Comparison of recent utilization trends in radionuclide myocardial perfusion imaging among radiologists and cardiologists

Recent Trends Suggest Possible Inappropriate Utilization of Myocardial Perfusion Imaging

PURPOSE

The aim of this study was to analyze the utilization of elective stress nuclear myocardial perfusion imaging (MPI) in the Medicare population.

METHODS

Nationwide Medicare Part B fee-for-service databases for 2004 to 2016 were reviewed. Current Procedural Terminology codes for stress MPI were selected: standard planar and single-photon emission computed tomography (STD) and PET. Utilization rates per 1,000 Medicare beneficiaries were calculated. Elective examinations were identified using place-of-service codes for private offices and hospital outpatient departments (HOPDs). Medicare physician specialty codes identified the performing physician. Because Medicare Part B databases are complete population counts, sample statistics were not required.

RESULTS

Elective STD MPI utilization peaked in 2006 at 74 studies/1,000 and had declined by 36% by 2016. Cardiologists' share of STD MPI grew from 79% to 87% between 2004 and 2016. Cardiologists perform STD MPI primarily in private offices, where utilization peaked in 2008 and then demonstrated an absolute decline of 28 studies/1,000 by 2016. During this same time period, cardiologists' use of STD MPI in HOPDs demonstrated an absolute increase of 8.1 studies/1,000. From 2004 to 2016, STD MPI use by radiologists declined by 58%. Elective PET MPI maintained an upward trend, reflecting increasing use by cardiologists in private offices.

CONCLUSIONS

Elective STD MPI use is declining, but cardiologists are performing an increasing share in outpatient settings. The drop in private office STD MPI among cardiologists was far greater than the corresponding increase in its use in HOPDs, suggesting that many studies previously performed in private offices were unindicated. Self-referred PET MPI utilization has rapidly grown in cardiology private offices.

Attributes of nuclear imaging centers impacting physician referrals for single-photon emission computed tomography myocardial perfusion imaging tests

AIM

To evaluate nuclear imaging center attributes that cardiologists and primary care physicians (PCPs) consider when referring patients for single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) tests, and how these attributes impact physician referral decisions in the United States.

METHODS

A targeted literature review and seven one-to-one interviews with physicians and imaging center directors were conducted to identify attributes that could impact physicians' referral decisions. The impact of the identified attributes was assessed via an online discrete choice survey among eligible PCPs and cardiologists randomly selected from a nationally representative panel, and quantified with an odds ratio (OR) scale estimated with a multivariable logistic regression.

RESULTS

Nine two-level attributes were identified: ease of the referral process, waiting time for tests, insurance preauthorization assistance, time to receive results, conclusive test reports, patient satisfaction, a protocol for rapid conversion from an exercise to a pharmacological stress test, patient communication, and assistance with parking/wheelchair access. A total of 410 physicians, including 208 (50.7%) cardiologists and 202 (49.3%) PCPs completed the survey. Among all physicians, a protocol that allows for a rapid conversion from an exercise to a pharmacological stress test (OR = 2.9) and preauthorization assistance (OR = 2.6) were the most impactful attributes. Additionally, cardiologists preferred imaging centers that provide an easy referral process (OR = 2.7), while PCPs favored centers offering a conclusive test report (OR = 2.4).

LIMITATIONS

Some center features that might impact physician referral decision were not evaluated in this study, if they were not easily changeable from an imaging center's perspective.

CONCLUSIONS

The availability of a protocol for rapid conversion from an exercise to a pharmacological stress test and preauthorization assistance had the most significant impact on physician referral decisions for SPECT-MPI. Additionally, cardiologists preferred centers providing an easy referral process, while PCPs favored those offering a concluding statement and actionable steps in test reports.

Outcomes after inappropriate nuclear myocardial perfusion imaging: A meta-analysis

BACKGROUND

The relationship between inappropriate MPI and cardiovascular outcomes is poorly understood. We sought to systematically review the literature on appropriate use criteria (AUC) for MPI, including temporal trend of inappropriate testing and resulting cardiovascular outcomes.

METHODS

We searched the MEDLINE database for studies related to AUC and MPI. The co-primary outcomes were abnormal test results and the presence of cardiac ischemia. Random effects odds ratios (OR) were constructed using DerSimonian-Laird method.

RESULTS

A total of 22 studies with 23,443 patients were included. The prevalence of inappropriate testing was 14.8% [95% confidence interval (CI) 11.6%-18.7%]. Inappropriate MPI studies were less likely to be abnormal (OR 0.41 95% CI 0.35-0.49, P < .0001) and to demonstrate ischemia (OR 0.40, 95% CI 0.24-0.67, P < .0001) compared to appropriate testing. No difference in the rate of inappropriate tests was detected based on the midpoint of the enrollment year (P = .54). The pattern of ordering inappropriate studies was not different between cardiology and non-cardiology providers (OR 0.74, 95% CI 0.51-1.06, P = .10).

CONCLUSION

Inappropriate MPI studies are less likely to yield abnormal results or demonstrate myocardial ischemia. The rate of inappropriate MPI has not decreased over time.

Have CT and MR Angiography Replaced Catheter Angiography in Diagnosing Peripheral Arterial Disease?

PURPOSE

To determine whether MR angiography (MRA) and CT angiography (CTA) have replaced diagnostic catheter angiography (DCA) in diagnosing peripheral arterial disease.

METHODS

Medicare Part B databases for 2002-2013 were reviewed. Current Procedural Terminology codes for extremity MRA, CTA, and DCA were selected. Physician specialty codes were used to classify providers as radiologists, cardiologists, or surgeons. Utilization rates per 100,000 Medicare beneficiaries were calculated.

RESULTS

Among all specialties, the combined utilization rate of all 3 types of angiography increased from 917 per 100,000 in 2002 to 1,261 in 2006 (+38%), after which it remained stable until 2010, and then declined to 1,010 in 2013. The overall rate of MRA and CTA together increased from 89 in 2002 to 440 in 2006 (+394%), after which it leveled off, and then gradually decreased to 331 in 2013. In 2013, 33% of the total procedures were MRA or CTA, up from 10% in 2002. Radiologists performed >85% of MRA and CTA examinations. Among radiologists, the DCA utilization rate decreased by 75% from 2002 to 2013, whereas among cardiologists and surgeons together, the overall DCA utilization rate increased by 64% from 2002 to 2010 before dropping somewhat in 2011.

CONCLUSIONS

Among radiologists, MRA and CTA have replaced DCA in diagnosing peripheral arterial disease. Although overall utilization of DCA has remained steady, it has risen sharply among cardiologists and surgeons, while dropping sharply among radiologists. Given the increased utilization of DCA among cardiologists and surgeons despite noninvasive alternatives, self-referral continues to be of concern in the setting of increasing health care costs.

Recent reimbursement changes and their effect on hospital and private office use of myocardial perfusion imaging

PURPOSE

The aims of this study were to examine recent trends in the utilization of radionuclide myocardial perfusion imaging (MPI) and to reflect on their causes and their implications for radiologists.

METHODS

Nationwide Medicare Part B databases for 2000 through 2010 were used. Codes for primary MPI studies (including PET) were selected. Medicare specialty codes were used to identify MPI examinations done by radiologists, cardiologists, and other physicians. Place-of-service codes were used to identify examinations performed in offices versus hospital settings. Utilization rates per 1,000 fee-for-service beneficiaries were calculated. Trends were assessed by place of service and specialty.

RESULTS

The overall MPI utilization rate rose from 2000 through 2004, followed by a period of stabilization from 2005 to 2008. A peak of 88.0 per 1,000 was reached in 2006. In 2009 and 2010, a decline occurred, with the rate dropping by 13% to 76.9. In private offices, cardiologists' utilization grew rapidly from 2000 through 2006, but growth stopped thereafter. Their rate peaked in 2008 at 50.6 but dropped to 44.4 by 2010 (-12%). Radiologists' role in office MPI was minimal. In hospital settings, radiologists predominated in 2000. Their rate remained stable through 2004 but thereafter began to decline steadily, dropping by 35% by 2010. Cardiologists' hospital-based utilization rate rose gradually, then flattened, but began to rise in 2009 and 2010. By 2010, cardiologists performed more hospital MPI examinations than radiologists.

CONCLUSIONS

Radiologists' initially predominant role in hospital-based MPI has eroded recently, while that of cardiologists has strengthened. This seems related to a shift among cardiologists away from office practice and into hospital affiliations.

The true cost of cardiovascular imaging: focusing on downstream, indirect, and environmental costs

To develop a more realistic assessment of costs, herein named “true” costs, the extra-cancer from medical radiation, environmental damage from imaging paraphernalia and radioactive wastes must be included as long-term costs from imaging examinations. It is urgent to define the “true” costs across imaging modalities as it interferes on physicians’ decision to request an exam and on research projects such as cost-effectiveness analysis. Cardiology is the specialty that most will benefit from the outcome as cardiovascular exams represent almost 30% of the total exams acquired annually worldwide.

Combating overutilization: radiology benefits managers versus order entry decision support

Radiology benefits managers (RBMs) and computerized decision support offer different advantages and disadvantages in the efforts to provide appropriate use of radiology resources. RBMs are effective in their hard-stop ability to reject inappropriate studies, incur a significant cost, and interpose an intermediary between patient and physician. Decision support is a more friendly educational product, but has not been implemented for all clinical indications and its efficacy is still being studied.

Utilization rates of neuroradiology across neuroscience specialties in the private office setting: who owns or leases the scanners on which studies are performed?

BACKGROUND AND PURPOSE

Recent literature shows an increasing portion of imaging studies being conducted and interpreted by nonradiologists, especially across the modalities with the highest RVUs. We examined the trends in the Medicare technical charges for private office neuroradiology studies submitted by subspecialists to identify utilization trends among MR and CT scanner owners or lessees over the last decade.

MATERIALS AND METHODS

The number of neuroradiology studies performed on MR and CT machines owned or leased in private offices was determined from the CMS PSPSMF for 1998-2008. Studies billed through technical and global charges were aggregated. Utilization rates and utilization rate CAGRs were computed by specialty and by imaging study.

RESULTS

Between 1998 and 2008, MR studies grew by a factor of 2.5 and CT studies grew by 2.1. In 2008, radiologists charged the technical/global fee in 1,386,669 (56.6%), neurologists in 82,360 (3.4%), neurosurgeons in 29,218 (1.2%), multi/IDTF in 617,933 (25.2%), and other specialists in 334,843 (13.7%) of neuroradiology cases. Changes from the 1998 base rate to the 2008 rate per 1000 Medicare beneficiaries were 24.1 to 39.7 for radiologists, 1.03 to 2.4 for neurologists, 0.15 to 0.84 for neurosurgeons, 2.2 to 17.7 for multi/IDTF, and 1.3 to 9.6 for other specialists. All specialties, except for multi/IDTF, showed greater MR utilization increases than CT. Neurology (CAGR of 10.6%), neurosurgery (22.1%), multi/IDTF (23.2%), and other specialists' (24.6%) MR growth outpaced that of radiology's (5.3%).

CONCLUSIONS

All nonradiologists showed greater overall utilization growth in private office neuroradiology than did radiology. Also, nonradiologists generally showed greater utilization increases in MR than CT. Radiologists' private office neuroradiology technical fee share shrank from 83.6% to 56.6% between 1998 and 2008.

Do imaging studies performed in physician offices increase downstream utilization?: an empiric analysis of cardiac stress testing with imaging

OBJECTIVES

The goal of this study was to compare patterns of downstream testing and procedures after stress testing with imaging performed at physician offices versus at hospital-outpatient facilities

BACKGROUND

Stress testing with imaging has grown dramatically in recent years, but whether the location of where the test is performed correlates with different patterns for subsequent cardiac testing and procedures is unknown

METHODS

We identified 82,178 adults with private health insurance from 2005 to 2007 who underwent ambulatory myocardial perfusion imaging (MPI) or stress echocardiography (SE). Subsequent MPI, SE, cardiac catheterization or revascularization within 6 months was compared between physician office and hospital outpatient settings.

RESULTS

Overall, 85.1% of MPI and 84.9% of SE were performed in physician offices. The proportion of patients who underwent subsequent MPI, SE, or cardiac catheterization was not statistically different between physician office and hospital outpatient settings for MPI (14.2% vs. 13.9%, p=0.44) or SE (7.9% vs. 8.6%, p=0.21). However, patients with physician office imaging had slightly higher rates of repeat MPI within 6 months compared with hospital-outpatient imaging for both index MPI (3.5% vs. 2.0%, p<0.001) and SE (3.4% vs. 2.1%, p<0.001), and slightly lower rates of cardiac catheterization after index MPI (11.4% vs. 12.2%, p=0.04) and SE (4.5% vs. 7.0%, p<0.001). Differences in 6-month utilization were observed across the 5 healthcare markets after index MPI but not after index SE CONCLUSIONS: Physician office imaging is associated with slightly higher repeat MPI and fewer cardiac catheterizations than hospital outpatient imaging, but no overall difference in the proportion of patients undergoing additional further testing or procedures. Although regional variation exists, especially for MPI, the relationship between physician office location of stress testing with imaging and greater downstream resource utilization appears modest.

Laboratory test ordering at physician offices with and without on-site laboratories

BACKGROUND

Physician self-referral, ordering a test or procedure or referring to a facility in which a physician has a financial interest, has been associated with increased utilization of health care services.

OBJECTIVE

To examine the association between on-site laboratories and laboratory test ordering among visits to group-practice physicians.

DESIGN

Cross-sectional study using data from the 2005 and 2006 National Ambulatory Medical Care Surveys.

STUDY POPULATION

Visits by adults to non-federally-funded, non-hospital-based group practices. Primary analyses focused on visits to physician owners; secondary analyses focused on visits to non-owners.

MAIN MEASURES

Ordering of five laboratory tests: complete blood count (CBC), electrolytes, glycoslyated hemoglobin A1c (HbA1c), cholesterol, and prostate-specific antigen (PSA).

KEY RESULTS

There were 19,163 visits to group-practice owners with 51.9% to a practice with an on-site laboratory. Visits to primary care physicians were more likely to be to a practice with an on-site laboratory when compared with visits to specialists (64.4% vs. 34.0%, p < 0.001). Among visits to specialist group owners, all five tests were ordered more often if there was an on-site laboratory, even after accounting for patient and practice characteristics: CBC: adjusted odds ratio[OR] = 8.01, 95% Confidence Interval [CI], 5.00-12.82, p < 0.001; electrolytes: aOR = 3.51, 95% CI, 1.93-6.40, p < 0.001; HbA1c: aOR = 4.91, 95% CI, 1.75-13.78, p = 0.003; cholesterol: aOR = 3.32, 95% CI, 1.85-5.93, p < 0.001; and PSA: aOR = 3.84, 95% CI, 1.93-7.65, p < 0.001. This association was not found among visits to primary care physician owners and all practice non-owners (both primary care and specialists). The estimated excess spending on these five tests by specialist owners with on-site laboratories was $75 million per 100 million visits.

CONCLUSIONS

In a nationally representative sample of visits to physician-owned group practices, specialist owners with on-site laboratories were more likely to order five common laboratory tests, potentially resulting in millions in excess healthcare spending.

Effect of advanced imaging technology on how biopsies are done and who does them

PURPOSE

To assess national levels and trends in utilization of biopsy procedures during the past decade and investigate the relative roles of biopsy approaches (open, endoscopic, and percutaneous) and physician specialties.

MATERIALS AND METHODS

Institutional review board approval was not necessary because only public domain data were used. Aggregated Medicare claims data were used to determine utilization of biopsies performed in 10 anatomic regions from 1997 to 2008. Utilization levels according to biopsy approach and anatomic region were calculated. Trends in the relative utilization of percutaneous needle biopsy (PNB) and imaging-guided percutaneous biopsy (IGPB) were assessed. The relative roles of radiologists and nonradiologists in the performance of all biopsies, PNBs, and IGPBs were evaluated.

RESULTS

Biopsy procedures with all approaches increased from 1380 to 1945 biopsies per 100,000 Medicare enrollees between 1997 and 2008, which represents a compound annual growth rate (CAGR) of 3%. Utilization of non-PNBs fell, while the absolute level and relative share of PNBs increased. In 2008, 67% of all biopsies were performed by using a percutaneous route. IGPB as a percentage of all PNBs increased over time in the regions for which data were available. Radiology was the leading specialty providing biopsy services. The total number of biopsies performed by radiologists increased at a CAGR of 8%, and radiologists' share of all biopsies increased from 35% to 56%.

CONCLUSION

During the past decade, there was continuing substitution away from invasive approaches and non-imaging-guided percutaneous approaches in favor of PNBs and IGPBs, likely related to increasing use of advanced imaging modalities for biopsy guidance. Consequently, radiologists are performing an increasing share of biopsies across all anatomic regions.

Trends and different educational pathways for training physicians in nuclear medicine

The introduction of positron emission tomography/computed tomography (CT), single photon-emission CT/CT, and software packages for multimodality imaging has accelerated the need for nuclear medicine physicians to obtain more training in cross-sectional imaging, especially in CT. In recent years, the Nuclear Regulatory Commission, the Accreditation Council for Graduate Medical Education, the American Board of Radiology, and the American Board of Nuclear Medicine have promulgated new rules and regulations. In addition, the Society of Nuclear Medicine, the American College of Radiology, and the American College of Cardiology Foundation have crafted new guidelines and training requirements. All these changes have consequences for the education of physicians in nuclear medicine. Self-referral and concerns about radiation exposure from nuclear medicine examinations and CT are also affecting the education of physicians practicing nuclear medicine. The authors examine the impact of these developments on training and certification in nuclear medicine and suggest another pathway to train some nuclear medicine physicians.

The Effect of the Introduction of MR and CT Angiography on the Utilization of Catheter Angiography for Peripheral Arterial Disease

PURPOSE

To determine whether the utilization rate of diagnostic catheter angiography (DCA) for peripheral arterial disease (PAD) has been affected by the utilization in recent years of magnetic resonance angiography (MRA) and computed tomographic angiography (CTA).

METHODS AND MATERIALS

Medicare Part B data sets for 2000 to 2004 were reviewed to study utilization trends in the Current Procedural Terminology, 4th ed., codes for DCA, MRA, and CTA of peripheral arteries. The Medicare physician specialty codes were used to indicate procedures performed by radiologists, cardiologists, surgeons, and other physicians. Utilization rates per 100,000 Medicare beneficiaries were calculated.

RESULTS

Between 2000 and 2004, the total utilization rate of all 3 types of angiographic procedures for PAD rose from 789 to 969 per 100,000 (+23%). The rate for DCA dropped slightly, from 767 to 761 per 100,000, whereas the rate for MRA and CTA together increased from 23 to 208 per 100,000. Almost all MRA and CTA were performed by radiologists. Among radiologists, the DCA utilization rate dropped from 486 to 334 per 100,000 (-31%); among cardiologists and surgeons together, the DCA rate increased from 228 to 387 per 100,000 (+70%). The total utilization rate of all diagnostic angiographic procedures for PAD among radiologists increased by 3%, compared with much higher rate increases among cardiologist and surgeons.

CONCLUSION

Among radiologists, a substitution effect occurred, in that noninvasive procedures such as MRA and CTA progressively replaced an invasive procedure, DCA. However, the rapid increase in DCA utilization among cardiologists and surgeons led to an increase in the overall utilization rate of angiographic procedures for diagnosing PAD. Increasing self-referral for an invasive procedure such as DCA among these two specialties is of concern at a time when less expensive, noninvasive alternatives are readily available.

Recent Trends in Utilization of Vascular Ultrasound Among Radiologists, Surgeons, Cardiologists, and Other Physicians

PURPOSE

To determine how much vascular ultrasound is performed by the various medical specialties and to assess the utilization trends among them in recent years.

METHODS AND MATERIALS

The nationwide Medicare Part B databases for 1998 through 2004 were used. The authors studied the 15 Current Procedural Terminology, Version 4, codes in the 93000 series pertaining to vascular ultrasound and determined the volume of examinations performed under global and professional component claims. Using Medicare's physician specialty codes, utilization rates per 1,000 Medicare beneficiaries and trends in these rates were determined for radiologists, surgeons, cardiologists, other physicians, and independent diagnostic testing facilities (IDTFs) over the 6-year period. Market shares were calculated for the different specialties.

RESULTS

In 2004, among all specialties, 171.8 vascular ultrasound studies were performed per 1,000 Medicare beneficiaries, an increase of 49% over 1998. For the various specialty groups, the 2004 utilization rates and percentage changes since 1998 were as follows: radiologists, 70.8 per 1,000 (+44%); surgeons, 44.6 per 1,000 (+47%); cardiologists, 23.1 per 1,000 (+93%); other physicians, 24.0 per 1,000 (+52%); and IDTFs, 9.3 per 1,000 (+12%). Market shares in 2004 were as follows: radiologists, 41.2%; surgeons, 26.0%; cardiologists, 13.4%; other physicians, 14.0%; and IDTFs, 5.4%. Although the percentage change in utilization rates over the 6 years was highest among cardiologists, the addition of new case volume was highest among radiologists. Radiologists added 1,110,961 new studies between 1998 and 2004, whereas surgeons added 713,251, cardiologists added 489,958, other physicians added 401,601, and IDTFs added 89,077.

CONCLUSIONS

Radiologists have the largest market share in vascular ultrasound. Between 1998 and 2004, they added more new volume than other specialties. Utilization trends suggest that radiologists will continue to have a strong role in this major aspect of vascular imaging.

The 2005 Robert D. Moreton Lecture: The Inappropriate Utilization of Imaging Through Self-Referral

Self-referral in diagnostic imaging has adverse consequences for our health care system. It inevitably leads to overutilization. If untrained physicians try to interpret images, they will make avoidable errors. Imaging facilities operated by untrained physicians are more likely to produce poor-quality examinations. These statements are backed up by abundant evidence in the medical literature. Major payers such as Medicare and the Blue Cross Blue Shield Association are aware of the problem. There are a number of possible remedies, and it remains to be seen whether they and other payers will adopt them.