Radiology: Rads rarely guilty of generating high-cost follow-up orders
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As Congress, payors and other stakeholders attempt to rein in imaging utilization, understanding self-referral by nonradiologist physicians as well as radiologists’ recommendations for imaging studies can provide improved insight into the drivers of imaging utilization.
Susanna I. Lee, MD, PhD, of the department of radiology at Massachusetts General Hospital (MGH) in Boston, and colleagues designed the current study to determine the proportion of imaging exams generated by radiologists’ recommendations for follow-up imaging and identify the imaging findings resulting in follow-up recommendations.
The researchers mined the RIS to identify outpatient chest CT, abdominal CT, brain MR imaging, lumbar spine MR imaging and body PET performed between July and December 2007 at MGH and employed an algorithm to identify which exams were based on a radiologist’s recommendation for follow-up imaging.
Lee and colleagues identified 29,232 high-cost imaging exams and calculated that 5.3 percent were based on a radiologist’s recommendation within the previous 60 days. Chest CT accounted for 9.4 percent of radiologists’ follow-up recommendations and was prompted by a chest x-ray finding nearly half of the time.
Pulmonary nodules spurred 35.9 percent of the follow-up recommendations, a finding in concordance with the National Lung Screening Trial and adherence to Fleischner Society guidelines for treatment of small pulmonary nodules. “It is possible that the higher proportion of recommendations for chest CT resulted from our radiologists’ adherence to these nationally recognized guidelines, which, in the context of early lung cancer detection, can be considered medically indicated,” wrote Lee and colleagues.
Other common findings leading to follow-up recommendations included pulmonary parenchymal abnormalities other than nodules or masses, adenopathy and renal lesions.
The researchers noted that radiologists struggle with management of adenopathy and renal lesions, which lack criterion to distinguish benign from malignant findings. A recently published American College of Radiology white paper that provides evidence-based guidelines for managing commonly encountered incidental abdominal findings might influence radiologists’ recommendations, according to the authors.
“Also of note, examinations with negative results were another relatively common reason for high-cost imaging following a radiologist’s recommendation (6.5 percent), with most of them (94.1 percent) resulting from inappropriate or suboptimal choice of modality for the preceding examination,” wrote Lee and colleagues. The authors suggested a knowledge gap regarding appropriate studies among referring physicians and noted that one of radiologists’ roles is to consult on the choice of imaging.