decreased to 1.4% from 2005 to 2008. From 2005 through 2008, the overall growth trends flattened dramatically for MRI and nuclear medicine and abated somewhat for CT, ultrasound, and echocardiography. In ambulatory settings, flattening of the advanced imaging growth curves was seen in both private offices and hospital outpatient facilities. From 1998 to 2005, the compound annual growth rate was 3.4% among radiologists and 6.6% among nonradiologist physicians. From 2005 to 2008, the compound annual growth rate decreased to 0.8% among radiologists and 1.8% among nonradiologists. CONCLUSION There has been a distinct slowing in the growth of discretionary noninvasive diagnostic imaging in the Medicare fee-for-service population since 2005. The slowdown has been most pronounced in MRI and nuclear medicine. This should allay some of the concerns of policymakers and payers. Both before and after 2005, growth was approximately twice as rapid among nonradiologist physicians as among radiologists.

Role of Magnetic Resonance Imaging in the Evaluation of the Hydroxyapatite Orbital Implant

This commentary discusses the overuse of diagnostic imaging tests and approaches to limit imaging studies and other tests and treatments that are inappropriate, unnecessary, wasteful, or redundant....

Turf Wars in Radiology: Updated Evidence on the Relationship Between Self-Referral and the Overutilization of Imaging

PURPOSE The aim of this study was to evaluate trends in the placement and removal of inferior vena cava (IVC) filters in the Medicare population. METHODS Summary Medicare claims data from 1999 through 2008 were used to identify the frequency of IVC filter placement procedures by specialty (radiology, surgery, cardiology, and all others) and site of service. Claims from 2003 (the first year the FDA cleared retrievable labeling for filters) through 2008 were used to identify intravascular foreign body retrieval procedures, and modeling was used estimate a frequency range of removal procedures. Trends over time were evaluated. RESULTS Between 1999 and 2008, total Medicare fee-for-service beneficiary frequency of IVC filter placement procedures increased by 111.5% (30,756 to 65,041). Volumes increased for radiologists (16,531 to 36,829 [+122.8%]), surgeons (11,295 to 22,606 [+100.1%]), and cardiologists (1,025 to 4,236 [+313.3%]). Relative specialty market shares changed little over time. Volumes increased by 114.2% (26,511 to 56,774) and 229.1% (2,286 to 7,524) for hospital inpatients and outpatients, respectively, and decreased by 62.1% (1,959 to 743) for those in all other locations combined. In 2008, with 65,041 filters placed, only an estimated 801 to 3,339 (1.2 to 5.1%) were removed. CONCLUSION The frequency of IVC filter placement has doubled over the past decade, and radiologists continue to perform more than half of all procedures. Although volume has more than tripled in hospital outpatients, the inpatient setting remains by far the most common site of service. In the Medicare population, IVC filters are not commonly removed.

Trends in Utilization Rates of the Various Imaging Modalities in Emergency Departments: Nationwide Medicare Data From 2000 to 2008

To explore the ability of magnetic resonance imaging (MRI) to depict the morphologic features of avascular necrosis (AVN) of the femoral head and to determine whether a classification based on stage of necrosis is possible, images of hips with 56 proved lesions were examined and correlated with roentgenographic stage, severity of pain and functional impairment, and available computed tomography (CT) scans. Six femoral heads with AVN were also studied ex vivo with MRI, CT, roentgenographic, and histologic examinations. These examinations were compared with 100 normal hips in 50 individuals and one normal proximal femoral specimen. The reactive interface between live and dead bone at the periphery of AVN lesions had a characteristic MRI appearance that facilitated diagnosis. Based on central signal intensity on two different pulse sequences, lesions could be separated into four classes that correlated with roentgenographic and clinical staging. Lesions that were isointense with fat on both sequences had an earlier roentgenographic stage and less severe symptoms than did lesions that were less intense than fat. Among hips with AVN in patients younger than 50 years of age, 67% had premature conversion to fatty intertrochanteric marrow outside the borders of the lesion. Detecting premature conversion to fatty marrow has important implications regarding the pathogenesis of AVN and may aid early diagnosis. MRI provides pathophysiologic information that is different from information obtained from conventional methods or various combinations of methods and may provide a basis for an improved system for grading AVN lesions.

SINONASAL IMAGING : Anatomy and Pathology

The role of magnetic resonance imaging (MRI) in the assessment of fibrovascular ingrowth in the integrated hydroxyapatite orbital implant is evaluated. Fifteen patients who underwent enucleation and placement of a hydroxyapatite orbital implant were evaluated for degree of implant vascularity with gadolinium-DPTA-enhanced MRI with surface coil before drilling the implant. On T1-weighted images, the hydroxyapatite sphere appeared with intermediate signal. After gadolinium-DPTA administration, all patients showed an enhancement in the implant consistent with the presence of fibrovascular ingrowth. The enhancement was most notable in the peripheral portions of the sphere and was seen as early as 5 months after implantation. Comparison of gadolinium-DPTA-enhanced MRI with contrast-enhanced computed tomography, ultrasonography, and color Doppler imaging suggests that these latter techniques are not as helpful in the detection of the fibrovascular tissue in the orbital implant. Bone scan, a technique used by many surgeons, demonstrates fibrovascular ingrowth, but it is limited by its one-dimensional low-resolution image. Because of its three-dimensional capability and its highest resolution, contrast-enhanced MRI with surface coil appears to be the best imaging method for evaluating the hydroxyapatite orbital implant and its fibrovascular ingrowth.

Geographic Variation in the Utilization of Noninvasive Diagnostic Imaging: National Medicare Data, 1998–2007

In a previous article in this series, published in 2004, the authors reviewed the medical literature for evidence on the relationship between self-referral and the utilization of imaging. That evidence demonstrated that self-referral led to substantially higher levels of utilization with its attendant increases in cost and the exposure of patients to unnecessary radiation. Since then, much new information has been published on this controversial subject. In this article, the authors update their previous article by summarizing all the recently published material. Once again, the evidence clearly indicates that self-referral results in the overutilization of imaging. Because radiologists have an important stake in the matter, it behooves them to be familiar with this recent evidence so they can bring it to the attention of policymakers in their areas.