Academic Radiology Practice Research Articles

Radiology residency oversight: A Qui Tam wake-up call

Like every physician practice, academic radiology practices must pay heed to all governmental regulations. The federal False Claims Act serves to protect US taxpayers and requires strict adherence. Violations, often brought forth by whistleblowers, can carry steep financial repercussions.

The Staffing Crisis and Burnout in Academic Radiology: Insights from a Survey Study in Korea

ObjectiveAcademic radiology is essential for advancing medical knowledge, improving patient care, and leading professional organizations. Any shortage of academic faculty affects the ability to provide quality education in radiology, conduct research, and advance the field. In this study, we aimed to identify contributors to the challenges faced by academic radiology in Korea and compare the work burden, career satisfaction, and burnout between academic radiology and private practice. MethodsA Google survey of members of the Korean Society of Radiology, conducted between August 19, 2022 and August 31, 2022, attracted responses from 642 radiologists, including 511 board-certified radiologists and 131 radiologist trainees. The survey assessed career satisfaction, burnout, and reasons for working in academia and frustrations with an academic career. ResultsOf the responding academic radiologists, 53% were located in Seoul, and of the responding private practice radiologists, 71% were located in regions outside Seoul. The reported volume of image readings per month (CT and/or MRI) was higher for academic radiologists than for private practice radiologists, but no significant difference in the time taken to complete the readings was evident between the two groups. Compared with private practice radiologists, academic radiologists required more time for education, clinical conferences, and additional nonclinical tasks. Lower scores for career satisfaction and higher scores for burnout were reported by academic radiologists, compared with private practice radiologists. DiscussionThe field of academic radiology in Korea faces challenges because of a faculty shortage. To prevent the collapse of education in radiology, interventions must address the identified contributors to this shortage, while increasing career satisfaction and reducing burnout among academic radiologists.

The Remote Academic Radiologist: AJR Expert Panel Narrative Review.

The importance of developing a robust remote workforce in academic radiology has come to the forefront owing to several converging factors. COVID-19, as well as the abrupt transformation it precipitated in terms of how radiologists work, has been the biggest impetus for change; concurrent factors such as increasing examination volumes and radiologist burnout have also contributed. How to best advance the most desirable and favorable aspects of remote work while preserving an academic environment that fulfills the tripartite mission is a critical challenge that nearly all academic institutions face today. In this AJR Expert Panel Narrative Review, we discuss current challenges in academic radiology, including effects of the COVID-19 pandemic, from three perspectives-those of the radiologist, the learner, and the health system-and address the following topics: productivity, recruitment, wellness, clinical supervision, mentorship and research, educational engagement, radiologist access, investments in technology, and radiologist value. Throughout, we focus on the opportunities and drawbacks of remote work, to help guide its effective and reliable integration into academic radiology practices.

Continuing to Thrive in Academic Radiology Despite Decreasing Reimbursement

Decreasing radiology reimbursement is a major challenge faced by academic radiology practices in the United States. The consequent increased workload from reading more radiological studies can lead to job dissatisfaction, burnout and adverse impact on research, innovation, and education. Thriving successfully in an academic practice despite low reimbursement requires modification of radiology business models and culture of the practice. In this article, we review the financial and operational strategies to mitigate low reimbursement and strategies for thriving in academic radiology without burnout.

Trainee and Faculty Perceptions of Remote PACS Workstations and Next Steps in a Large US Academic Medical Institution

ObjectiveRemote workstations were rapidly deployed in our academic radiology practice in late March 2020 in response to the COVID-19 pandemic. Although well-received by faculty, there were concerns for the impact on resident education. Materials and MethodsSurveys of the radiology trainees and faculty were conducted online seven- and thirteen-months following workstation deployment as a part of a quality improvement project to assess the impact on radiology education and faculty wellness, as well as assess the desired trajectory of remote work in an academic setting. ResultsThe majority of trainees (52%) reported the implementation had negatively impacted resident education, greatest among lower level residents (p < .001). This perception did not change despite interventions and perceived improvement in teleconferencing.Greater than 75% of radiologists with remote workstations reported improved wellness and lower stress levels compared to the onsite radiologists. The majority of all respondents voted to continue or expand remote work following the COVID-19 pandemic in both surveys. ConclusionsOnsite teaching is important for the education of residents, particularly for lower-level residents. However, the adoption of a hybrid model in an academic setting may prove beneficial for faculty wellness and recruitment of the next generation.

Use of a PACS Embedded System for Communicating Radiologist to Technologist Learning Opportunities and Patient Callbacks

ObjectiveThis study aimed to determine effect of modality, care setting, and radiology subspecialty on frequency of diagnostic image quality issues identified by radiologists during image interpretation. MethodsThis Institutional Review Board-exempt retrospective study was performed 10/1/18-6/30/20 at an academic radiology practice performing 700,000+ examinations annually. A closed-loop communication tool integrated in PACS workflow enabled radiologists to alert technologists to image quality issues. Radiologists categorized communications as requiring patient callback, or as technologist learning opportunities if image quality was adequate to generate a diagnostic report. Fisher's exact test assessed impact of imaging modality, radiology subspecialty, and care setting on radiologist-identified image quality issues. Results976,915 imaging examinations were performed during the study period. Radiologists generated 1,935 technologist learning opportunities (0.20%) and 208 callbacks (0.02%). Learning opportunity rates were highest for MRI (0.60%) when compared to CT (0.26%) and radiography (0.08%) (p<0.0001). The same was true for patient callbacks (MRI 0.13%, CT 0.02%, radiography 0.0006%; p<0.0001). Outpatient examinations generated more learning opportunities (1479/637,092; 0.23%) vs. inpatient (305/200,206; 0.15%) and Emergency Department (151/139,617; 0.11%) (p<0.0001). Abdominal subspecialists were most likely to generate learning opportunities when compared to other subspecialists and cardiovascular imagers were most likely to call a patient back. ConclusionsImage quality issues identified by radiologists during the interpretation process were rare and 10 times more commonly categorized as learning opportunities not interfering with a clinically adequate report than as requiring patient callback. Further work is necessary to determine if creating learning opportunities leads to fewer patients requiring repeat examinations.

Integration of a Community Radiology Division into a Subspecialty-Focused Academic Radiology Department

IntroductionAssimilate a general radiology division into a subspecialty-focused radiology department at an academic medical center. MethodsThis Institutional Review Board-approved quality improvement initiative was performed at an academic medical centers’ subspecialty-focused academic radiology department, aiming to assimilate a general radiology division providing interpretive services for a distributed set of community ambulatory practices. An Oversight Committee charged by the department chair created a charter with unambiguous goal, timelines, clear decision-making, and conflict resolution processes. The Committee assessed the resources and clinical capabilities of the general radiologists, and the anticipated shift in exam volume from the community into subspecialty divisions. Primary outcome, percentage of targeted organ systems-specific interpretations by general radiologists based on assigned subspecialty division, and secondary outcome of report turnaround time (TAT) for all ambulatory exams, were compared before and after sub-specialization. ResultsAmong 10 general radiologists, 4.5 were assigned to subspecialty divisions; 5.5 continued to cover an independent general radiology practice in a for-profit delivery network. In the 5 months’ post-transition, a total 86.6% (11,668/13,477) of reports by the integrated general radiologists were within designated subspecialty divisions vs 23.9% (2,586/10,829) pre-transition (P < 0.01). There was no change in ambulatory radiology report TAT for non-urgent care center (UCC) or UCC exams pre- vs post-integration. DiscussionA quality improvement initiative with unambiguous decision-making and conflict resolution processes incorporated a general radiology practice (radiologists and exams) into a subspecialty-focused academic radiology practice without negatively impacting TAT metrics. Future studies would be needed to assess impact on quality of interpretations.

Quantifying the Financial Impact of Delayed Adoption of CPT Code Changes in Radiology

PurposeTo quantify the financial effect of delayed reporting of new moderate sedation (MS) Current Procedural Terminology (CPT) codes at an academic radiology practice, and to identify barriers to timely reporting. Materials and MethodsBilling and reimbursement data was collected for a 28-month period (January 1, 2017-April 30, 2019). Reporting of new MS codes was identified and compared to the number of procedures performed by radiology over the study period. Using the number of procedures performed and payment data, losses were estimated. A root cause analysis was then performed to further understand delayed reporting. ResultsMS was reported with 2.5% of cases in 2017, 47.8% of cases in 2018 and 69.1% of cases in 2019. Appropriate coding was not achieved until June 2018, equating to a 17-month lag in implementation. Lost revenue from inaccurate reporting of MS alone was $21,357 ± $3,945 per month. Primary barriers to an efficient transition included (1) updating billing systems, (2-5) coder, nursing, technologist, and operator education and coordination, and (6) drafting and vetting new procedural report templates. ConclusionsDelayed reporting of the new moderate sedation codes resulted in a $363,069 ± $67,065 loss of procedural revenue at an academic radiology practice. Primary drivers of the delay were lags in education and coordination at multiple points in the reporting chain. As healthcare policy shifts and changes to coding become more frequent and significant, timely adoption becomes more salient for radiologists.

Financial Effect of Unbundling Moderate Sedation from Procedural Codes in Radiology

PurposeTo assess and quantify the financial effect of unbundling newly unbundled moderate sedation codes across major payors at an academic radiology practice. Materials and MethodsBilling and reimbursement data for 23 months of unbundled moderate sedation codes were analyzed for reimbursement rates and trends. This included 10,481 and 28,189 units billed and $443,257 and $226,444 total receipts for codes 99152 (initial 15 minutes of moderate sedation) and 99153 (each subsequent 15 minute increment of moderate sedation), respectively. Five index procedures—(i) central venous port placement, (ii) endovascular tumor embolization, (iii) tunneled central venous catheter placement, (iv) percutaneous gastrostomy placement, and (v) percutaneous nephrostomy placement—were identified, and moderate sedation reimbursements for Medicare and the dominant private payor were calculated and compared to pre-bundled reimbursements. Revenue variation models across different patient insurance mixes were then created using averages from 4 common practice settings among radiologists (independent practices, all hospitals, safety-net hospitals, and non-safety-net hospitals). ResultsDepartmental reimbursement for unbundled moderate sedation in FY2018 and FY2019 totaled $669,701.34, with high per-unit variability across payors, especially for code 99153. Across the 5 index procedures, moderate sedation reimbursement decreased 1.3% after unbundling and accounted for 3.9% of procedural revenue from Medicare and increased 11.9% and accounted for 5.5% of procedural revenue from the dominant private payor. Between different patient insurance mix models, estimated reimbursement from moderate sedation varied by as much as 29.9%. ConclusionsDepartmental reimbursement from billing the new unbundled moderate sedation codes was sizable and heterogeneous, highlighting the need for consistent and accurate reporting of moderate sedation. Total collections vary by case mix, patient insurance mix, and negotiated reimbursement rates.

Trainee and Attending Perspectives on Remote Radiology Readouts in the Era of the COVID-19 Pandemic

Rationale and ObjectivesSocial distancing mandates due to COVID-19 have necessitated adaptations to radiology trainee workflow and educational practices, including the radiology “readout.” We describe how a large academic radiology department achieved socially distant “remote readouts,” provide trainee and attending perspectives on this early experience, and propose ways by which “remote readouts” can be used effectively by training programs beyond COVID-19.Materials and MethodsBeginning March 2020, radiologists were relocated to workspaces outside of conventional reading rooms. Information technologies were employed to allow for “remote readouts” between trainees and attendings. An optional anonymous open-ended survey regarding remote readouts was administered to radiology trainees and attendings as a quality improvement initiative. From the responses, response themes were abstracted using thematic analysis. Descriptive statistics of the qualitative data were calculated.ResultsRadiologist workstations from 14 traditional reading rooms were relocated to 36 workspaces across the hospital system. Two models of remote readouts, synchronous and asynchronous, were developed, facilitated by commercially available information technologies. Thirty-nine of 105 (37%) trainees and 42 of 90 (47%) attendings responded to the survey. Main response themes included: social distancing, technology, autonomy/competency, efficiency, education/feedback and atmosphere/professional relationship. One hundred and forty-eight positive versus 97 negative comments were reported. Social distancing, technology, and autonomy/competency were most positively rated. Trainees and attending perspectives differed regarding the efficiency of remote readouts.Conclusion“Remote readouts,” compliant with social distancing measures, are feasible in academic radiology practice settings. Perspectives from our initial experience provide insight into how this can be accomplished, opportunities for improvement and future application, beyond the COVID-19 pandemic.

Subspecialty Employment Needs in Academic Radiology Settings Across Canada.

The purpose of this survey was to identify current and projected subspecialty employment needs across Canadian academic radiology practices. An electronic survey was distributed to academic radiology department heads within the faculties of medicine at Canadian universities between September and October 2019. Respondents identified the number of partnership track radiologists hired in the last academic year, the number of fellowship-trained new hires, and the top 3 subspecialties for new and prospective hires. Descriptive statistics were used to summarize the data. Nine academic radiology department heads responded to the survey (75% response rate) with good regional representation across Canada. Ninety-five percent of new hires within the last academic year were subspecialty fellowship trained. The top subspecialties for new hires in the last year were abdominal imaging and interventional neuroradiology, with 77.8% and 44.4% of academic leaders reporting them as one of the top 3 subspecialties, respectively. The top 3 subspecialties for prospective hires in the next academic year included musculoskeletal imaging (n = 6, 66.7%), followed by abdominal imaging (n = 5, 55.6%), with pediatric radiology (n = 3, 33.3%) and cardiothoracic imaging (n = 3, 33.3%) tying for third place. There was some variability in the subspecialty needs for hires between regions. The survey results provide valuable information about the current and future subspecialty needs of academic radiology practices. The data obtained can provide guidance to trainees regarding fellowship training options that will optimize their future employability.

Radiology Report Template Optimization at an Academic Medical Center.

OBJECTIVE. Variability in reports of the same imaging study performed at the same institution may be confusing to referrers and patients, hindering results communication. The purpose of this study was to introduce a quality improvement initiative aimed at reducing variation in radiology report templates at a large academic center. MATERIALS AND METHODS. The quality improvement initiative was undertaken at a large multisite, multidivision academic radiology practice performing more than 820,000 radiologic examinations annually. A project charter defined the goals, scope, and personnel of the initiative and an escalation pathway for conflict resolution. Standard requirements for templates were initially developed. From September 2017 to May 2018, an oversight committee (24 organ system and modality-based work groups with representatives from nine subspecialty divisions) reviewed and harmonized all institutional radiology report templates across the enterprise irrespective of the imaging site or division that interpreted the study. The primary outcome measure was percentage reduction in report templates after harmonization. The secondary outcome measure was monthly adherence to harmonized templates for 9 months after implementation assessed by manual review of 40 randomly selected reports per month. The paired t test was used to assess template reduction, and the chi-square trend test was used to study trend in adherence to harmonized templates. RESULTS. Among 19,687 total templates at baseline, 597 harmonized templates remained after harmonization (p < 0.001). There was variation in template reduction by work group (multiple p < 0.05; reduction range, 79.2-99.3%). Radiologist adherence to harmonized templates ranged from 88.0% to 100%, unchanged in the 9 months after implementation (p = 0.23, chi-square trend). CONCLUSION. A radiology report harmonization initiative reduced 97.0% of report templates with a sustained high degree of adherence to harmonized templates after implementation at a large multisite multidivision academic radiology practice.

Accuracy of Synthetic 2D Mammography Compared With Conventional 2D Digital Mammography Obtained With 3D Tomosynthesis.

OBJECTIVE. The purpose of this study was to compare the diagnostic performance of synthetic 2D imaging generated from 3D tomosynthesis (DBT) with traditional 2D full-field digital mammography (FFDM) by use of the most up-to-date software algorithm in an urban academic radiology practice. MATERIALS AND METHODS. The records of patients undergoing screening mammography with DBT, synthetic 2D imaging, and FFDM between August 13, 2014, and January 31, 2016, were retrospectively collected. The cohort included all biopsy-proven breast cancers detected with screening mammography during the study period (n = 89) and 100 cases of negative or benign (BI-RADS category 1 or 2) findings after 365 days of follow-up. In separate sessions, three readers blinded to outcome reviewed DBT plus synthetic 2D or DBT plus FFDM screening mammograms and assigned a BI-RADS category and probability of malignancy to each case. The diagnostic performance of each modality was assessed by calculating sensitivity and specificity. Reader performance was assessed by ROC analysis to estimate the AUC of the likelihood of malignancy. RESULTS. No statistically significant difference was found in diagnostic accuracy (sensitivity, specificity, positive predictive value, or negative predictive value) between DBT plus synthetic 2D mammography and DBT plus FFDM. There was no statistically significant difference between the AUC of DBT plus synthetic 2D mammography and the AUC of DBT plus FFDM for any reader. CONCLUSION. DBT plus synthetic 2D mammography performs as well as and not worse than DBT plus FFDM in measures of diagnostic accuracy and may be a viable alternative for decreasing radiation dose without sacrificing diagnostic performance.

CT and MRI Protocol Variation and Optimization at an Academic Medical Center

PurposeTo reduce CT and MRI protocol variation across a multisite radiology practice at an academic medical center so that patients with similar clinical presentations are examined the same way. Materials and MethodsThis study was performed at a large academic radiology practice performing ∼800,000 radiology examinations annually. To diminish variability across the enterprise (2 general radiology divisions; 10 subspecialty imaging divisions), a Harmonization Oversight Committee was created and tasked with ensuring patients with similar clinical presentations undergo the same CT or MRI protocol, regardless of where they are imaged. A process for decision making and conflict resolution was established, supported by the department chair. Primary outcome measure was standardization of CT and MRI protocols across all sites. Secondary outcome was percent reduction of CT and MRI protocols postharmonization. ResultsOver the 5-month harmonization process, most conflicts arose for abdominal imaging protocols because they are performed in four distinct subspecialty divisions, but all were addressed effectively through the conflict resolution process. Overall, there was a 31% reduction in the total number of CT and MRI protocols (before harmonization 481, after harmonization 331). There was significant variation in reduction of protocols per workgroup (multiple P values; range <.0001 to .9) with largest reduction in workgroups that overlapped multiple divisions. ConclusionA structured, organ system– and consensus-based quality improvement process with unambiguous decision-making and conflict resolution processes can be used to harmonize imaging protocols across complex, matrixed, multisite radiology practices so that patients with similar clinical presentations are imaged with the same imaging protocol.

The Community-Based Academic Radiologist

As academic radiology practices expand into the community, the lines that have historically distinguished the academic from private practice radiologist are becoming increasingly blurred. In this article, we introduce the new concept of the community-based academic radiologist and address some of the unique challenges and opportunities faced by these radiologists navigating this new hybrid role of academician and radiologist in community-based private practice.

Improving Performance of Mammographic Breast Positioning in an Academic Radiology Practice.

The purpose of this project was to achieve sustained improvement in mammographic breast positioning in our department. Between June 2013 and December 2016, we conducted a team-based performance improvement initiative with the goal of improving mammographic positioning. The team of technologists and radiologists established quantitative measures of positioning performance based on American College of Radiology (ACR) criteria, audited at least 35 mammograms per week for positioning quality, displayed performance in dashboards, provided technologists with positioning training, developed a supportive environment fostering technologist and radiologist communication surrounding mammographic positioning, and employed a mammography positioning coach to develop, improve, and maintain technologist positioning performance. Statistical significance in changes in the percentage of mammograms passing the ACR criteria were evaluated using a two-proportion z test. A baseline mammogram audit performed in June 2013 showed that 67% (82/122) met ACR passing criteria for positioning. Performance improved to 80% (588/739; p < 0.01) after positioning training and technologist and radiologist agreement on positioning criteria. With individual technologist feedback, positioning further improved, with 91% of mammograms passing ACR criteria (p < 0.01). Seven months later, performance temporarily decreased to 80% but improved to 89% with implementation of a positioning coach. The overall mean performance of 91% has been sustained for 23 months. The program cost approximately $30,000 to develop, $42,000 to launch, and $25,000 per year to maintain. Almost all costs were related to personnel time. Dedicated performance improvement methods may achieve significant and sustained improvement in mammographic breast positioning, which may better enable facilities to pass the recently instated Enhancing Quality Using the Inspection Program portion of a practice's annual Mammography Quality Standards Act inspections.

William G. Bradley, Jr, MD, PhD, FACR (1942-2017).

William G. Bradley, Jr, MD, PhD, FACR (1942-2017).

Social Media Utilization at an Academic Radiology Practice

We report social media (SoMe) utilization trends at an academic radiology department, highlighting differences between trainees and faculty and between Baby Boomers versus Generation X and Millennials. An anonymous online survey regarding SoMe utilization and SoMe-based educational curriculum was distributed to all radiologists (trainees and faculty) in our department. Regular chi-square, ordered (Mantel-Haenszel) chi-square, and Fischer exact tests were performed. The survey instrument was sent to 172 radiologists with a 65% completion rate (N = 112). Eighty-three percent (n = 92) of the respondents use SoMe, with Facebook (67%, n = 75), YouTube (57%, n = 64), Instagram (26%, n = 29), and Twitter (21%, n = 23) as the most commonly used platforms. Eighty-one percent (n = 91) use SoMe for 30 minutes or less per day. Thirty-five percent (n = 39) reported previously using SoMe for educational purposes, although 66% (n = 73) would be willing to join SoMe for educational activities. The faculty are more likely than trainees to avoid using SoMe (30% vs 9%, P < 0.03). Trainees are more likely than faculty to find an electronic case-based curriculum valuable (95% vs 83%, P < 0.05) and are willing to spend more time on cases (P < 0.01). Baby Boomers are less interested in joining SoMe for educational activities than Generation X and Millennials (24% vs 73%, P = 0.0001). Generation gaps between trainees and faculty, as well as between Generation X and Millennials versus Baby Boomers, exist with regard to the use of SoMe, which may be underutilized in radiology education.

Collaborative Branding of Partnered Health Systems in Radiology

In an effort to expand clinical reach and achieve economies of scale, academic radiology practices are strategically expanding into the community by establishing partnerships with existing community health systems. A challenge with this model is to effectively brand the collaboration in a way that underscores the strengths of both partners. In this article, the authors look at the benefits and risks of cobranding and review cobranding strategies for implementation by academic radiology practices considering partnership-based network expansion.

Performance of a Machine Learning Classifier of Knee MRI Reports in Two Large Academic Radiology Practices: A Tool to Estimate Diagnostic Yield.

The purpose of this study is to evaluate the performance of a natural language processing (NLP) system in classifying a database of free-text knee MRI reports at two separate academic radiology practices. An NLP system that uses terms and patterns in manually classified narrative knee MRI reports was constructed. The NLP system was trained and tested on expert-classified knee MRI reports from two major health care organizations. Radiology reports were modeled in the training set as vectors, and a support vector machine framework was used to train the classifier. A separate test set from each organization was used to evaluate the performance of the system. We evaluated the performance of the system both within and across organizations. Standard evaluation metrics, such as accuracy, precision, recall, and F1 score (i.e., the weighted average of the precision and recall), and their respective 95% CIs were used to measure the efficacy of our classification system. The accuracy for radiology reports that belonged to the model's clinically significant concept classes after training data from the same institution was good, yielding an F1 score greater than 90% (95% CI, 84.6-97.3%). Performance of the classifier on cross-institutional application without institution-specific training data yielded F1 scores of 77.6% (95% CI, 69.5-85.7%) and 90.2% (95% CI, 84.5-95.9%) at the two organizations studied. The results show excellent accuracy by the NLP machine learning classifier in classifying free-text knee MRI reports, supporting the institution-independent reproducibility of knee MRI report classification. Furthermore, the machine learning classifier performed well on free-text knee MRI reports from another institution. These data support the feasibility of multiinstitutional classification of radiologic imaging text reports with a single machine learning classifier without requiring institution-specific training data.