Radiology Collaboration Enhances Patient Care

How do we enhance patient care and contain costs? By determining IF a radiology imaging test is necessary. The question that too often is being asked, by regulators aiming to contain costs, is how many imaging tests were ordered or performed. A given patient population may require more imaging tests than another. Regulators attempt to determine the answer to "how many" and "how much" with cost-cutting algorithms that may not be appropriate on a case-by-case basis.

Patient care can improve with decision support models such as ACRSelect, which is a program that is designed to assist medical providers when ordering radiology imaging tests/procedures. Using ACR Appropriateness criteria, the use of ACRSelect can improve the ordering process by ensuring that tests that are ordered are appropriate from an evidence-based standpoint.

But much more is needed than a passive, front-line, computer order entry assistant.

Radiologists are in the best position to assist our clinical colleagues when ordering radiology imaging tests and procedures. While ordering tests/procedures has traditionally been thought of as the purview of the "ordering" physician, few know better than radiologists the irony of the federal regulators who continue to look to radiology as a source for reimbursement cuts.  

When I first started residency, we radiologists were sort of still functioning in the role of "gatekeepers," an adversarial-sounding term that has unpleasant connotations to both radiologists and referring clinicians alike. For example, as a resident on overnight call, we would discuss with the ordering physicians, typically other resident physicians, whether the test they were requesting was appropriate and why. Such discussions, you might imagine, could easily become contentious considering that the person attempting to obtain the test felt it was needed and often didn't understand why an explanation was necessary.

But in today's cost conscious world, such discussions are necessary, and are even required if we are to wend our way through appropriateness criteria and cost-effective care. Eliminate the puerile contentiousness and enhance the collegiality of the interaction and you have the makings of a helpful interaction designed to enhance patient care. Closed-door radiologists are anachronistic. Although few radiologists have their phones always on and their doors always open like I and many of my partners do, it is imperative to do so now. The current goal of the American College of Radiology, with Imaging 3.0, is to demonstrate the continued value of radiologists in the patient care paradigm.

We radiologists have a fund of knowledge at our fingertips that can assist our clinical colleagues in their efforts to care for their patients. And what our clinical colleagues know about their patients can help radiologists to contribute more effectively to patient care through collaborative discussions.

By utilizing the expertise of the local radiologist, answers can be obtained to seemingly difficult questions. By visiting the radiologist in the reading room when possible, face to face discussions can be held about patient care nuances. The value of complementary imaging studies can be discussed and the optimal study can be identified.

The day has arrived for radiologists to be more involved with the ordering clinicians to ensure that the appropriate test is ordered. Radiologists offer value to patients and clinicians alike by being involved in the decision-making process.

Free CT Screenings - Good or Bad?

Free radiology imaging screening studies - an idea which undoubtedly stems from multiple desires. At first glance, an altruistic attempt to give everyone a fighting chance to access the same aspect of health care. Upon more reflection, however, free anything reminds us that there is no free lunch. Everything must come with a cost.

The Lahey Hospital in Burlington, MA, has implemented a CT chest screening program where the study is offered free of charge.

Obviously, such an offer is made with the idea that a certain percentage of the screening studies will yield positive findings which then require, or could benefit from, additional radiology imaging studies to either confirm, deny or follow the original findings. The screenings are therefore a loss leader.

Such a program is easily compared to self-referral: Does the ordering physician end up pushing his patients towards more imaging or follow-up procedures in order to make up for the revenue lost by offering free screening studies?

A cost analysis can readily determine whether offering free screening studies results in a sustainable financial situation for the imaging center or hospital.

The bigger question is whether free universal screenings identify positive findings that require follow-up studies/procedures which result in a public health benefit? Or, do they result in numerous unnecessary additional tests and procedures that do not serve any public health purpose but that, instead, further increase health care costs and possibly harm patients?

It is certainly a positive-sounding decision, on its face, to state categorically that free screenings will now be offered for everyone. The devil is always in the details, however.

CT Scan Radiation - Understand Your Risks

Misinformation abounds about medical imaging radiation exposure.

Children and young adults are more susceptible to the effects of ionizing radiation. It is accepted by the scientific community that it takes approximately 10 to 20 years to develop a radiation-induced malignancy. Folklore and the media, however, create an hysteria around imaging-related radiation exposure that results in a general impression that a CT scan “causes” cancer.  I have watched prominent physicians categorically make comments similar to the following: one in 400 people who undergo a CT scan will get cancer. This kind of statement is misleading, incomplete, inaccurate and is detrimental to the general population.

Based on a 2009 study, published in the Journal of the American Medical Association, the data clearly demonstrated that CT scan radiation dose varied widely depending on the type of scan protocol utilized and the body part that was being evaluated.

The report stated:

“The estimated number of CT scans that will lead to the development of a cancer varied widely depending on the specific type of CT examination and the patient’s age and sex. An estimated 1 in 270 women who underwent CT coronary angiography at age 40 years will develop cancer from that CT scan (1 in 600 men), compared with an estimated 1 in 8100 women who had a routine head CT scan at the same age (1 in 11 080 men). For 20-year-old patients, the risks were approximately doubled, and for 60-year-old patients, they were approximately 50% lower.”

The key to anything is to understand the information given. Here, the report states that a certain type of CT scan, designed to specifically and exclusively evaluate the arteries that supply the heart, results in a risk of cancer of 1 in 270 for a woman and 1 in 600 for a man. Other scans result in a much smaller radiation dose and, hence, a much smaller increased risk of cancer. These are risk estimates. They do not identify which patient will get cancer. Such estimates merely indicate the risk of cancer in the group of people identified. Statistics, unfortunately, are challenging to explain and understand. Consequently, they can also be “spun” by the person making the comments.

The report clearly indicates that there is a risk of cancer related to radiation exposure. It does not, however, state that all CT scans confer an equal risk. The truth is far from it, in fact.

Know your risks. Understand the data. Knowledge is power and fear is overcome through understanding.

When in doubt, ask your radiologist. Your radiologist is the medical provider who has been trained to understand the risks of imaging-related radiation. It is our job to keep the conferred dose to a minimum.  Since the 2009 JAMA study there have been multiple advances in imaging that have resulted in continued decreases in ionizing radiation exposure during CT scans.

Radiology continues to care for patients under the tenet of As Low As Reasonably Achievable. You can count on it.

Health Care Delivery - A Doctor-Patient Collaboration

The era of physicians competing with other physicians is rapidly coming to a close.

Job security can only occur through collaboration with like-minded individuals. While hospitals and insurance companies vie for position, anticipating a possible sea-change from fee-for-service to bundled payments, doctors and patients risk being marginalized and left out of the party.

Now more than ever before, physicians are seeking employment by hospitals, hoping that choosing such employment will result in more security, not less. But there is a flaw in this perspective.

Let us examine why:

Hospitals are run by administrators who, regardless of not-for-profit or for-profit status, are tasked with finding the lowest cost solutions that still allow delivery of the best possible care.

Insurance companies are typically publicly run companies who, as a result, must maximize shareholders returns. Insurers reimburse provider-delivered care. Reimbursements to providers (e.g. doctors, nurses, therapists, etc.) correlate negatively with profit margins and returns on investment.

Doctors care for patients. Such care delivery has value, which translates into income.

Patients expect and deserve the highest quality care at the lowest reasonable cost. In the USA, most health care is subsidized by health insurance, which drastically reduces the actual out-of-pocket costs that individuals have to pay.

But the cost of health care stopped being reasonable long ago.

So where do we stand?

At a crossroads - In one direction, the health care system becomes controlled by administrators, with care delivery doled out according to lowest cost units, measured by availability and accessibility.

In the opposite direction, the health care system and care delivery retains value according to demand and necessity, with access and availability dictated by reasonable supply and demand.

It defies logic for physicians to choose employment, where income is doled out by administrators charged with finding the lowest cost solutions. The losing proposition for caretakers is obvious under such a scenario.

While governments, hospitals, insurance companies and corporations focus on decreasing costs, doctors continue to care for patients and patients continue to need care. Patient care is being devalued. But the facilities and the administrators were never intended to also be the employers. Caregivers are not commodities. Physicians, nurses, etc., are highly trained specialists treating people with widely disparate ailments. Devaluing health care through indiscriminate cost-cutting will leave America’s health care system in shambles, reducing care delivery to an 8-5, weekday-only venture that will result in a rapid decline in access and quality. I’m not inclined towards that future.

What we need is a sea-change in the opposite direction. Diminish the central role of insurers. Place hospitals in the position to function as receptacles for patients and their caregivers. Hospitals have value just as care delivery has value. Neither the facility nor the people should be devalued.

Doctors and patients must establish new payment algorithms. Caregivers must retain their central role in health care. Already, concierge medical practices are successfully eliminating the insurance company in the doctor-patient relationship. Such paradigms will continue to increase the efficiency of care delivery, while valuing medical delivery services appropriately.

Entities such as Doctors for Patient Care aim to redirect the current pathway America is heading down. Such organizations want to keep doctors and patients central in America’s health care system.  The solution is to allow care delivery to proceed as usual, valuing it appropriately and fixing areas that need improvement. It will take continued work, but together doctors and patients will prevail.

Health Care Reform - Highest Quality, Not Lowest Cost

Quality, not cost, should be our main focus when discussing health care.

There is much discussion about health care reform, with an alphabet soup of acronyms such as ACO, EMR, HIE, PPACA, etc. There is much room for error and success when it comes to reforming such a complex system. Two goals of health care reform are quality improvement and increased access to care.

I am an interventional radiologist. My training consisted of four years of medical school, one year of internship, four years of diagnostic radiology and one year of interventional radiology fellowship. I obtained my medical license by sitting for a three part medical licensure board examination. I obtained my Radiology board certification by sitting for written, oral and physics examinations which took place on three separate days over a one year time span. I was examined yet again to obtain my Interventional Radiology board “certificate of added qualification” (now known as a “subspecialty certificate”) while in my first year of private practice. In order to practice in my state, I met specific requirements and took an appropriate licensure examination to obtain my state medical license. It is necessary to fulfill such requirements in each state in which one wishes to practice.

Patients who meet with a board-certified doctor should therefore have a reasonable level of confidence in the quality of the physician seated before them. If a doctor has been board certified, s/he has attained the highest level of training documentation available to us in our respective professions. Board certification should therefore give patients a certain level of confidence in their doctors.

But quality health care is not just achieved through training and examinations. Quality care is delivered with integrity, through teamwork and collaborative cooperation. The health care system of yesterday was a much more individualistic enterprise, with doctors doing their best to care for patients, hospitals attempting to create a profitable environment for care delivery, and insurance companies focusing mainly on the income streams produced as a result.

The health care system of tomorrow must include a much more collaborative effort by patients and physicians. Currently, we are being marginalized by hospitals and insurance companies, who are vying for position as they anticipate bundled payments and shrinking reimbursements. Medicare is being altered with the aim of paying hospitals and ACOs (Affordable Care Organizations) a lump sum, to be disbursed to caregivers like Charlton Heston’s “Soylent Green.”

This method of payment for care delivery creates disincentives and has already demoralized thousands of physicians. The end result will likely not be high quality care. Instead we are on track to deliver the cheapest care possible. As we all know, you get what you pay for.

What we should be clamoring for is coordinated care, with a team-oriented approach to address the patient’s needs. Such an approach would result in the best quality of care delivered at a reasonable cost. A coordinated effort would reduce redundancy and maximize expertise. Whether this process can be accomplished remains to be seen. If caregivers realize that the only solution is to come together to care for the patient as a whole, health care reform may in fact end up well for our country.

Coordination of care delivery by caregivers, with the involvement of our patients, will result in the highest quality health care. It will result in decreased costs through fewer mistakes and improved outcomes. Time will tell which system wins. I hope we do.

Radiology Imaging - Gentle Guidance via ACR Select

A radiologist as gatekeeper is an unpopular position. No one wants to be told "no" when they ask for something. Radiology once had such a distinction as the gatekeepers of radiology imaging orders/requests. It is an inherently, though inadvertently, adversarial position. The radiologist is not the primary caregiver and therefore is typically less informed as to the clinical scenario at hand.

Recent decades have seen an explosion of imaging utilization, driving health care costs upward. In fact, radiology imaging has been so lucrative that non-radiologists bought their own scanners. As recently reported in the Journal of the American College of Radiology and by the United States Government Accountability Office, Medicare payments for radiology imaging, including MRI and CT scans, were higher to non-radiologists than radiologists between 2004 and 2010, a clear indicator that self-referral has driven imaging utilization.

This practice is not just done in the outpatient world. In hospitals, imaging has become commonplace for many symptoms to the point that the science, or evidence-based component, is absent in many cases.

Now, the American College of Radiology has finally produced a product called ACR Select, which can assist health-care providers manage expenses and care for their patients by integrating decision support with the order entry process. A passive gatekeeper, the program is designed to work with the electronic medical record (EMR) and electronic order entry process. 

The ACR has long produced Appropriateness Criteria, which are revised as often as necessary. These criteria are supposed to assist caregivers with their decision-making process when ordering tests such as CT scans and MRIs. The ACR Select product can be integrated into the EMR to provide a user-friendly method of access and education for the appropriateness criteria. As a result, providers can better identify when an imaging study is indicated based on the provided patient's symptoms.

How does it work? When a provider enters an order for an imaging study, a screen pops up on the workstation, with the relevant Appropriateness criteria for the specific clinical scenario. Appropriateness criteria ranks different studies in terms of appropriateness and level of radiation. The ordering physician can then choose the appropriate study, and can even choose references that substantiate the study being ordered.

ACR Select is a front-line gatekeeper that is designed to be a non-adversarial system component, integrated into the EMR, that assists ordering physicians to better meet their patients' needs. The role of radiologists is rapidly changing towards playing a more visible part in patient care. It is long in coming and should be embraced by the medical community as a help, not a hindrance. I applaud its development and hope that forward-thinking regulators and policy-makers see its obvious benefits.

Radiology Imaging - Your Choice, Your Life

Do you know what a radiologist does?

A radiologist is a medical doctor who interprets radiology imaging studies. You undergo an imaging study, such as a CT scan, MRI or ultrasound, usually after you visit your doctor with a specific complaint.

Do you know what it takes to become a radiologist?

Becoming a radiologist involves one of the lengthier training regimens in Medicine. The typical pathway starts with four years of college/university, followed by four years of medical school. Afterward, there is one year of training called an Internship, followed by four years of Diagnostic Radiology residency. Finally, many radiologists choose to do a final one or two years of  Fellowship training to obtain a sub-specialty certificate. Fellowships are available in areas such as Interventional Radiology, Pediatric Radiology, Neuroradiology, Women's Imaging, and others.

Do you know that you have a choice when it comes to your radiology imaging?

Recent health care law changes have created much confusion. Suffice it to say, however, that you, as a patient, have more choices and fewer restrictions than ever. For example, you visit your doctor with a complaint of back and leg pain. Your doctor suggests an MRI of the lumbar spine to determine whether a herniated disk is causing your symptoms and gives you a prescription for the study.

You can take that prescription to any imaging center of your choice. You are not limited to the imaging center located "conveniently" in your doctor's building/office. Ask your friends who they trust. Where did they receive prompt attention and courteous care? An imaging study may take less than an hour of your time, but knowing who your radiologist is can make a significant difference in the quality of the interpretation you receive. 

Ask questions of the imaging center such as: 

Is the interpreting doctor a radiologist? Board-certified? Fellowship-trained? If the interpreting physician is not a radiologist, how many similar studies has s/he previously interpreted? Some doctors have an ownership interest in imaging centers. Such ownership is not unethical and perfectly legitimate. But the responsibility is yours to ask your doctor whether the imaging study being requested is medically necessary.

These types of questions help ensure that you are well cared for and that your images are interpreted with the highest quality in mind and at the highest levels of expertise.

Knowing the answers to these questions can help you when you need an imaging study such as a CT scan, MRI or ultrasound.

Radiologists Care About You

Radiologists care about their patients, even though most diagnostic radiologists don't meet and greet their patients the same way direct-care clinicians do.

Some people have the erroneous perspective that radiologists and pathologists don’t care about the welfare of their patients. It is possible for us to understand that view if we look at radiologists and pathologists as isolated workers who work in dimly lit rooms. But that perspective is woefully short-sighted and anachronistic. For this post, ignore the fact that I see patients daily as an interventional radiologist. We are the "surgeons" within the radiology community and I greatly enjoy the hands-on nature of my sub-specialty.

As a radiologist, I am reminded daily that an interpretation of an imaging study such as a CT scan or an ultrasound could send a patient to surgery or change their life forever with an unexpected diagnosis of cancer. My colleagues and I discuss various studies daily in order to learn from "interesting" interpretations. There are learning points to take away from many studies that pass in front of my eyes each day.

Sometimes, though, we view a study and there are findings which are "indeterminate," or are otherwise unable to be neatly categorized into "known" entities. This fact is the nature of the beast, unfortunately. We are all human and humans do not always fit neatly into understandable categories. So why should we expect every imaging finding to be clear and understandable?

Also, cancers start from one cell. So, one should be able to readily understand that, until a cancer becomes a certain size, it may be "too small to further categorize." A surgeon, used to dealing with tangible structures such as a liver, gallbladder or kidney, may not readily accept that a 4 mm vague "splotch" on a chest x-ray is not able to be categorized as more than "indeterminate." In fact, the Fleischner society has published clear and concise recommendations for indeterminate lung nodules.

It is a fundamental truth of life that humans are not categorized into neat little groups. What we try to do, as radiologists and as physicians, is make definitive diagnoses where possible, dismiss benign, irrelevant findings whenever possible, and offer helpful suggestions about the remaining “indeterminate” findings. Understanding that radiologists and pathologists attempt to restore order to that chaos may help you understand what we radiologists wrestle with when findings are indeterminate.

Radiation Safety - A Radiologist's Area of Expertise

Reducing radiation dose is paramount to radiologists to ensure that patients continue to receive safe, appropriate care. While there have yet to be any proven cases of cancer related to routine CT scan radiation exposure, it is imperative that we in the radiology industry continue to improve the techniques available to keep radiation exposure as low as reasonably achievable, aka ALARA.

The monitoring of fluoroscopy times during procedures has long been in place. There are standards of care which include dose limits beyond which appropriate counseling is required if exceeded. There are techniques such as active collimation, which "can reduce the dose anywhere from 5% to about 30% for helical scanning.” CT scans also use 2D and 3D filters to reduce radiation dose. Iterative reconstruction is a very attractive technique where, once the patient is scanned, the computer "makes several passes over the data to produce a more accurate model of the image and reduce the amount of noise. These extra computations also allow the image to be acquired with a much lower dose, anywhere from 40% to 80% less depending on the manufacturer, the type of scan, and the scanner that’s used."

The technical aspects of CT scanning and fluoroscopy are not the issues to focus upon. Rather, rest assured that you and your loved ones are being cared for with your safety in mind when you visit a radiology department.

An ACR-accredited radiology department or imaging center is required to meet and follow specific regulations regarding radiation exposure. Becoming an accredited facility and maintaining that accreditation gives visitors peace of mind that their safety is first and foremost. Ask your doctor whether the facility you are going to visit for a needed radiology imaging study is appropriately accredited. Your safety and health depend on it.

Radiologists - Patient Advocates for Safety and Appropriate Imaging

Have you ever heard the phrase: The Doctor's Doctor? Well, that is just one role of a radiologist.

Typically, a radiologist's role in the care of a patient is different from that of, for example, a gastroenterologist. When a patient undergoes a test such as a CT scan or an MRI, s/he communicates the findings to the patient's primary doctor either by written report or by verbal communication when the findings need to be more urgently conveyed.

But the time of closed-door radiologists is past. Nowadays, information needs to be conveyed to the patient in addition to the patient's doctor. Radiologists need to be more visible in this regard. The advent of HIEs, or Health Information Exchanges, raises the possibility that patients may be able to obtain their imaging study reports and keep them in their own personal health care file. There are early attempts to accomplish this goal with Microsoft's HealthVault, for example.

The time has come for radiologists to lead the way. Rampant over-utilization of radiology imaging is contributing to rising health care costs and resulting in increased federal scrutiny and imaging backlash. Patients would suffer if they could no longer obtain needed imaging studies to diagnose ailments. We would find ourselves back in the early days when CT scanners were few and far between, because they'd be too costly to maintain.

If non-radiologist over-utilization is corrected, and the government fairly values the use of appropriate imaging studies, then patient care may be enhanced. "Medicare payments to nonradiologists for noninvasive medical imaging recently surpassed those received by radiologists, according to studies at the Jefferson Medical College and Thomas Jefferson University Hospital in Philadelphia." One could argue that imaging studies that are ordered by financially independent physicians may be more likely to be medically indicated.

Radiologists are patient advocates. We have an interest in medical imaging, as it is our lifeblood. But because radiologists are typically independent from the ordering process, the risk of over-utilization is diminished. In addition, radiologists are well-trained to understand the risks and benefits of ionizing radiation. The same cannot be said for most other physicians.

Bottom line: If the utilization of radiology imaging is appropriate, and the government fairly values imaging studies, then patient care and safety may be enhanced.

Stroke Centers - All About Interventional Radiology!

The following passages are excerpted from “Interventional Quarter,” issue 2, July 2010.

Click here to go to the actual issue.

People need to be aware of their options. Today, we have vastly improved stroke treatment options compared to 30, 20 or even 10 years ago. I am amazed at the techniques and technology that is currently available. With continued education, stroke awareness has become much more widespread. Treatment options continue to improve. Remember, speed is of the essence. The window for treatment of a stroke is within SIX hours from TIME OF ONSET of symptoms.

____________________________________________________________________

Begin Excerpts:

STROKE

The medical affliction of stroke has been known for almost 2,500 years, being described by Hippocrates (then called apoplexy). However, all that was known until recently were the symptoms - the sudden onset of paralysis. The cause and the cure remained outside the influence of medicine for many, many centuries. Therapy has only become available in recent years as doctors discovered more about the causes and mechanisms of stroke. Currently, many stroke patients can experience no or few disabilities - provided they get treated promptly.

According to the WHO, stroke is the leading cause of long-term disability worldwide, as well as being the second most important cause of cognitive impairment after Alzheimer’s disease. This can have a terrible effect on the quality of life of the affected individual and their families, and results in massive healthcare and pension costs. It is also the third greatest cause of death worldwide, after coronary heart disease and cancer1. But far from being untreatable, a substantial body of evidence has established the efficacy of various strategies for the prevention and treatment of stroke.

Ischemic stroke is caused by a blockage of blood vessels which irrigate the brain, and accounts for 80% of strokes. Ischemic stroke can result from different causes, but large artery atherosclerosis is generally the most frequent cause. Ischemic stroke affects both a core area and the surrounding tissue (penumbra). The core area is usually damaged irreparably, but the penumbra can often be salvaged, if blood supply is re-established in time. Saving this tissue is the focus of most treatments.

Risk factors

Risk factors for stroke are either non-modifiable (age, sex, race/ethnicity, family history) or modifiable. Modifiable factors include cigarette smoking, arterial hypertension, diabetes mellitus, hypercholesterolemia, obesity, contraceptive pill or hormone replacement therapy, atrial fibrillation and other cardiac diseases, and stenosis and occlusion of cerebral arteries.

Symptoms

Accordingly, the Face Arm Speech Test (FAST) is a simple way to recognize if someone has suffered a stroke or TIA. Any of these signs can indicate stroke:

  • Face: Mouth or eye drooping, inability to smile normally
  • Arms: Weakness, inability to raise both arms properly
  • Speech: Slurred or unintelligible speech, inability to understand speech of others

➡ Time to call the emergency services

The most important thing when faced with stroke or TIA is to seek urgent medical attention. The longer the brain is deprived of oxygen, the less chance that the brain will survive unharmed.

As the experts say, “time is brain” - up to 2 million brain cells can die every minute that oxygen perfusion is cut off.

Ischemic stroke

Thrombolytic drugs (tissue plasminogen activator or t-PA) can often dissolve a clot, returning blood flow to normal. Studies have shown that intravenous thrombolysis (IVT) given within 4.5 hours of symptom onset is beneficial in selected stroke patients. This medication carries a slight risk of symptomatic hemorrhage (about 5% in routine clinical practice), but used correctly by experienced doctors, the benefits usually outweigh the risks.

This 4.5-hour window can be extended up to 6 hours by intra-arterial thrombolysis (IAT) or up to 8 hours by mechanical thrombectomy (MT), performed by an interventional radiologist. IAT uses a catheter to deliver the drugs directly to the clot site. Many centers also use "bridging" - a two-step thrombolytic treatment where the first dose is delivered intravenously and the remaining one intra-arterially. 

Why IR is gaining ground

According to current WHO data, between 1981 and 2001, the number of minimally invasive preventative stroke treatments performed increased steadily, while surgical treatment numbers remained constant or declined. This clearly shows the growing importance of interventional treatments in stroke therapy. Given that there has been a phenomenal increase in the number of dedicated stroke units since this data was collected, it can only be assumed that this trend has continued even more steeply.

Dedicated stroke units

With increased patient volumes, hospitals are in a position to dedicate resources to this patient population. Many hospitals are establishing dedicated stroke units, which adhere to increasingly uniform treatment protocols and standards for ensuring swift and suitable treatment.

In larger hospitals with appropriate interventional radiology staffing arrangements, IR techniques such as intra-arterial thrombolysis and thrombectomy can be offered on a 24-hour basis. However, both in terms of availability of staff, and in terms of quality standards and costs, it is not feasible to offer the full range of available treatments in every hospital.

It goes without saying that patient outcomes improve in centers that are capable of achieving a case volume that ensures a threshold level of technical and clinical experience.

Of the total number of stroke patients who present to a stroke centre for acute therapy, an estimated 10-20% requires IR intervention.

Health economics

Some of these treatments may be costly, but the bottom line is that stroke treatment is nearly always a money-saving venture. Without treatment, patients who are lucky enough to survive their stroke inevitably face some degree of disability.

Minimally invasive stroke treatment options provide both patient and health provider with opportunities that could not have been dreamed of 30 years ago. Incorporating their potential into the range of treatments made available to patients is essential if the burden of stroke is to be countered and reduced. Advances in medicine are continually offering patients new options, and interventional radiology is certainly playing its part.

Websites of interest:

www.strokeassociation.org (American Stroke Association/US)

www.stroke.org.uk (The Stroke Association/UK)

www.irishheart.ie (Irish Heart Foundation/IE)

www.world-stroke.org (World Stroke Organisation/WSO)

www.eso-stroke.org (European Stroke Organisation/ESO)

www.safestroke.org (Stroke Alliance for Europe/SAFE)

Quality, not Imaging, is Often the Answer to Great Health Care

People in the United States of America have long been used to getting what they want, when they want it. We do not like to wait six or eight months to see the doctor. We don't like to wait in line at the bank, grocery store, Disney World, or the movie theater. Even when on vacation, we tend to drive fast to get to where we are going. So it is perfectly understandable, if a bit laughable, to realize that we also tend to insist on antibiotics or an imaging study, such as a CT or MRI, when we visit the doctor with a complaint.

But here's the deal - as my knowledgeable colleague and orthopedic surgeon friend Howard Luks commented in his blog post - many people who present with an ailment do not necessarily need an imaging study to identify the root of the problem. What they need is a bit of faith in the doctor's ability to form an accurate diagnosis, and an understanding that a CT scan may help us see inside, but it doesn't tell us whether a perceived problem needs attention.

PPACA, aka Obamacare, is forcing hospitals to change the ball game. The dollar signs are undeniable. Hospitals are rapidly attempting to form Accountable Care Organizations and other such top-down entities that aim to control health care costs by controlling who gets paid for what. The difficulty, I see, is that some hospitals aim to control costs by controlling the providers.

Imagine the following possible scenario: Hospital X employs a general surgeon and other providers who may be necessary to care for a patient who presents with a sick gallbladder. Because the physicians and other caretakers are employed, any payment the hospital receives goes directly to the hospital, minus its expenses. The caretakers receive a salary, so any incentive they each have to control costs is eliminated. A patient complaint may be met with another CT scan or another lab test. The wait times may increase because a salaried professional has little or no incentive to "rush" to care for more people in the same time frame. 

What the above scenario does is carry the risk of lowest cost provider, regardless of quality provided. I'm not sure I'd like to visit that hospital if I were a patient, would you?

The problem with the above scenario, therefore, is that quality is trumped by cost-containment. In my opinion, higher quality helps lower costs because high quality health care includes high levels of expertise among providers who better recognize when a lab test or imaging study will make a difference in a person's care. Taking time to explain findings and diagnoses to patients and documenting findings and impressions in a patient's chart are additional important steps for the providers. The liability/defensive medicine argument is diminished or eliminated if proper communication has been accomplished. Patients do not typically feel slighted or ignored if their provider has discussed his/her impressions in a thoughtful, caring manner.

As I said before, a picture may be worth a thousand words, but sometimes all you need to hear is "you'll be fine."

Imaging can be life-saving: Understand the radiation risks.

Radiation is emitted in various forms. Understandably, CT scan radiation “absorbs” the attention of the public and media. As explained: “X rays, γ rays, and neutron beams are considered ionizing radiation. Ionizing radiation may break molecules into pieces, creating ionic free radicals that can be very damaging to tissue.”

For this reason, it is imperative that the use of radiation is only by highly trained personnel and that the public is appropriately educated so that they understand their risks as it relates to their health care. 

People come in all different sizes, and CT scans are obtained of different areas of the body, so actual absorbed radiation doses vary. Unfortunately, there have also been examples of over-exposure of patients due to computer errors that resulted in some individuals being scanned multiple times over the usual amount. These errors must obviously be corrected. There is no excuse.

The good news, however, is that radiologists are focused on the issue of decreasing radiation dose. In fact, researchers at the University of California - Davis, suggested that CT scanners be made more uniform, allowing technologists to better control the radiation dose.

Through continued discussion and research, medical personnel and non-medical people alike must stay informed as to actual radiation risks. Possible risks should be discussed and understood in context and without emotional hype or political spin. If  health care personnel are well-informed, then the public and media will be better able to understand our message regarding this very important issue.

The message:

When needed, CT imaging is useful to your health. Judicious use of CT imaging is essential. The risk of cancer from imaging-related radiation, if used appropriately and only when necessary, is small. No cancers have been proven to be caused by CT imaging radiation exposure.

The Society of Interventional Radiology has previously formally presented written testimony to the Energy and Commerce Committee on “Medical Radiation: An Overview of the Issue.” Most of the time was spent discussing ways to prevent further radiation overexposure and the means by which such prevention should be accomplished.

The SIR also recently published a position statement on imaging-related radiation use, which appropriately concludes: “We recognize that the physician has a responsibility to advise patients of the potential risks of radiation in a particular procedure so they can be weighed against possible benefits. The best decisions can be achieved when an informed physician and patient work together as a team.”

One of the most important aspects of imaging-related radiation exposure is that patients and physicians balance the risks with the benefits. As an interventional radiologist, I discuss the risks and benefits of procedures daily with my patients.

For example, a lung biopsy carries the risks of bleeding, infection and pneumothorax (or collapse of the lung), in addition to a small amount of radiation exposure related to the CT imaging used to guide the needle. But the benefits, one would hope and assume, outweigh those risks and include obtaining a rapid diagnosis so that treatment can be initiated.

In the case of a person who suffers a car accident, the ER physician may request a full body CT scan to evaluate for potentially life-threatening injuries. 

The bottom line is that we weigh the risks and benefits of each decision. Medical imaging carries small but real risks related to ionizing radiatino exposure. But, the public and mainstream media should understand that health care personnel are interested mainly in ensuring the health and well-being of their patients. 

AMA Daily Excerpt: "Study: Biennial mammograms may be better for some women."

The following is from the AMA daily email. Bottom line on mammography is that it is more of an individual topic that should be discussed with your doctor. The recommendations and controversies surrounding recent research reports mandate that women discuss the benefits, and small but quantifiable risks, with their doctors to make an informed decision.

___________________________________________________________________

Begin excerpts:

Research suggesting that annual mammograms may not be best for most women received a fair amount of coverage online, and was featured on two of last night's national news broadcasts. Most sources point to the fact that advice on mammogram frequency varies among medical groups, and that these findings back up recommendations from the US Preventive Services Task Force. Meanwhile, some sources mention that certain groups were critical of the study. The CBS Evening News (3/18, story 8, 2:30, Schieffer, 5.58M) reported that a new study has "found that doing mammography every two years rather than every year did not increase the risk of advanced breast cancer."

        ABC World News (3/18, story 5, 2:05, Sawyer, 7.43M) reported that the study "revealed 60% of abnormal mammograms turn out to be false positives, not cancer at all, even though they can lead to biopsies, even surgery." During a second segment on the topic on ABC World News (3/18, story 6, 0:50, Sawyer, 7.43M), ABC's Dr. Richard Besser said, "I think this is one of the most important things you can do, with whatever serious illness you have. It's to ask this question. Say to your doctor, 'Before we go forward with any treatment, let's get a second opinion. And is there someone you can refer me to?' The best doctors are going to welcome another set of eyes, another way of looking at it."

        CBS News (3/19) reports on its website, "The results, which were published on March 18 in JAMA Internal Medicine, follow the 2009 recommendation by the US Preventive Services Task Force that advocated for biennial mammography for women in this age group instead of the previous suggestion of getting screened every one to two years." In the new study, "the researchers looked at data from 11,474 women with breast cancer and 922,624 women without breast cancer who underwent screenings at US facilities involved in the long-running Breast Cancer Surveillance Consortium (BCSC) from January 1994 to December 2008." The researchers fond that "women who went every two years for a screening were not associated with an increased risk of advance stage breast cancers or large tumors, even if the woman had dense breasts or used hormone replacement therapies, when compared with women who were screened every year."

        Bloomberg News (3/19, Cortez) reports, "The study found an exception for women 40 to 49 years old with extremely dense breasts." These individuals "were about twice as likely to be diagnosed with large tumors or advanced cancer if they skipped mammograms." Additionally, "they...had higher rates of false-positive results."

        Reuters (3/19, Steenhuysen) reports, however, that some groups, including the American College of Radiology, criticized the study, arguing that its methodology was flawed.

        HealthDay (3/19, Doheny) reports, "In a statement, the American College of Radiology (ACR) pointed to an analysis published in 2011 in the American Journal of Roentgenology finding that under the biennial model, about 6,500 more women annually in the United States would die of breast cancer." Comparing "early versus late-stage cancer is not the best way to judge the best interval for mammograms, according to the ACR statement." Instead, "it said, researchers should look at such factors as tumor size and other markers of detecting cancers early." Also covering the story are Aunt Minnie (3/19, Keen), MedPage Today (3/19, Fiore) and Medscape(3/19, Brown).

        False-positive mammograms may have negative psychological effects. The Los Angeles Times (3/19, Brown, Times, 692K) reports, "Long after learning that a troubling reading on a screening mammogram was just a false alarm, women continued suffering negative psychological effects, researchers in Denmark have reported" in the Annals of Family Medicine. Researchers found that, "six months after hearing they did not have breast cancer, women with these false positives experienced changes in 'existential values' and 'inner calmness' as great as for women who had cancer."

        On its website, ABC News (3/19, Moisse) reports that additionally, "women who had false positives were...more likely to report disturbances in sleep and sexuality, according to the study."

        The NBC News (3/19, Fox) "Vitals" blog reports that the researchers wrote, "False-positive findings on screening mammography causes long-term psychosocial harm: Three years after a false-positive finding, women experience psycho-social consequences that range between those experienced by women with a normal mammogram and those with a diagnosis of breast cancer."

AMA Daily Excerpt: "CDC: Many Americans admit to calling, texting while driving."

The following excerpts are taken from the AMA Daily email I receive. It is obvious that texting/emailing while driving is a serious public health hazard. Perhaps car manufacturers could get together with the Feds and mandate that all cars be outfitted with devices that deactivate cell phone signals when the cars start to move. Of course, that means you wouldn't be able to make a call from the passenger side but somebody must be able to come up with a reasonable solution that keeps the driver (and the rest of us) safe.

____________________________________________________________________

Begin excerpts:

NBC Nightly News (3/14, story 14, 0:15, Williams, 7.86M) reported, "More numbers from the CDC: Most Americans now admit to talking on their cell phones while driving. A third of us admit to texting or e-mailing while at the wheel. Mostly young drivers they say, but the rates of usage here are much higher than in Europe."

        The Los Angeles Times (3/15, Mohan, 692K) reports in its "Booster Shots" blog that "nearly a third of US drivers aged 18 to 64 admitted they had read or sent a text message while driving during a 30-day period, compared with 15% in Spain, according to" a report published March 14 in the CDC's Morbidity and Mortality Weekly Report. Additionally, two-thirds of Americans said they have talked on a cellphone while driving, "compared with a low of 21% in Britain."

        Bloomberg News (3/15, Edney) reports that according to the National Safety Council, about 3.5 million people "suffer serious injuries in traffic crashes" in America each year, "and an estimated 24 percent of those accidents involve mobile telephone use." CDC Director Tom Frieden said in a statement, "The cell phone can be a fatal distraction for those who use it while they drive. Driving and dialing or texting don't mix."

        The AP (3/15) notes the researchers did not provide an "explanation for why the use of distracting mobile devices is more common in the US than other countries. Mobile device markets in the US. and Europe are similarly saturated, making it unlikely that the findings are attributable to differing portions of the population owning devices in the countries, the study said." The study's author, CDC epidemiologist Rebecca Naumann, said, "We can't really say why a greater percentage of drivers in the US appear to be engaging in these behaviors. We really don't know."

        According to the NPR (3/15, Stein) "Shots" blog, the CDC said "there were no differences between men and women, but younger adults - ages 18 to 34 - were more likely to use a device while driving than those who were middle-aged or elderly."

        Also covering the story Reuters (3/15, Johnson), the NBC News (3/15, Fox) "Vitals" blog, and HealthDay (3/15, Reinberg).

And THIS is why doctors are not commodities

The Robotic Doctor is In

Robots are taking over operating rooms everywhere. Should you trust them? PopMech reports from the robotic surgery revolution.

By Erik Sofge


 "Every patient is different," says Catherine Mohr, director of medical research at Intuitive Surgical. In theory, a self-guided version of the da Vinci could be loaded with a general map of the region and the ability to find and remove the prostate. Half of the time the results might be suitable. But the other half, when the nerves don't line up, you'd wind up with patients who were impotent, incontinent, or both. 

Read more: The Robotic Doctor is In - Popular Mechanics 

 

Why We Are Where We Are...Ask Why

We often read, talk and hear about the rising costs of health care. but how did we get to this point? Greed? Corruption? Liability? A complete lack of caring? Perhaps these reasons hold partial truths to the matter. But in my observation, a large part of why things happen is because few people ask the simplest of questions before ordering or undergoing a test - WHY?

One of my earliest medical rotations as a medical student was in Internal Medicine. The Director made a simple, yet profound comment, that I have always since carried with me: "Ask WHY before you order any test."

It seems straightforward, yet it does not seem to be the main focus behind usual decision-making that occurs between doctors and patients.

If there is no definite reason for a given test or procedure, then what might be the benefit of the results? Fishing expeditions are rarely fruitful.

This simple admonishment allows me to think more clearly when I try to figure out a patient care question. It is essential that doctors and patients alike ask WHY before any test or procedure. After all, it is your body we are talking about. You have a vested interest in this game, even if you do not directly (yet) see the costs associated with the questions being asked and e tests or procedures being performed.