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Christensen EW, Liu CM, Duszak R, Hirsch JA, Swan TL, Rula EY. Association of State Share of Nonphysician Practitioners With Diagnostic Imaging Ordering Among Emergency Department Visits for Medicare Beneficiaries. JAMA Netw Open 2022; 5:e2241297. [PMID: 36355374 PMCID: PMC9650604 DOI: 10.1001/jamanetworkopen.2022.41297] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
IMPORTANCE The use of nonphysician practitioners (NPPs) in the emergency department (ED) continues to expand, yet little is known about associations between NPPs and ED imaging use. OBJECTIVE To investigate whether the state share of ED visits for which an NPP was the clinician of record is associated with imaging studies ordered, given that state NPP share is associated with state-level NPP scopes of practice. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study compared diagnostic imaging ordering patterns associated with ED visits based on 2005-2020 Medicare claims for a nationally representative 5% sample of fee-for-service beneficiaries. For all 50 states and the District of Columbia, the state NPP share of ED visits by year was used to represent state-specific practice patterns for NPPs and physicians and how those patterns have evolved over time. The analysis controlled for patient demographic characteristics, Charlson Comorbidity Index scores, ED visit severity, year, and principal diagnosis. EXPOSURES The share of ED visits in each state in each year (state share) for which an NPP was the evaluation and management clinician. MAIN OUTCOMES AND MEASURES The main outcomes were the number and modality of imaging studies associated with ED visits. Analyses were by logistic regression and generalized linear model with γ-distribution and log-link function. RESULTS Among 16 922 274 ED visits, 60.0% involved women, and patients' mean (SD) age was 70.3 (16.1) years. The share of all ED visits with an NPP as the clinician increased from 6.1% in 2005 to 16.6% in 2020. Compared with no NPPs, the presence of NPPs in the ED was associated with 5.3% (95% CI, 5.1%-5.5%) more imaging studies per ED visit, including a 3.4% (95% CI, 3.2%-3.5%) greater likelihood of any imaging order per ED visit and 2.2% (95% CI, 2.0%-2.3%) more imaging studies ordered per visit involving imaging. CONCLUSIONS AND RELEVANCE In this study, use of NPPs in the ED was associated with higher imaging use compared with the use of only physicians in the ED. Although expanded use of NPPs in the ED may improve patient access, the costs and radiation exposure associated with more imaging warrants additional study.
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Affiliation(s)
- Eric W. Christensen
- Harvey L. Neiman Health Policy Institute, Reston, Virginia
- Health Services Management, University of Minnesota, St Paul
| | - Chi-Mei Liu
- Harvey L. Neiman Health Policy Institute, Reston, Virginia
| | - Richard Duszak
- Department of Radiology, University of Mississippi Medical Center, Jackson
| | - Joshua A. Hirsch
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Shah R, Elangovan A, Jordan DW, Katz J, Cooper GS. 10-Year Trend of Abdominal Magnetic Resonance Imaging Compared With Abdominal Computed Tomography Scans in Inflammatory Bowel Disease. Inflamm Bowel Dis 2022; 28:1357-1362. [PMID: 34935946 DOI: 10.1093/ibd/izab284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND Patients with inflammatory bowel disease (IBD) frequently undergo multiple computed tomography (CT) examinations. With the widespread availability of magnetic resonance imaging (MRI), it is unclear whether the use of CTs in IBD has declined. We aimed to analyze the trends of CT and MRI use in a large cohort of IBD patients in a 10-year period. METHODS We retrospectively analyzed adults ≥18 years of age using a de-identified database, IBM Explorys. Patients with ≥1 CT of the abdomen (± pelvis) or MRI of the abdomen (± pelvis) at least 30 days after the diagnosis of Crohn's disease (CD) or ulcerative colitis (UC) were included. We examined the factors associated with patients undergoing multiple CTs (≥5 CTs of the abdomen) and performed a trend analysis from 2010 to 2019. RESULTS Among 176 110 CD and 143 460 UC patients, those with ≥1 CT of the abdomen annually increased from 2010 to 2019 with mean annual percentage change of +3.6% for CD and +4.9% for UC. Similarly, annual percentage change for patients with ≥1 MRI (CD: +15.6%; UC: +22.8%) showed a rising trend. There was a 3.8% increase in CD patients receiving ≥5 CTs of the abdomen annually compared with a 2.4% increase among UC patients in the 10-year period. Age ≥50 years, men, African Americans, public insurance payors, body mass index ≥30kg/m2, and smoking history were associated with ≥5 CTs. CONCLUSIONS There is a considerable increase in the number of CT scans performed in IBD patients. Further studies can explore factors influencing the use of CT and MRI of the abdomen in IBD patients.
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Affiliation(s)
- Raj Shah
- Division of Gastroenterology, Case Western Reserve University/University Hospitals Cleveland Medical Center, Cleveland, OH, USA.,Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA, USA
| | - Abbinaya Elangovan
- Division of Gastroenterology, Case Western Reserve University/University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - David W Jordan
- Department of Radiology, Case Western Reserve University/University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jeffry Katz
- Division of Gastroenterology, Case Western Reserve University/University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Gregory S Cooper
- Division of Gastroenterology, Case Western Reserve University/University Hospitals Cleveland Medical Center, Cleveland, OH, USA
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Moore SJ. Comparing physicians and PAs as solo providers in a rural ED: A pilot study. JAAPA 2021; 34:1-6. [PMID: 34162814 DOI: 10.1097/01.jaa.0000753912.30975.43] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To examine the use of physician assistants (PAs) as solo providers in rural EDs. METHODS This study compared ED metrics and patient characteristics between physicians and PAs at a critical access hospital in Arizona. RESULTS Nearly 26,000 patient encounters from the ED of the host institution were analyzed. Although minor variances in metrics were appreciated, transfers, 72-hour returns, and death rates were all similar among provider types. Results from this work do not demonstrate a clinically meaningful difference among ED metrics between physicians and PAs. CONCLUSIONS Results from this study suggest that an appropriately trained and experienced PA can meet commonly used metrics in the care of patients presenting to this rural ED.
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Affiliation(s)
- S Jason Moore
- S. Jason Moore is a clinical researcher and an ED provider. The author has disclosed no potential conflicts of interest, financial or otherwise
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Sung YS, Dravenstott RW, Darer JD, Devapriya PD, Kumara S. SuperOrder: Provider order recommendation system for outpatient clinics. Health Informatics J 2019; 26:999-1016. [PMID: 31266390 DOI: 10.1177/1460458219857383] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study aims at developing SuperOrder, an order recommendation system for outpatient clinics. Using the electronic health record data available at midnight, SuperOrder predicts the order contents for each upcoming appointment on a daily basis. A two-level prediction framework is proposed. At the base-level, the predictions are produced by aggregating three machine learning methods. The meta-level predictions are generated by integrating the base-level predictions with the order co-occurrence network. We used the retrospective data between 1 April 2014 and 31 March 2015 in pulmonary clinics from five hospital sites within a large rural health care facility in Pennsylvania to test the feasibility. With a decrease of 6 per cent in the precision, the improvement of the recall at the meta-level is approximately 20 per cent from the base-level. This demonstrates that the proposed order co-occurrence network helps in increasing the performance of order predictions. The implementation will bring a more effective and efficient way to place outpatient orders.
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Affiliation(s)
- Yi-Shan Sung
- University of Arkansas for Medical Sciences, USA
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Emprechtinger R, Fischer S, Holzer LA, Klimek P, Stanak M, Oikarinen H, Wild C. Methods to detect inappropriate use of MRI and CT for musculoskeletal conditions: A scoping review. ZEITSCHRIFT FUR EVIDENZ, FORTBILDUNG UND QUALITAT IM GESUNDHEITSWESEN 2018; 137-138:20-26. [PMID: 30413357 DOI: 10.1016/j.zefq.2018.09.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 09/20/2018] [Accepted: 09/20/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Identify and evaluate methods suitable for detecting inappropriate use of MRI or CT in the musculoskeletal system. DESIGN Systematic review of studies that described methods to measure inappropriate use of MRI or CT in the musculoskeletal system. We used a multi-step strategy to classify identified methods into categories. These categories were then analyzed according to the data needed and their limitations. ELIGIBILITY CRITERIA FOR SELECTING STUDIES English or German language studies that measured inappropriate use of MRI or CT in the musculoskeletal system. Articles were also included if they reported a general approach to the measurement of inappropriate imaging regardless of body region. Expert opinions, unsystematic reviews, commentaries, articles without abstracts, and studies on cancer were excluded. RESULTS 47 studies met the inclusion criteria. The categorization of the studies resulted in seven individual approaches to measure inappropriate use: (1) availability of meaningful diagnostic information; (2) predictors associated with imaging use; (3) comparison with guideline recommendations; (4) assessment by experts; (5) comparison or analysis of patients' paths; (6) comparison with surgery findings; (7) geographic variation. All these approaches have specific data requirements and individual advantages and disadvantages regarding risk of bias and needed data. CONCLUSIONS We could not find a single method of choice to detect inappropriate use of MRI or CT in the musculoskeletal system. A combination of different approaches is the preferred strategy to deal with the advantages and disadvantages of the individual methods.
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Affiliation(s)
| | - Stefan Fischer
- Ludwig Boltzmann Institute for Health Technology Assessment, Vienna, Austria
| | - Lukas A Holzer
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz; AUVA Trauma Center, Klagenfurt am Wörthersee, Austria
| | - Peter Klimek
- Section for Science of Complex Systems, CeMSIIS, Medical University of Vienna, Vienna; Complexity Science Hub Vienna, Vienna, Austria
| | - Michal Stanak
- Ludwig Boltzmann Institute for Health Technology Assessment, Vienna, Austria
| | - Heljä Oikarinen
- Department of Diagnostic Radiology, Oulu University Hospital, OYS, Oulu, Finland
| | - Claudia Wild
- Ludwig Boltzmann Institute for Health Technology Assessment, Vienna, Austria
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Baloescu C. Diagnostic Imaging in Emergency Medicine: How Much Is Too Much? Ann Emerg Med 2018; 72:637-643. [PMID: 30146444 DOI: 10.1016/j.annemergmed.2018.06.034] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Indexed: 01/11/2023]
Affiliation(s)
- Cristiana Baloescu
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT.
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Kuehl DR, Berdahl CT, Jackson TD, Venkatesh AK, Mistry RD, Bhargavan-Chatfield M, Raukar NP, Carr BG, Schuur JD, Kocher KE. Advancing the Use of Administrative Data for Emergency Department Diagnostic Imaging Research. Acad Emerg Med 2015; 22:1417-26. [PMID: 26575944 DOI: 10.1111/acem.12827] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 07/09/2015] [Indexed: 01/18/2023]
Abstract
Administrative data are critical to describing patterns of use, cost, and appropriateness of imaging in emergency care. These data encompass a range of source materials that have been collected primarily for a nonresearch use: documenting clinical care (e.g., medical records), administering care (e.g., picture archiving and communication systems), or financial transactions (e.g., insurance claims). These data have served as the foundation for large, descriptive studies that have documented the rise and expanded role of diagnostic imaging in the emergency department (ED). This article summarizes the discussions of the breakout session on the use of administrative data for emergency imaging research at the May 2015 Academic Emergency Medicine consensus conference, "Diagnostic Imaging in the Emergency Department: A Research Agenda to Optimize Utilization." The authors describe the areas where administrative data have been applied to research evaluating the use of diagnostic imaging in the ED, the common sources for these data, and the strengths and limitations of administrative data. Next, the future role of administrative data is examined for answering key research questions in an evolving health system increasingly focused on measuring appropriateness, ensuring quality, and improving value for health spending. This article specifically focuses on four thematic areas: data quality, appropriateness and value, special populations, and policy interventions.
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Affiliation(s)
- Damon R. Kuehl
- Department of Emergency Medicine; Virginia Tech Carilion School of Medicine; Roanoke VA
| | - Carl T. Berdahl
- Department of Emergency Medicine; Los Angeles County + University of Southern California Medical Center; Los Angeles CA
| | - Tiffany D. Jackson
- Department of Emergency Medicine; University of Alabama Birmingham; Birmingham AL
| | | | - Rakesh D. Mistry
- Department of Emergency Medicine; Section of Emergency Medicine; Children's Hospital Colorado; Aurora CO
| | | | - Neha P. Raukar
- Department of Emergency Medicine; Warren Alpert Medical School of Brown University; Providence RI
| | - Brendan G. Carr
- Department of Emergency Medicine; Sidney Kimmel Medical College; Thomas Jefferson University; Philadelphia PA
| | - Jeremiah D. Schuur
- Department of Emergency Medicine; Brigham and Women's Hospital; Boston MA
| | - Keith E. Kocher
- Department of Emergency Medicine; University of Michigan School of Medicine; Ann Arbor MI
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Kanzaria HK, Probst MA, Ponce NA, Hsia RY. The association between advanced diagnostic imaging and ED length of stay. Am J Emerg Med 2014; 32:1253-8. [PMID: 25176565 PMCID: PMC7199801 DOI: 10.1016/j.ajem.2014.07.038] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Revised: 07/28/2014] [Accepted: 07/29/2014] [Indexed: 10/24/2022] Open
Abstract
OBJECTIVE There has been a rise in advanced diagnostic imaging (ADI) use in the emergency department (ED). Increased utilization may contribute to longer length of stay (LOS), but prior reports have not considered improved methods for modeling skewed LOS data. METHODS The 2010 National Hospital Ambulatory Medical Care Survey data were analyzed by 5 common ED chief complaints. Generalized linear model (GLM) was compared to quantile and ordinary least squares (OLS) regression to evaluate the association between ADI and ED LOS. Receipt of computed tomography or magnetic resonance imaging was the primary exposure. Emergency department LOS was the primary outcome. RESULTS Of the 33,685 ED visits analyzed, 17% involved ADI. The median LOS for patients without ADI was 138 minutes compared to 252 minutes for those who received ADI. Overall, GLM offered the most unbiased estimates, although it provided similar adjusted point estimates to OLS for the marginal change in LOS associated with ADI. The effect of imaging differed by LOS quantile, especially for patients with abdominal pain, fever, and back symptoms. CONCLUSIONS Generalized linear model offered an improved modeling approach compared to OLS and quantile regression. Consideration of such techniques may facilitate a more complete view of the effect of ADI on ED LOS.
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Affiliation(s)
- Hemal K Kanzaria
- Robert Wood Johnson Foundation Clinical Scholars program, US Department of Veterans Affairs, Emergency Medicine Center, University of California Los Angeles, 10940 Wilshire Blvd, Suite 710, Los Angeles, CA.
| | - Marc A Probst
- Emergency Medicine K12 Scholar, Department of Emergency Medicine, Mount Sinai Medical Center
| | - Ninez A Ponce
- Department of Health Policy and Management, University of California Los Angeles, Fielding School of Public Health, UCLA Center for Health Policy Research
| | - Renee Y Hsia
- Department of Emergency Medicine, University of California San Francisco, San Francisco General Hospital
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9
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Computed tomography utilization rates after the placement of a scanner in an emergency department: a single-center experience. Emerg Radiol 2014; 21:473-8. [DOI: 10.1007/s10140-014-1217-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Accepted: 03/21/2014] [Indexed: 12/14/2022]
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10
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Sierzenski PR, Linton OW, Amis ES, Courtney DM, Larson PA, Mahesh M, Novelline RA, Frush DP, Mettler FA, Timins JK, Tenforde TS, Boice JD, Brink JA, Bushberg JT, Schauer DA. Applications of justification and optimization in medical imaging: examples of clinical guidance for computed tomography use in emergency medicine. Ann Emerg Med 2013; 63:25-32. [PMID: 24134958 DOI: 10.1016/j.annemergmed.2013.08.027] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Revised: 08/29/2013] [Accepted: 08/29/2013] [Indexed: 11/26/2022]
Abstract
Availability, reliability, and technical improvements have led to continued expansion of computed tomography (CT) imaging. During a CT scan, there is substantially more exposure to ionizing radiation than with conventional radiography. This has led to questions and critical conclusions about whether the continuous growth of CT scans should be subjected to review and potentially restraints or, at a minimum, closer investigation. This is particularly pertinent to populations in emergency departments, such as children and patients who receive repeated CT scans for benign diagnoses. During the last several decades, among national medical specialty organizations, the American College of Emergency Physicians and the American College of Radiology have each formed membership working groups to consider value, access, and expedience and to promote broad acceptance of CT protocols and procedures within their disciplines. Those efforts have had positive effects on the use criteria for CT by other physician groups, health insurance carriers, regulators, and legislators.
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Affiliation(s)
- Paul R Sierzenski
- Section of Emergency Ultrasound, Department of Emergency Medicine, Christiana Care Health Services, Newark, DE.
| | | | - E Stephen Amis
- Department of Radiology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY
| | - D Mark Courtney
- Department of Emergency Medicine, Northwestern University, Chicago, IL
| | | | - Mahadevappa Mahesh
- Russel H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Robert A Novelline
- Harvard Medical School and Emergency Radiology Division, Massachusetts General Hospital, Boston, MA
| | - Donald P Frush
- Division of Pediatric Radiology, Duke University Medical Center, Durham, NC
| | - Fred A Mettler
- Department of Radiology, New Mexico VAHCS, Albuquerque, NM
| | | | - Thomas S Tenforde
- National Council on Radiation Protection and Measurements, Bethesda, MD
| | - John D Boice
- National Council on Radiation Protection and Measurements, Bethesda, MD
| | - James A Brink
- Department of Radiology, Massachusetts General Hospital, Boston, MA
| | - Jerrold T Bushberg
- Department of Radiology, University of California, Davis, Sacramento, CA
| | - David A Schauer
- National Council on Radiation Protection and Measurements, Bethesda, MD
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Sierzenski PR, Linton OW, Amis ES, Courtney DM, Larson PA, Mahesh M, Novelline RA, Frush DP, Mettler FA, Timins JK, Tenforde TS, Boice JD, Brink JA, Bushberg JT, Schauer DA. Applications of justification and optimization in medical imaging: examples of clinical guidance for computed tomography use in emergency medicine. J Am Coll Radiol 2013; 11:36-44. [PMID: 24135540 DOI: 10.1016/j.jacr.2013.09.023] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Availability, reliability, and technical improvements have led to continued expansion of computed tomography (CT) imaging. During a CT scan, there is substantially more exposure to ionizing radiation than with conventional radiography. This has led to questions and critical conclusions about whether the continuous growth of CT scans should be subjected to review and potentially restraints or, at a minimum, closer investigation. This is particularly pertinent to populations in emergency departments, such as children and patients who receive repeated CT scans for benign diagnoses. During the last several decades, among national medical specialty organizations, the American College of Emergency Physicians and the American College of Radiology have each formed membership working groups to consider value, access, and expedience and to promote broad acceptance of CT protocols and procedures within their disciplines. Those efforts have had positive effects on the use criteria for CT by other physician groups, health insurance carriers, regulators, and legislators.
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Affiliation(s)
- Paul R Sierzenski
- Section of Emergency Ultrasound, Department of Emergency Medicine, Christiana Care Health Services, Newark, Delaware.
| | | | - E Stephen Amis
- Department of Radiology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York
| | - D Mark Courtney
- Department of Emergency Medicine, Northwestern University, Chicago, Illinois
| | - Paul A Larson
- Radiology Associates of the Fox Valley, Neenah, Wisconsin
| | - Mahadevappa Mahesh
- Russel H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Robert A Novelline
- Harvard Medical School and Emergency Radiology Division, Massachusetts General Hospital, Boston, Massachusetts
| | - Donald P Frush
- Division of Pediatric Radiology, Duke University Medical Center, Durham, North Carolina
| | - Fred A Mettler
- Department of Radiology, New Mexico VAHCS, Albuquerque, New Mexico
| | | | - Thomas S Tenforde
- National Council on Radiation Protection and Measurements, Bethesda, Maryland
| | - John D Boice
- National Council on Radiation Protection and Measurements, Bethesda, Maryland
| | - James A Brink
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Jerrold T Bushberg
- Department of Radiology, University of California, Davis, Sacramento, California
| | - David A Schauer
- National Council on Radiation Protection and Measurements, Bethesda, Maryland
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