Utilization Of Advanced Imaging Research Articles

Developing Preoperative Nomograms to Predict Any-Stage and Stage III-IV Endometriosis in Infertile Women.

Study objective: To generate and validate nomograms to predict any-stage and stage III-IV endometriosis before surgery in infertile women.Design: A single center retrospective cohort study.Setting: University affiliated hospital.Patients: Infertile patients (n = 1,016) who underwent reproductive surgery between July 1, 2016 and June 30, 2019.Interventions: None.Main outcome measurements: We randomly selected 2/3 of the included patients (667 patients, training sample) to analyze and generate predictive models and validated the models on the remaining patients (339 patients, validation sample). A multivariate logistic regression model was used with the training sample to select variables using a back stepwise procedure. Nomograms to predict any-stage and stage III–IV endometriosis were constructed separately. The discriminations and calibrations of both nomograms were tested on the overall population and a subgroup without endometrioma diagnosed on transvaginal sonography (TVS) of training and validation samples. The impact of different variables in these models was evaluated.Results: There were 377 (55.7%) women in the training sample and 196 (57.8%) in the validation sample who were diagnosed with endometriosis. The nomogram predicting any-stage endometriosis had an area under the curve (AUC) of 0.760 for the training sample and 0.744 for the validation sample, with favorable calibrations in the overall population. However, the performance was significantly decreased in patients without endometrioma on TVS, with an AUC of 0.726 in the training sample and 0.694 in the validation sample. Similarly, the nomogram predicting stage III–IV endometriosis had an AUC of 0.833 and 0.793 for the training and validation samples, respectively, as well as a favorable calibration. However, the performance of the nomogram on patients without endometrioma on TVS was poor. Endometrioma on TVS strongly predicted both any stage and stage III–IV endometriosis on both samples.Conclusion: We developed nomograms to predict any-stage and stage III–IV endometriosis but their performance were significantly decreased in patients without endometrioma on TVS. Endometrioma on TVS strongly predicted any and III–IV stage endometriosis in both sample groups. Therefore, we recommend that this study be used as encouragement to advance the utilization of advanced imaging for endometriosis for better clinical prognosis.

Associations Over Time Between Paid Medical Malpractice Claims and Imaging Utilization in the United States.

The aim of this study was to explore state-level relationships between the incidence and payout amounts for medical malpractice claims and Medicare imaging utilization and spending across the United States. Using claims data from a 5% sample of Medicare beneficiaries for 2004 to 2016, annual state population-adjusted rates of imaging utilization and spending were calculated. Using National Practitioner Data Bank files, all paid physician malpractice claims were identified, and lagged state population-adjusted rolling averages of paid claim frequencies and payout amounts were calculated. Controlling for secular trends and state fixed effects with robust standard errors clustered at the state level to account for serial autocorrelation, associations between imaging utilization and lagged paid malpractice claims were assessed using multivariate regression models. Log-log model specification was used to obtain elasticity measures. Between 2004 and 2016, national Medicare diagnostic imaging utilization and spending declined by 31.4% and 47.2%, respectively (from 355,057 to 243,517 examinations and from $28,591,146 to $15,099,291 per 100,000 beneficiaries). Overall national paid malpractice claims and payout amounts declined by 46.4% and 39.6%, respectively (from 4.83 to 2.59 claims and from $1,803,565 to $1,089,112 per 100,000 population). After controlling for secular trends and state fixed effects, advanced imaging utilization was positively associated with the lagged number of per capita paid malpractice claims. Each 1% increase in average paid malpractice claims was associated with a subsequent 0.20% increase in advanced imaging utilization (P= .001). Positive associations between paid malpractice claims and advanced Medicare imaging utilization support the contention that US physicians use medical imaging as a defensive medicine strategy.

National Trends in Oncologic Diagnostic Imaging.

To characterize national trends in oncologic imaging (OI) utilization. This retrospective cross-sectional study used 2004 and 2016 CMS 5% Carrier Claims Research Identifiable Files. Radiologist-performed, primary noninvasive diagnostic imaging examinations were identified from billed Current Procedural Terminology codes; CT, MRI, and PET/CT examinations were categorized as "advanced" imaging. OI examinations were identified from imaging claims' primary International Classification of Diseases-9 and International Classification of Diseases-10 codes. Imaging services were stratified by academic practice status and place of service. State-level correlations of oncologic advanced imaging utilization (examinations per 1,000 beneficiaries) with cancer prevalence and radiologist supply were assessed by Spearman correlation coefficient. The national Medicare sample included 5,051,095 diagnostic imaging examinations (1,220,224 of them advanced) in 2004 and 5,023,115 diagnostic imaging examinations (1,504,608 of them advanced) in 2016. In 2004 and 2016, OI represented 4.3% and 3.9%, respectively, of all imaging versus 10.8% and 9.5%, respectively, of advanced imaging. The percentage of advanced OI done in academic practices rose from 18.8% in 2004 to 34.1% in 2016, leaving 65.9% outside academia. In 2016, 58.0% of advanced OI was performed in the hospital outpatient setting and 23.9% in the physician office setting. In 2016, state-level oncologic advanced imaging utilization correlated with state-level radiologist supply (r=+0.489, P < .001) but not with state-level cancer prevalence (r=-0.139, P= .329). OI usage varied between practice settings. Although the percentage of advanced OI done in academic settings nearly doubled from 2004 to 2016, the majority remained in nonacademic practices. State-level oncologic advanced imaging utilization correlated with radiologist supply but not cancer prevalence.

PND33 BUDGET IMPACT MODELLING OF CT ANGIOGRAPHY AND PERFUSION IMAGING IN ACUTE ISCHEMIC STROKE CARE

Stroke has a significant health impact and presents an ongoing challenge for the ongoing availability of healthcare resources. These rising healthcare costs have been partly attributed to the utilization of advanced imaging with CT angiography and perfusion (CTAP). Thus, we investigate the budget impact of implementing advanced imaging for diagnosis and treatment decision-making in acute stroke patients at a comprehensive stroke center (CSC).

Management of Primary Headache in the Emergency Department

Headache is a common presentation to emergency departments (EDs), comprising nearly 4% of all ED admissions.‎1 While the overwhelming majority of patients present with a primary headache disorder, particularly migraine, the emergency physician’s role calls for the simultaneous exclusion of severe or life-threatening pathology while providing judicious and effective symptom relief.‎2 Notably, recent investigations suggest that this dual mandate performs well, excluding more than 99% of conditions resulting in serious adverse neurologic sequelae, though at the cost of high-frequency and low-yield advanced imaging utilization.‎3‎, 4 While a comprehensive understanding of the diagnostic process and underlying pathophysiology associated with headache disorders is critical for the emergency clinician, this review is meant to chiefly describe the treatment of primary headache and the variety, efficacy, and indications of those interventions. While individual headache type classification can be helpful in targeting approach or therapy, diagnosis can be difficult in the emergency setting, and primary headaches of most types are often approached similarly in the ED. Interestingly, the overwhelming majority of patients who present to an emergency department with acute primary headache have migraine, but the majority of patients receive a less specific diagnosis and a treatment that is correspondingly nonspecific.‎5 Importantly, however, the dynamic, diverse, and unique nature of different headache presentations to the ED make an algorithmic or step-wise approach to headache management ill-advised. The emergency practitioner must have a working knowledge of the array of treatment options available and apply therapies in a considered and informed manner. Following effective analgesia, however, the most important intervention emergency physicians can deliver for their headache patients is to connect them with outpatient physicians savvy about headache management, who will then provide these headache patients with appropriate acute therapeutics, initiate preventive therapy and provide anticipatory guidance about their disease process.‎6

Management of Primary Headache in the Emergency Department

Headache is a common presentation to emergency departments (EDs), comprising nearly 4% of all ED admissions.‎ While the overwhelming majority of patients present with a primary headache disorder, particularly migraine, the emergency physician’s role calls for the simultaneous exclusion of severe or life-threatening pathology while providing judicious and effective symptom relief.‎ Notably, recent investigations suggest that this dual mandate performs well, excluding more than 99% of conditions resulting in serious adverse neurologic sequelae, though at the cost of high-frequency and low-yield advanced imaging utilization.‎ While a comprehensive understanding of the diagnostic process and underlying pathophysiology associated with headache disorders is critical for the emergency clinician, this review is meant to chiefly describe the treatment of primary headache and the variety, efficacy, and indications of those interventions. While individual headache type classification can be helpful in targeting approach or therapy, diagnosis can be difficult in the emergency setting, and primary headaches of most types are often approached similarly in the ED. Interestingly, the overwhelming majority of patients who present to an emergency department with acute primary headache have migraine, but the majority of patients receive a less specific diagnosis and a treatment that is correspondingly nonspecific.‎ Importantly, however, the dynamic, diverse, and unique nature of different headache presentations to the ED make an algorithmic or step-wise approach to headache management ill-advised. The emergency practitioner must have a working knowledge of the array of treatment options available and apply therapies in a considered and informed manner. Following effective analgesia, however, the most important intervention emergency physicians can deliver for their headache patients is to connect them with outpatient physicians savvy about headache management, who will then provide these headache patients with appropriate acute therapeutics, initiate preventive therapy and provide anticipatory guidance about their disease process.‎

Changes in Emergency Department Care Intensity from 2007-16: Analysis of the National Hospital Ambulatory Medical Care Survey

IntroductionEmergency departments (ED) in the United States (US) have increasingly taken the central role for the expedited diagnosis and treatment of acute episodic illnesses and exacerbations of chronic diseases, allowing outpatient management to be possible for many conditions that traditionally required hospitalization and inpatient care. The goal of this analysis was to examine the changes in ED care intensity in this context through the changes in ED patient population and ED care provided.MethodsWe analyzed the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2007–2016. Incorporating survey design and weight, we calculated the changes in ED patient characteristics and ED care provided between 2007 and 2016. We also calculated changes in the proportion of visits with low-severity illnesses that may be safely managed at alternative settings. Lastly, we compared ED care received and final ED dispositions by calculating adjusted relative risk (aRR) comparing ED visits in 2007 to 2016, using survey weighted multivariable logistic regression.ResultsNHAMCS included 35,490 visits in 2007 and 19,467 visits in 2016, representing 117 million and 146 million ED visits, respectively. Between 2007 and 2016, there was an increase in the proportion of ED patients aged 45–64 (21.0% to 23.6%) and 65–74 (5.9% to 7.5%), while visits with low-severity illnesses decreased from 37.3% to 30.4%. There was a substantial increase in the proportion of Medicaid patients (22.2% to 34.0%) with corresponding decline in the privately insured (36.2% to 28.3%) and the uninsured (15.4% to 8.6%) patients. After adjusting for patient and visit characteristics, there was an increase in the utilization of advanced imaging (aRR 1.29; 95% confidence interval [CI], 1.17–1.41), blood tests (aRR 1.16; 95% CI, 1.10–1.22), urinalysis (aRR 1.22; 95% CI, 1.13–1.31), and visits where the patient received four or more medications (aRR 2.17; 95% CI, 1.88–2.46). Lastly, adjusted hospitalization rates declined (aRR 0.74; 95% CI, 0.64–0.84) while adjusted discharge rates increased (aRR 1.06; 95%CI 1.03–1.08).ConclusionFrom 2007 to 2016, ED care intensity appears to have increased modestly, including aging of patient population, increased illness severity, and increased resources utilization. The role of increased care intensity in the decline of ED hospitalization rate requires further study.

Toward a cure for lumbar spinal stenosis: The potential of interspinous process decompression

There is a growing impetus to treat aging as a disease in the quest to significantly extend the human life span through cellular regeneration methods. This approach, while promising, overlooks the fact that the evolutionary adaptation to bipedalism puts the human body in a distinctively vulnerable biomechanical and functional position. Orthograde human posture places unusually-high axial compressive loads on the weight-bearing joints of the skeleton, resulting in arthritic deterioration with aging. The effects are particularly robust in the lumbar spine were age-related degeneration, most commonly lumbar spinal stenosis (LSS), is ubiquitous among the elderly. It is postulated that re-establishing a favorable mechanical environment via interventions that unload the affected spinal joint complex may mitigate and potentially reverse the structural damage that is the cardinal pathoanatomical feature of this disease. The hypothesis of this paper is that a minimally-invasive surgical procedure, interspinous process decompression (IPD), which utilizes a stand-alone intervertebral spacer, effectively unloads the diseased spinal motion segment providing a healthy micro-environment to reverse and repair age-related and genetic deterioration of the spinal motion segment. Several lines of supporting evidence are provided from long-term follow-up results of a randomized controlled trial of IPD safety and effectiveness of the Superion® device including clinical outcomes, reoperation rates, opioid analgesic usage and advanced imaging utilization. All of these outcomes show uniquely-favorable trends with time that imply that the benefits of IPD are structural. The compendium of evidence suggests that IPD offers both a durable palliative effect due to direct blocking of back extension and a disease-modifying effect due to unloading of the spinal joint complex.

Seeing Isnʼt Believing: Utilization of Advanced Imaging to Guide Diagnosis of Abdominal Pain Post RYGB

Patients presenting with gastrointestinal complaints after Roux-en-Y gastric bypass (RYGB) can pose challenging diagnostic dilemmas for clinicians. Comprehensive history and employment of advanced imaging can provide insight. A 46-year-old healthy male with an uncomplicated laparoscopic RYGB in 2011 presented with 3 days of acute onset progressive, positional epigastric pain with radiation to the left upper quadrant (LUQ). He had a normal appetite and bowel habits, and no extra-intestinal complaints. He did not take medicine, had no toxic habits, and no family history of gastrointestinal conditions. On presentation, he appeared well with normal vital signs. His abdomen was non-distended, with normoactive bowel sounds, and tenderness in the LUQ and epigastrium. Laboratory testing was significant for leukocytosis of 13.7 K/uL, creatinine 1.2 mg/dL, and alkaline phosphatase 142 IU/L. Abdominal CT (Figure 1) reported jejunal thickening with a soft tissue tract concerning for fistula, edema of the J-J anastomosis, local perforation, and wall thickening of adjacent transverse colon with a fistula and small abscess. Inflammatory markers were elevated to ESR 55 mm/h and CRP 192 mg/L. An interim diagnosis of fistulizing Crohn's Disease was proposed. However, subsequent MR Enterography (Figure 2, 3) delineated significant inflammation around the J-J anastomosis, surrounding mesentery and adjacent bowel loops with resulting adhesions producing low-grade obstruction around the anastomotic loop. Final diagnosis of partial obstruction due to adhesion and likely internal herniation was established. With conservative management and bowel rest, the patient made a stable recovery without symptom recurrence. Abdominal pain after RYGB is endorsed by over one-third of patients. Pain description can be useful in distinguishing etiology, with common causes of severe, intermittent, positional LUQ discomfort including internal herniation and intussusception. Internal herniation typically presents 2-3 years after bypass with an incidence of 3-16%, more frequent with laparoscopic approach and retrocolic Roux limb orientation. The case emphasizes the utility of advanced imaging such as MR Enterography in accurately diagnosing a complex case, whereas CT imaging suggested alternative pathology. Given the clinical context, this technique allowed for appropriate management.2529_A Figure 1. Axial image from admission CT abdomen and pelvis performed with IV and oral contrast demonstrates a (A) segment of LUQ small bowel wall thickening with surrounding edema, consistent with enteritis involving a jejunal-jejunal anastomosis; (B) a blind ending sinus tract extending laterally from a loop of jejunum consistent with a localized perforation; (C) tethering of loops of jejunum suggesting the presence of adhesions; (D) interloop phlegmonous change with small abscess formation anteriorly and to the left.2529_B Figure 2. Coronal T2 MRE performed with IV gadolinium and oral biphasic endoluminal contrast demonstrates borderline dilatation and tethering of the jejunaljejunal anastomotic loops to the small bowel mesentery suggesting the presence of partial bowel obstruction secondary to adhesions.2529_C Figure 3. Coronal fluid sensitive balanced fast field echo (bFFE) image from an MRE examination performed with IV gadolinium and oral biphasic endoluminal contrast demonstrates thick walled, edematous loops of jejunum and adjacent thick walled, edematous and narrowed loops of mid-distal transverse colon with surrounding phlegmonous change, suggesting the presence of a localized perforation in the LUQ with secondary regional inflammatory change.

Trends in advanced imaging and hospitalization for emergency department syncope care before and after ACEP clinical policy

ObjectivesTo describe recent trends in advanced imaging and hospitalization of emergency department (ED) syncope patients, both considered “low-value”, and examine trend changes before and after the publication of American College Emergency Physician (ACEP) syncope guidelines in 2007, compared to conditions that had no changes in guideline recommendations. MethodsWe analyzed 2002–2015 National Hospital Ambulatory Medical Care Survey data using an interrupted-time series with comparison series design. The primary outcomes were advanced imaging among ED visits with principal diagnosis of syncope and headache and hospitalization for ED visits with principal diagnosis of syncope, chest pain, dysrhythmia, and pneumonia. We adjusted annual imaging and hospitalization rates using survey-weighted multivariable logistic regression, controlling for demographic and visit characteristics. Using adjusted outcomes as datapoints, we compared linear trends and trend changes of annual imaging and hospitalization rates before and after 2007 with aggregate-level multivariable linear regression. ResultsFrom 2002 to 2007, advanced imaging rates for syncope increased from 27.2% to 42.1% but had no significant trend after 2007 (trend change: −3.1%; 95%CI −4.7, −1.6). Hospitalization rates remained at approximately 37% from 2002 to 2007 but declined to 25.7% by 2015 (trend change: −2.2%; 95%CI −3.0, −1.4). Similar trend changes occurred among control conditions versus syncope, including advanced imaging for headache (difference in trend change: −0.6%; 95%CI −2.8, 1.6) and hospitalizations for chest pain, dysrhythmia, and pneumonia (differences in trend changes: 0.1% [95%CI −1.9, 2.0]; −0.9% [95%CI −3.1, 1.3]; and −1.2% [95%CI −5.3, 2.9], respectively). ConclusionsBefore and after the release of 2007 ACEP syncope guidelines, trends in advanced imaging and hospitalization for ED syncope visits had similar changes compared to control conditions. Changes in syncope care may, therefore, reflect broader practice shifts rather than a direct association with the 2007 ACEP guideline. Moreover, utilization of advanced imaging remains prevalent. To reduce low-value care, policymakers should augment society guidelines with additional policy changes such as reportable quality measures.

Impact of an Advanced Imaging Utilization Review Program on Downstream Health Care Utilization and Costs for Low Back Pain.

Early magnetic resonance imaging (MRI) for acute low back pain (LBP) has been associated with increased costs, greater health care utilization, and longer disability duration in workers' compensation claimants. To assess the impact of a state policy implemented in June 2010 that required prospective utilization review (UR) for early MRI among workers' compensation claimants with LBP. Interrupted time series. In total, 76,119 Washington State workers' compensation claimants with LBP between 2006 and 2014. Proportion of workers receiving imaging per month (MRI, computed tomography, radiographs) and lumbosacral injections and surgery; mean total health care costs per worker; mean duration of disability per worker. Measures were aggregated monthly and attributed to injury month. After accounting for secular trends, decreases in early MRI [level change: -5.27 (95% confidence interval, -4.22 to -6.31); trend change: -0.06 (-0.01 to -0.12)], any MRI [-4.34 (-3.01 to -5.67); -0.10 (-0.04 to -0.17)], and injection [trend change: -0.12 (-0.06 to -0.18)] utilization were associated with the policy. Radiograph utilization increased in parallel [level change: 2.46 (1.24-3.67)]. In addition, the policy resulted in significant decreasing changes in mean costs per claim, mean disability duration, and proportion of workers who received disability benefits. The policy had no effect on computed tomography or surgery utilization. The UR policy had discernable effects on health care utilization, costs, and disability. Integrating evidence-based guidelines with UR can improve quality of care and patient outcomes, while reducing use of low-value health services.

Impact of Delayed Time to Advanced Imaging on Missed Appointments Across Different Demographic and Socioeconomic Factors

PurposeThe aim of this study was to investigate the impact of wait days (WDs) on missed outpatient MRI appointments across different demographic and socioeconomic factors. MethodsAn institutional review board–approved retrospective study was conducted among adult patients scheduled for outpatient MRI during a 12-month period. Scheduling data and demographic information were obtained. Imaging missed appointments were defined as missed scheduled imaging encounters. WDs were defined as the number of days from study order to appointment. Multivariate logistic regression was applied to assess the contribution of race and socioeconomic factors to missed appointments. Linear regression was performed to assess the relationship between missed appointment rates and WDs stratified by race, income, and patient insurance groups with analysis of covariance statistics. ResultsA total of 42,727 patients met the inclusion criteria. Mean WDs were 7.95 days. Multivariate regression showed increased odds ratio for missed appointments for patients with increased WDs (7-21 days: odds ratio [OR], 1.39; >21 days: OR, 1.77), African American patients (OR, 1.71), Hispanic patients (OR, 1.30), patients with noncommercial insurance (OR, 2.00-2.55), and those with imaging performed at the main hospital campus (OR, 1.51). Missed appointment rate linearly increased with WDs, with analysis of covariance revealing underrepresented minorities and Medicaid insurance as significant effect modifiers. ConclusionsIncreased WDs for advanced imaging significantly increases the likelihood of missed appointments. This effect is most pronounced among underrepresented minorities and patients with lower socioeconomic status. Efforts to reduce WDs may improve equity in access to and utilization of advanced diagnostic imaging for all patients.

Trends in the utilization of advanced diagnostic imaging and lumbar disc disorders diagnosis in the Warmia and Mazury Province, Poland

1. Sąsiadek M, Hendrich B. [Diagnostic imaging of the spine, including new imaging techniques]. Pol Przegl Neurol. 2010;6(1):38–45 [in Polish]. Google Scholar

Advanced Imaging Utilization and Cost Savings Among Medicare Shared Savings Program Accountable Care Organizations: An Initial Exploratory Analysis

IntroductionThe purpose of this study was to explore associations between CT and MRI utilization and cost savings achieved by Medicare Shared Savings Program (MSSP)-participating accountable care organizations (ACOs). MethodsSummary data were obtained for all MSSP-participating ACOs (n = 214 in 2013; n = 333 in 2014). Multivariable regressions were performed to assess associations of CT and MRI utilization with ACOs’ total savings and reaching minimum savings rates to share in Medicare savings. ResultsIn 2014, 54.4% of ACOs achieved savings, meeting minimum rates to share in savings in 27.6%. Independent positive predictors of total savings included beneficiary risk scores (β = +20,265,720, P = .003) and MRI events (β = +19,964, P = .018) but not CT events (β = +2,084, P = .635). Independent positive predictors of meeting minimum savings rates included beneficiary risk scores (odds ratio = 2108, P = .001) and MRI events (odds ratio = 1.008, P = .002), but not CT events (odds ratio = 1.002, P = .289). Measures not independently associated with savings were total beneficiaries; beneficiaries’ gender, age, race or ethnicity; and Medicare enrollment type (P > .05). For ACOs with 2013 and 2014 data, neither increases nor decreases in CT and MRI events between years were associated with 2014 total savings or meeting savings thresholds (P ≥ .466). ConclusionHigher MRI utilization rates were independently associated with small but significant MSSP ACO savings. The value of MRI might relate to the favorable impact of appropriate advanced imaging utilization on downstream outcomes and other resource utilization. Because MSSP ACOs represent a highly select group of sophisticated organizations subject to rigorous quality and care coordination standards, further research will be necessary to determine if these associations are generalizable to other health care settings.

Changes in Emergency Department Imaging: Perspectives From National Patient Surveys Over Two Decades

PurposeTo use patient-generated data to assess the changing role of emergency department (ED) imaging for a spectrum of clinical indications. MethodsThe Household Component Emergency Room Visits File was obtained from 1996 through 2014 for the Medical Expenditure Panel Survey, a nationally representative survey of US households. Percentage of visits associated with various imaging modalities was computed annually, stratified by respondents’ self-reported primary condition during the visit. Modality characteristics were assessed for conditions most frequently imaged in 1996 or 2014. ResultsFor most conditions, use of advanced imaging (defined by Medical Expenditure Panel Survey as CT or MRI) in the ED increased significantly (P < .001). The largest growth occurred for urinary calculus (from 0% to 48.5%) and headache (from 17.5% to 33.3%), which were the most commonly imaged conditions by CT or MRI in 2014. For ultrasound, the most commonly imaged condition was pregnancy in 1996 (32.9%) and 2014 (44.5%). No other condition was associated with ultrasound in >20% of visits. For radiography, the most commonly imaged conditions were extremity wounds and fractures in 1996 (range 84.5%-90.2%) and 2014 (range 93.4%-93.9%). Use of radiography decreased for urinary calculus from 67.4% to 24.2% (P < .001). ConclusionFor many conditions, ED utilization of advanced imaging increased significantly, though growth was variable across conditions. In certain scenarios, advanced ED imaging is adding to, rather than replacing, other modalities. Ultrasound and radiography utilization was overall unchanged. That national patient survey data mirror traditional claims-based studies suggests an expanded role for patient-generated data in identifying areas of imaging utilization that may benefit from targeted optimization efforts.

The Effect of Access to Electronic Health Records on Throughput Efficiency and Imaging Utilization in the Emergency Department.

To evaluate whether the availability of Electronic Health Records (EHRs) reduces throughput time and utilization of advanced imaging for patients in an academic ED. All patients arriving at an academic Emergency Department (ED) via ambulance between June 1, 2011, and June 4, 2012, were included in the study. This accounted for 9,970 unique ambulance patient visits. Retrospective noninterventional analysis of patients in an academic ED. The primary independent variable was whether the patient had a prior EHR at the study hospital. Main outcomes were throughput time, number of advanced diagnostic imaging studies (CT, MRI, ultrasound), and the associated cost of these imaging studies. A set of controls, including age, gender, ICD9 codes, acuity measures, and NYU ED algorithm case severity classifications, was used in an ordinary least-squares (OLS) regression framework to estimate the association between EHR availability and the outcome measures. A patient with a prior EHR experienced a mean reduction in CT scans of 13.9 percent ([4.9, 23.0]). There was no material change in throughput time for patients with a prior EHR and no difference in utilization of other imaging studies across patients with a prior EHR and those without. Cost savings associated with prior EHRs are $22.52 per patient visit. EHR availability for ED patients is associated with a reduction in CT scans and cost savings but had no impact on throughput time or order frequency of other imaging studies.

Pre-authorization processes have no effect on patients undergoing knee MRI in a pediatric setting when evaluated by specialists.

Pre-authorization processes are often used by medical insurance companies to reduce costs by managing the utilization of advanced diagnostic imaging, and their impact on patient care is unclear. The purpose of our study is to determine if a pre-authorization process increases the rate of surgically significant abnormal knee MRI and surgical referrals compared with patients referred from pediatric orthopedic specialists who do not undergo a pre-authorization process. A retrospective study was performed; 124 patients were identified who were referred for knee MRI by a pediatric orthopedist. The study population included patients who underwent an insurance pre-authorization process and the control group consisted of those who did not. The results of the MRI and whether they were deemed surgically significant, in addition to surgical referral, were recorded and compared. The study and control groups showed no statistically significant difference in outcome with regard to surgically significant findings on MRI (p = 0.92) or whether the patient required surgery (p = 0.6). In this population, there is no difference in the likelihood of an abnormal knee MRI demonstrating surgically significant findings or referral to surgery in patients who did and those who did not undergo an insurance pre-authorization process when patients are referred from a pediatric orthopedic specialist. The insurance pre-authorization process does not appear to have an impact on patient diagnosis and treatment and may unnecessarily add bureaucracy and costs.

Advanced endoscopic imaging: European Society of Gastrointestinal Endoscopy (ESGE) Technology Review.

Background and aim: This technical review is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). It addresses the utilization of advanced endoscopic imaging in gastrointestinal (GI) endoscopy. Methods: This technical review is based on a systematic literature search to evaluate the evidence supporting the use of advanced endoscopic imaging throughout the GI tract. Technologies considered include narrowed-spectrum endoscopy (narrow band imaging [NBI]; flexible spectral imaging color enhancement [FICE]; i-Scan digital contrast [I-SCAN]), autofluorescence imaging (AFI), and confocal laser endomicroscopy (CLE). The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was adopted to define the strength of recommendation and the quality of evidence. Main recommendations:1. We suggest advanced endoscopic imaging technologies improve mucosal visualization and enhance fine structural and microvascular detail. Expert endoscopic diagnosis may be improved by advanced imaging, but as yet in community-based practice no technology has been shown consistently to be diagnostically superior to current practice with high definition white light. (Low quality evidence.) 2. We recommend the use of validated classification systems to support the use of optical diagnosis with advanced endoscopic imaging in the upper and lower GI tracts (strong recommendation, moderate quality evidence). 3. We suggest that training improves performance in the use of advanced endoscopic imaging techniques and that it is a prerequisite for use in clinical practice. A learning curve exists and training alone does not guarantee sustained high performances in clinical practice. (Weak recommendation, low quality evidence.) Conclusion: Advanced endoscopic imaging can improve mucosal visualization and endoscopic diagnosis; however it requires training and the use of validated classification systems.

P.067 Incidence of tissue-defined stroke and large vessel occlusion in acute stroke alerts in a non-teaching hospital system

Background: Stroke alerts are used to triage patients with acute neurologic change for rapid imaging evaluation. CTA has been advocated to rapidly triage stroke patients for endovascular therapy. However, the yield of this approach is not well established. We evaluated the stroke alert yield in a non-teaching hospital system. Methods: A retrospective review of radiology reports for stroke alerts using PACS archive. Cases were then followed for 72 hours to determine the types of advanced imaging obtained and the findings of those studies. Results: From January to March 2014, 269 stroke alert head CTs were performed. Subsequent imaging included 128 MRIs (48%), 25 CTAs (9%) and 2 angiograms (0.7%). There were 58 (22%) tissue-defined strokes and 16 were non-lacunar (6% stroke alerts). 61% of stroke alert head CTs were negative or reported microvascular change. Other findings included large vessel occlusion (5%), intracranial stenosis (1.5%), extracranial stenosis(1.5 %), intracranial hemorrhage (9%) and masses (13%). Conclusions: Most stroke alerts were negative for tissue-defined stroke. Based on this data, universal use of CTA in the ER to triage patients with acute neurologic symptoms may not be appropriate. An updated triage system to facilitate endovascular rescue is being analyzed for changes to advanced imaging utilization and yield.

The importance of time: Time delays in acute stroke

BackgroundEndovascular treatment (EVT) of severe acute ischemic stroke (AIS) determined by large vessel occlusion (LVO) is effective and safe. Debate still goes on especially about time importance and utilization of advanced penumbra imaging at the expense of loosing valuable minutes. MethodsWe did a meta-analysis focused on time of randomized clinical trials (RCTs) that started to use methodically the new-tech stent retrievers. The chosen time interval was onset-groin time (from last seen well to sheath insertion in the cathlab). Primary outcome was good functional outcome (mRS of 0–2) at 90 days, and secondary outcomes were mortality at 90 days and symptomatic intra-cerebral hemorrhage (sICH). Furthermore, we did a sub-analysis of the EVT patients to find a correlation between faster times and outcomes. We did the same sub-analysis including also single-arm registries that used modern stent retrievers. ResultsTotally data from 1287 patients (5 RCTs) were analyzed, whose 634 EVT patients were divided into two groups based on time (faster/slower than 240min). Furthermore 1501 EVT-treated patients (9 studies) were divided into two pre-specified groups (fast/slow) and analyzed. In both meta-analysis and sub-analysis, the fast group had better functional outcome at 90 days [logOR=−2.07, 95% CI (−3.00, −1.14)] and less deaths [logOR=−0.56, 95% CI (−3.66, −2.55)], demonstrating that onset-groin time has a strong impact even on mortality. On the other hand, sICH resulted to be more frequent in the slow group [logOR=0.18, 95% CI (−1.36, −1.71)] emphasizing how delays could even worsen AIS. ConclusionsThis meta-analysis supports the “Time is brain” strategy in treatment of acute ischemic stroke. In general, fast endovascular treatment (groin puncture within <4h) significantly improves patients’ outcomes. Healthcare systems should develop maximal effort to shorten pre-hospital and in-hospital delays in acute stroke patients. The earlier the patient is presenting, the more important is the fast track, offering chance for full neurologic recovery.