John Rodney - psot.com · Web viewThis chapter is a reaffirmation of the role played by non-radiologists in the interpretation of images. Assuming similar proportions for non-radiologists’

Rodney WM, Rodney JRM,TBAPfenninger Chapter-Plain radiography in the Office May 10,2008 DRAFT

Wm. MacMillan Rodney MD, JR MacMillan Rodney MD, Arnold KRMRadiology for Nonradiologists-Xrays in the Office

UPDATED MAY 10Mark Needham MD has been teaching this at the AAFP and NPI since 1995 or

longer. His perspective is Santa Monica private practice which is an over-doctored urban area. He is a graduate of the Santa Monica FP residency which formerly was a “top ten” program 1972-2002 when it was dismantled by UCLA. He trained for 3 years as a radiology resident prior to joining FP.

We appreciated the tremendous amount of work he has done in creating and refining the 13 hours of lecture he presented in San Antonio. We discussed how our private practice experiences are equally valid but different. For example, MEDICOS no longer recommends “casting” torus fractures, and prefers the simplicity of splints. Other style differences are noted below. Dr. Needham’s presentation and the courtesy extended by NPI reminds us to thank these entities in an acknowledgement.

Dr. Needham repeatedly punctuated the chest series with “normal” views., and then cases which were clearly “abnormal”. His 3 years of radiology training led to a perspective which is somewhat different that the one we have developed. For example he stated, “When the elephant’s in the room, you have to ignore him[until you have made sure that you don’t miss any other abnormalities], and “Look beyond the obvious pathology”. This raises the question of how much time should the clinician spend and does it add value? For our practice, once the elephant is detected we go to the hospital or splint/cast.

He recommends over-reading every film by radiology, but allows that the MEDICOS style of selective consultation is valid. The fear of “not missing anything” is universal but creates a slippery slope ultimately leading to analysis paralysis. His handout states, “Become a radiologist”. I don’t think we can ever resolve this dilemma to the universal satisfaction of everyone. Maybe #6 in the second section should be moved up on the list, but we cannot spend too much time on philosophy and politics.

Dr. Needham stated that the most commonly needed skill is the ability to interpret a chest film. Therefore, ”Interpretation of the Chest Radiograph” is a section which stands on its own. This section would include our one page medical record form as a strongly recommended guideline. With image examples, this chapter starts with a brief introduction about this technology as an essential [nonoptional] keystone in the practice of community medicine.

TC or PC or both Add explanations

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INTRODUCTION—The acquisition and interpretation of an image is a procedural skill. These diagnostic skills require special equipment and have been identified as distinct procedures by the Current Procedural Terminology system[CPT-4]. This chapter is a reaffirmation of the role played by non-radiologists in the interpretation of images. Assuming similar proportions for non-radiologists’ Medicare claims in 2003 and similar proportions for total personal healthcare expenditures, $1.17 billion was paid to non-radiologists for musculoskeletal and chest radiography in 2003. Using 1993 Medicare data, Spettell and associates estimated that 73.2 percent of outpatient radiographs of the chest, spine, pelvis, hip, and upper and lower extremities were performed and interpreted by nonradiologists.6 While using 1991 claims data from a private insurer, Levin found that 70 percent of office studies were performed by nonradiologists.7

Studies on imaging outcomes have documented quality of care with a particular focus on family medicine and emergency medicine. This chapter will focus on the adult chest film and the principles of purchase, maintenance, and staffing of equipment in the private practice office. This is a compendium of advice found to be helpful over 30 years of teaching and practice. Our published data suggests that consultation is helpful on 2-5% of cases.[Ref]..

Guidelines are not “standards of care”. Medico-legal risk cannot be eliminated, but it can be minimized by timely application of procedural skills such as interpretation of images at the point of service. The clinical advantage of bedside correlation and subsequent follow-up cannot be overemphasized. At times, the clinical suspicion of lung cancer has been sufficiently high that we have obtained consultation despite a “normal” chest radiogram.

Family Medicine is one specialty that has defined itself as a specialty distinct from radiology. Residency training is sufficient to interpret images when needed, and/or seek consultation when needed. These levels of comfort vary from physician to physician, and should not be micromanaged by remote authority. The content has been reviewed and is consistent with the world’s literature. Generally, “Ten percent of the information makes over ninety percent of the clinical difference.”

THE EXAMPLE OF CHEST RADIOGRAPHY

Demonstrating and explaining guidelines for expected documentation operationally defines a summary of skills needed to maintain quality and survive audit. Quality improvement and professional development occurs through the use of a written interpretation for each case. Procedural skills require the ability to multitask while controlling for equipment, technique, probability, and the skill of each individual physician. One example is shown below[insert Figure 1], and it is followed by text explanation for each step.

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Figure 1—One page form recommended for practice. Please feel free to copy

and use in your office.

INTERPRETATION OF THE CHEST X-RAYMethod of Wm. MacMillan Rodney, M.D., FAAFP, FACEP--Original 1992, Updated May 11 2008

Please fill this form out completely. This improves quality of care for the patient.I. CLINICAL CONTEXT—Date of Exam __________Patient ID#____________

Patient ID#/Name_____________________________ Age:______ Sex:_____Old Films Available for Comparison? Yes NoREVIEW OF SYSTEMS (circle those that apply)Cough Dyspnea Pleuritic Pain Chest pain Hemoptysis HTNOther Illnesses, signs, or symptoms________________________________________DURATION OF PROBLEM in days, weeks, or months_____________ _______________

II. VALIDITY—Does the image need to be repeated? Yes NoTechnique used PA Lateral AP Portable Decubitus

Is this film rotated? Yes NoIs there an adequate inspiration? Yes NoIs the amount of penetration within normal limits? Yes No

III. Survey the bones and soft tissues. Significant abnormalities? Yes NoIV. Is the appearance of the mediastinum within normal limits? Yes NoV. Review the cardiac silhouette. Any significant abnormalities? Yes NoVI. Review the diaphragms. Any significant abnormalities? Yes NoVII. LungsA. Are there any significant abnormalities on the left or right hilum? Yes NoB. Any significant abnormalities to the lung parenchyma? Yes NoC. Any significant abnormalities to of the lung pleurae? Yes NoVIII. Review the lateral image.A. Any abnormalities of the anterior clear space or posterior cardiac space? Yes or No?B. Any other abnormalities Yes NoIX. My interpretation is:

A. Within normal limits. B. Normal, but I want to comment on some findings which are probably insignificant.

Consultation not required. a. Questionable findings exist and consultation will be requested.b. Abnormalities which require comment at this time include the following:

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i. Noneii. Others, please list_____________________ ___________________

X.-----MY PLAN IS

XI.----SIGNATURES--Student/Resident:___________ Attending Physician: _____________

INTERPRETATION GUIDELINES FOR THE ADULT PA AND LATERAL CHEST RADIOGRAPH—“HOW TO DO IT”Include ten images of “top ten conditiions’ for illustration

I. CLINICAL CONTEXTThe clinician who performs the history and bedside examination has a tremendous

advantage compared to a radiologist remote in time and space. The immediacy of these data differentiate imaging as an adjunctive diagnostic procedure for the patient in real time versus a radiologic consultation which arrives on a piece of paper. The bedside examination, review of systems, and past medical history increase diagnostic accuracy. Additionally, extenuating psychosocial circumstances such as schizophrenia, noncompliance, and uninsured status differentiate “best” academic management from what is realistically available in the community. Physicians at the point of service have the medicolegal responsibility for management of the patient in real time. Radiologists do not.II. VALIDITY

Physicians must understand the differences among imaging options such as postero-anterior[PA], lateral, antero-posterior[AP], and other views. Ideal views are not necessary to gain useful information, but a disclaimer describing technique limitations must be inserted with every film. For chest films, the acronym RIP describes the characteristics of rotation, inspiration, and penetration[aka exposure]. Images must be labeled and dated. These validities must be addressed prior to any other interpretation.

For example cardiomegaly definitions are different on PA versus AP views. Without a lateral, lesions in the retrocardiac and poststernal[anterior clear space] space can be missed.

Is this film rotated? Yes or no? Measuring the distance from the spinous processes to the medial heads of the clavicles is recommended. Allow for the usual case where there is 2-3 mm of rotation. Slight rotation does not invalidate the film. Generally this is a good test of fundamental anatomical knowledge. Without this the physician should stop.

Is there an adequate inspiration? Yes or no? Inadequate inspiration is a cause of decreased sensitivity for lung parenchyma. There is “best” method of counting visible ribs by counting posterior ribs as they join the spine. A minimally adequate inspiration uncovers nine. Avoid ranges and counting anterior ribs which are less predictable.

Is the amount of penetration within normal limits? Yes or no? This is a word for describing the amount of radiation exposure applied to the tissue. A practical rule of thumb of evaluating over-penetration and under-penetration is the anatomical point at which the vertebral interspaces are no longer visible. Over-exposure-penetration burns out the ability to see the lung

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parenchyma and vessels; ie turns the lung fields black. In an over-penetrated PA chest image there will be a “spine film” with all elements of the vertebral bodies visible down into the abdomen. When penetration technique is ideal, inter-vertebral spaces disappear somewhere in the cardiac shadow and do not appear beneath the diaphragm.

In the lung fields, excessive penetration will obliterate the visible vessels which normally start to disappear as they approach the chest wall. Needham has state that usually extend two-thirds of the way toward the chest wall.There is a requirement to comment on limitations of interpretation as caused by suboptimal technique. The physician of record has the right to request additional views or insert a disclaimer about techniques. This includes the need for a lateral image.III. Does a survey of the bones and soft tissues reveal any significant abnormalities? Yes or no? This area is of limited value when the indication is dyspnea, cough, hypertension, and other routine cardiovascular issues.We have not seen a case of litigation for failure to diagnose coarctation of the aorta due to rib notching on a previous film. A systemic sweep ob ones and soft tissues is mandatory.EXPLAIN--IV. Is the appearance of the mediastinum within normal limits? Yes NoThe physician cannot miss a shifted or widened mediastinum. An exact numerical dimension for “wide” is not known. The mediastinum cannot be too thin. ROCCO-KELLY find the reference for wide.V. Does a review of the cardiac silhouette reveal any significant abnormalities?

Yes or no? ROCCO-KELLY WRITE THISEXPLAIN—Cardiomegaly, and chamber enlargement, thin heart of deep inspiration[COPD]VI. Does a review of the diaphragm reveal any significant abnormalities?

Yes No ROCCO-KELLY TURN THIS IN TO ENGLISHExplain—R higher than left usually 5-10 mm. Can see abnormal elevation due to lung atalectasis or effusion; can’t miss air under the diaphragmsVII. LungsA. Are there any significant abnormalities on the left or right hilum? Yes NoROCCO,KELLYEXPLAIN –Left is always higher than R; finding the center of an ambiguous mass is clinical judgmentB. Any significant abnormalities to the lung parenchyma? Yes NoROCCO,KELLYEXPLAIN—Describe visual ping-pong method to detect flagrant asymmetries, cover obvious[hemothorax, metastatic nodules, sarcoid, primary TB, etc] and the “not obvious” mild viral pneumonias, subtle TB, etc.] briefly; Comment on vessels approaching but not reaching, the chest wall. Explain the normal taper of vessels as they head cephalad in the lung fields, and then give an example of “cephalization of flow”

Explain the “freshman forest” on the R where vessels can give the appearance of a pseudo infiltrate. On the left side symmetry is hidden by the heart shadow.Disease patterns “air space disease” vs interstitial disease”Distinguish benign granuloma from solitary nodules from masses

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C. Any significant abnormalities to of the lung pleurae? Yes NoROCCO-KELLYEXPLAIN—Can’t miss pneumoVIII. --Review the Lateral image

A. Retorocardiaac and anterior clear spaces OK? Yes NoB. Any other abnormalities Yes No

IX.--My interpretation is: This is the heart and soul of the “free range community physician method” Intial focus in on “normal or not normal”

A.Within normal limits.Findings you don’t want to miss-- shifted mediastinum, widened mediastinum, pneumothorax, air under diaphragm

B. Normal, but I want to comment on some findings which are probably insignificant. Consultation not required. ______________________________________________________________________C. Questionable findings exist and consultation will be requested. This could include a CT of the chest which is the most commonly ordered test for ambiguous finding on the plain radiograph. Consultation reports can be ambiguous to wrong. CHF can appear to be pneumonia and vice versa.D. Abnormalities which require comment at this time include the following:

iii. Noneiv. Others, please list_____________________ ___________________

____________________X. --MY PLAN IS----This is a key advantage of offering an interpretation or a ”preliminary interpretation” in the office at the point of service. Risks of missing something are less frequent than poorly worded or ambiguous interpretations which arrive days after the patient has left the office. With the best of intentions some physicians fail to pick up messages and/or staff may sign for a registered letter only to lose it. The beauty of imaging is the high predictive value of a positive. Specificity is high when lesions are obvious, and delay of management pending formal interpretation is not wise.

The risk of a false negative[low sensitivity] is always present. Multiple studies have documented that failure to diagnose a lesion of significance is less than 1-2% .

Student/Resident:_______________________Attending Physician: _______________________

Date:____________________________

THE NEXT SECTION STILL NEEDS TO BE WRITTEN BUT WE HAVE AGREED UPON AN OUTLINE WHICH FOLLOWS.

COMMENTS FROM 8 May 2008

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Rocco, you got a nice start on this, and I love the internet learning resources which remain for further editing and comment. Since our initial assignment, we have been redirected.

Our section editor, Mike Petrizzi MD, suggested that this has to be incredibly brief and very practical. There may not be room for anything but a few examples and a reference to our website. The website may offer a performance based learning drill which leads to a test for self assessment: Here is a proposed outline for the second part of the chapter. #1 and #6 will probably go at the front of the chest section.

1. Why bother? How does plain film radiography add value to patient care in the physician’s office?

a. Define the prevalence of conditions for which this technology is useful. The book already has a chapter on fractures, so we probably can use chest radiography as our example and refer to the chapter on fractures.

b. Family Medicine-ER is a different issue which might be mentioned parenthetically.

c. Define the risks of failing to have this technology in the office.d. We can use frequencies from the JABFP 2002 study declaring 1323 x-

rays during the study year 1997. Medicos 2006 there were approx 800 billed xrays collecting $34,000 in a population 97% Medicaid and uninsured. During the study years each office saw approx 30,000 office visits.

e. Medicos Memphis and Nashville data are available from the software 2006 and 2007. This allows a frequency calculation for almost 100,000 visits.

f. Basically the Medicos experience suggests that musculoskeletal complaints are a frequent need in offices where “open access”, as recommended by the “Future of Family Medicine” project, increases the number of urgent carevisits. Xray frequency is 5-10 per 100 office visits.

2. How much does the installation of equipment cost? Research the retail and used prices for equipment.

a. We have received one equipment quote of $60,000 with a probable $10,000 cost for installation of a lead lined room and subsequent state inspection.

b. This quote included digital cassette technology which excludes the need for a processor, chemical, film storage, and environmentally safe disposal of chemicals.

3. Has digital radiography changed the cost/benefit ratio?a. Yesb. But why and how? You already mentioned some of this in your first

draft.Digital radiography offers an opportunity for community based physicians by providing lower cost, higher reliability technology in the office. It eliminates several cumbersome aspects of traditional film. The space that developers, darkrooms, and films (both exposed and unexposed) occupied can be more efficiently used for patient care. This

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technology also promotes safety by eliminating developer chemicals that must be stored and disposed. By decreasing the number of retakes, radiation to patients and office staff is reduced. Finally, images are easily stored and can be shared more quickly and efficiently, which prevents unnecessary repeated studies and minimizes expense and radiation exposure.

Installation requires planning and cost-benefit analyses that must include the following: Radiographic department design; equipment, maintenance (routine and unexpected); lead planning (room lining, body shields, operator barrier); patient and staff safety; staff training (many states require that X-rays be taken by a certified technician or physician.)

4. What is the reimbursement that the family physician can expect from Medicaid, Medicare, and others? Where is the break even point for profitability? Medicos data will be helpful here and Jack’s book on reimbursement will be cited.--TC or PC or both? Add explanations

5. What is the regulatory expense?a. Can non-radiologists legally own equipment and interpret images? b. Using your Tennessee experience, can physicians legally perform

plain radiography? c. Can office staff perform imaging? Do they need a state license and any

training/certification? Doctors are assumed to be knowledgeable in kVp, mAs, etc. In our experience, a medical license qualifies the physician to press the button, obtain the image, and interpret the image.

d. What is the storage requirement for images?6. What is the medico-legal risk of interpretation?

a. Should all films be over-read?b. Should some films be over-read?c. Should the licensed physician obtain consultation according to clinical

judgment?d. Can or should the physician contract with a remote interpretation

service?7. What is the experience of Medicos 1999-2009 after 300,000 visits?8. Others

ROCCO INITIAL DRAFTOutpatient Computed Radiography – Fundamentals and Principals

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Procedures for Primary Care PhysiciansMarch 24, 2008

Introduction:To be successful in design and safety, the physician must understand how the

equipment works, which requires knowing the following basic terms and principals. Peak kilovoltage (kVp) determines the kinetic energy of the electrons in the x-ray tube; essentially determining the radiographic contrast and is based on the type of tissue being imaged. Milleampere seconds (mAs) which is the product of the tube current and the exposure time. Duration of exposure, mAs, kVp, and the proximity to the x-ray source are directly proportional to the radiation dose. Radiation dosimetry is mandatory radiology department staff. All patients and staff must be appropriately shielded and are pregnant until proven otherwise.

To be successful in evaluating and treating patients, the physician must order the appropriate test based on the history and physical examination and then accurately describe the image using the appropriate terminology. For example, suppose a patient might have a hand fracture, and the physician orders “hand x-ray.” The staff member sees the order, but does not know which hand, what part of the hand (phalanges, metacarpals, carpals), or what view of the hand (PA, AP, Lateral, Oblique.) Not only will this waste time for all involved but more importantly you will unnecessarily expose the staff and patient to radiation.

In the outpatient setting, musculoskeletal and chest images are the most common radiographs. Physicians must systematically describe and evaluate these images using precise and accurate language. Failure to do so can jeopardize the patient and will diminish colleagues and consultants’ perception of your professionalism. There are several studies that describe non-radiologist physicians accurately interpreting most x-rays. Furthermore, several studies demonstrate non-radiologist physicians’ ability to appropriately request a second reading. Given a national shortage of radiologists outside of metropolitan areas, it is unrealistic and impossible for such specialists to read every x-ray, especially considering that the number of imaging studies has increased dramatically over the last 15 years. At the least, family physicians should be able to describe an image to another physician without having to use the image to illustrate the salient features. The following systems and terms will guide appropriate descriptive analysis of musculoskeletal and chest radiographs.

At this point, I would recommend a glossary of essential terms in the descriptive analysis of muscoloskeletal and chest x-rays followed by the PSOT chest x-ray interpretation sheet and a similar one based on the questions asked in the PSOT handout (e.g. open, angulated, displaced, comminuted, etc.) Links would follow for case presentations, quizzes, and more thorough discussions on important topic limited by the size requirements of the chapter.

Chest Case Suggestions:

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PneumoniaCoin LesionPleural EffusionFractured ribs, clavicular fracture, and pneumothoraxFree air under diaphragm secondary to perforated bowel

Musculoskeletal terms and system:

References regarding clinical indications for foot, knee, and ankle X-rays taken from: AAFP Position Paper on Radiology

http://www.aafp.org/online/en/home/policy/policies/r/radiology.html

1. (23) Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Worthington JR. A study to develop clinical decision rules for the use of radiography in acute ankle injuries. Ann Emerg Med 1992;21:384-390.

2. (24) Pigman EC, Klug RK, Sanford S, Jolly BT. Evaluation of the Ottawa clinical decision rules for the use of radiography in acute ankle and midfoot injuries in the emergency department: an independent site assessment. Ann Emerg Med 1994;24:41-45.

3. (25) Stiell IG, Greenberg GH, Wells GA, McKnight RD, Cwinn AA, Cacciotti T. Derivation of a decision rule for the use of radiography in acute knee injuries. Ann Emerg Med 1995;26:405-413.

4. (26) Stiell IG, Wells GA, Hoag RH, Sivilotti ML, Cacciotti TF, Verbeek PR, et al. Implementation of the Ottawa Knee Rule for the use of radiography in acute knee injuries. JAMA 1997; 278:2075-2079.

5. (27) Nugent P. Ottawa ankle rules accurately assess injuries and reduce reliance on radiographs. J Fam Pract 2004;53:785-788.

6. (28) Halvorsen JG, Swanson D. Indications for office radiographs. J Fam Pract 1990;31:521-529.

Learning Radiology Website:Wrist fractures: http://www.learningradiology.com/notes/bonenotes/wristfxs.htmPerilunate dislocations: http://www.learningradiology.com/notes/bonenotes/perilunatedislocatepage.htmGamekeeper’s Thumb: http://www.learningradiology.com/notes/bonenotes/gamekeeperspage.htmVolar Plate Page: http://www.learningradiology.com/notes/bonenotes/volarplatepage.htm

Recognizing Fractures: http://www.learningradiology.com/medstudents/recognizingseries/recognizingfxs_files/frame.htm

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http://www.learningradiology.com/medstudents/recognizingseries/recognizingfxs_files/frame.htm

http://www.learningradiology.com/medstudents/recognizingseries/recognizingfxs_files/frame.htm

http://www.learningradiology.com/notes/bonenotes/volarplatepage.htm

http://www.learningradiology.com/notes/bonenotes/gamekeeperspage.htm

http://www.learningradiology.com/notes/bonenotes/perilunatedislocatepage.htm

http://www.learningradiology.com/notes/bonenotes/wristfxs.htm



PSOT Website:http://www.psot.com/ESS_FRACTURE.htmhttp://www.psot.com/MusculoMod3.htmhttp://www.psot.com/AcuteKnee.htmhttp://www.psot.com/FRAC_LANGUAGE.htmhttp://www.psot.com/X_RAY_CASE.htm

The following Emedicine articles give a more thorough description of presentation, management, etc.:

Foot fractures: http://www.emedicine.com/EMERG/topic195.htmAnkle fractures: http://www.emedicine.com/sports/topic4.htmHand fractures: http://www.emedicine.com/EMERG/topic197.htmWrist fractures: http://www.emedicine.com/emerg/topic844.htm

Chest terms and system.

17”x14” plaque; 20% of lung fields are obscured by heart, bones, diaphragm, and other soft tissues. Over-reading vs. Under-reading.

Learning Radiology Websites:

Adequate Study Recognition:

http://www.learningradiology.com/medstudents/recognizingseries/recognizegoodchestnet_files/frame.htm

Recognizing Pneumothorax:

http://www.learningradiology.com/medstudents/recognizingseries/recognizeptxnet_files/frame.htm

Recognizing Opacified Hemithorax:

http://www.learningradiology.com/medstudents/recognizingseries/opacifiedheminet_files/frame.htm

PSOT Website:

1) Chest X-ray Interpretations form: http://www.psot.com/X_INTERPRET.doc2) Approach to chest x-ray interpretation:

http://www.psot.com/Chest2_files/frame.htm3) Approach to Chest X-ray, indications, and uses

http://www.psot.com/syllabus.htm4) How to read a chest x-ray (Drs. Krone and Weiner):

http://www.psot.com/c_xray.pdf

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http://www.psot.com/c_xray.pdf

http://www.psot.com/syllabus.htm

http://www.psot.com/Chest2_files/frame.htm

http://www.psot.com/X_INTERPRET.doc







http://www.emedicine.com/emerg/topic844.htm

http://www.emedicine.com/EMERG/topic197.htm

http://www.emedicine.com/sports/topic4.htm

http://www.emedicine.com/EMERG/topic195.htm

http://www.psot.com/X_RAY_CASE.htm

http://www.psot.com/FRAC_LANGUAGE.htm

http://www.psot.com/AcuteKnee.htm

http://www.psot.com/MusculoMod3.htm

http://www.psot.com/ESS_FRACTURE.htm


5) Pneumonia and Chest X-Rays (Dr. Montgomery): http://www.psot.com/pneu.pdf

6) Chest Cases: “Cut that Meat!!!!!” http://www.psot.com/CXIMG_1.HTML

Direct Quotations taken from AAFP’s website – Radiology (Position Paper)


In 2003, 17 percent of Medicare’s $281 billion expenditures were for physician services and about 2 percent of physician services were for plain film radiography (musculoskeletal and chest).2 Maitino recently reported that Medicare utilization rates for noninvasive diagnostic imaging have been increasing although utilization for general radiology (plain films) has decreased slightly.3

Assuming similar proportions for non-radiologists’ Medicare claims in 2003 and similar proportions for total personal healthcare expenditures, $1.17 billion was paid to non-radiologists for musculoskeletal and chest radiography in 2003

Using 1993 Medicare data, Spettell and associates estimated that 73.2 percent of outpatient radiographs of the chest, spine, pelvis, hip, and upper and lower extremities were performed and interpreted by nonradiologists.6 While using 1991 claims data from a private insurer, Levin found that 70 percent of office studies were performed by nonradiologists.7

There has been concern that on-site radiography leads to more frequent use and results in increased health care costs.8-12 However, one study reported that a decision by an insurer to deny claims for professional charges for radiologic services performed by nonradiologists resulted in a 12 percent increase in expenditures.13 Another study of general practitioners in New Zealand reported an increase in emergency department referrals and hospital admissions in areas of decreased patient access to imaging services.14

Several studies have evaluated the frequency of agreement between a primary care physician’s reading of office radiographs and the radiologist’s reading. Concordance between readings by family physicians and radiologists was found in 72.5 to 92.4 percent of all radiographs.42-46 In addition, concordance between readings by internists and radiologists was found in 92 percent of all radiographs.47 Concordance for extremity films was higher, from 79 to 96 percent.42,44,46 Concordance rates were lower for chest radiographs, ranging from 41.9 to 89.5 percent,42,44,46-50 probably reflecting a greater level of complexity. Different criteria for concordance were used, so results from different studies are not directly comparable.

Smith reported a study of 1393 pairs of radiograph readings from 86 primary care clinicians in 9 ambulatory practices in Wisconsin. In a subgroup of 553 pairs when the clinician would not have hypothetically requested radiology consultation there was a 2.5% frequency of any change in clinical care and zero substantial changes in care.46

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http://www.psot.com/CXIMG_1.HTML

http://www.psot.com/pneu.pdf


Similarly Halvorsen reported 4/508 radiographs with clinically significant discordance and zero substantial changes in care.42

1. (2) Medicare Payment Policy Advisory Commission. Medicare Payment Policy, Report to Congress. March 2005. Accessed November 29, 2005 http://www.medpac.gov/publications/congressional_reports/Mar05_Ch03.pdf

2. (3) Maitino A, Levin D, Parker L, Rao V, Sunshine J. Nationwide trends in rates of utilization of noninvasive diagnostic imaging among the Medicare population 1993-1999. Radiology 2003;227:113-117.

1. (6) Spettell CM, Levin DC, Rao VM, Sunshine JH, Bansal S. Practice patterns of radiologists and nonradiologists: national Medicare data on the performance of chest and skeletal radiography and abdominal and pelvic sonography. Am J Roentgenol 1998,171:3-5.

2. (7) Levin DC, Merrill C. The practice of radiology by nonradiologists: cost, quality and utilization issues. Am J Roentgenol 1994;162:513-518.

3. (8) Hillman BJ, Joseph CA, Mabry MR, Sunshine JH, Kennedy SD, Noether M. Frequency and costs of diagnostic imaging in office practice — a comparison of self-referring and radiologist-referring physicians. N Engl J Med 1990;323:1604-1608.

4. (9) Levin DC, Edmiston RB, Ricci JA, Beam LM, Rosetti GF, Harford RJ. Self-referral in private offices for imaging studies performed in Pennsylvania Blue Shield subscribers during 1991. Radiology 1993;189:371-375.

5. (10) Radecki SE, Steele JP. Effect of on-site facilities on use of diagnostic radiology by nonradiologists. Invest Radiol 1990;25:190-193.

6. (11) Kouri B, Parsons G, Alpert H. Physician self-referral for diagnostic imaging: review of the empiric literature. AJR 2002;179:843-850.

7. (12) Litt A, Ryan D, Batista D, Perry K, Lewis R, Sunshine J. Relative procedure intensity with self-referral and radiologist referral: extremity radiography. Radiology 2005;235:142-147.

8. (13) Hillman B, Olson GT, Colbert RW, Bernhardt LB. Response to a payment policy denying professional charges for diagnostic imaging by nonradiologist physicians. JAMA 1995:274;885-887.

9. (14) Durham J, McLeod D. Use of diagnostic imaging services in the central region by general practitioners. N Z Med J 1999;112:233-236.

1. (42) Halvorsen JG, Kunian A, Gjerdingen D, Connolly J, Koopmeiners M, Cesnik J. The interpretation of office radiographs by family physicians. J Fam Prac, 1989;28(4):426-432.

2. (43) Halvorsen JG, Kunian A. Radiology in family practice: a prospective study of 14 community practices. Fam Med 1990;22(2):112-117.

3. (44) Bergus GR, Franken EA Jr, Koch TJ, Smith WL, Evans ER, Berbaum KS. Radiologic interpretation by family physicians in an office practice setting. J Fam Pract 1995:41(14):352-356.

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http://www.medpac.gov/publications/congressional_reports/Mar05_Ch03.pdf


4. (45) Franken EA Jr, Bergus GR, Koch TJ, Berbaum KS, Smith WL. Added value of radiologist consultation to family practitioners in the outpatient setting. Radiology 1995;197:759-762.

5. (46) Smith P, Temte J, Beasley J, Mundt M. Radiographs in the Office: is a second reading always needed? J Am Board Fam Prac 2004;17:256-263.

6. (47) Knollmann BC, Corson AP, Twigg HL, Schulman KA. Assessment of joint review of radio-logic studies by a primary care physician and a radiologist. J Gen Intern Med 1996;11:608-612.

7. (48) Hopper KD, Rosetti GF, Edmiston RB, Madewell JE, Beam LM, Landis JR. Diagnositic radiology peer review: a method inclusive of all interpreters of radiographic examinations regardless of specialty. Radiology 1991;180:557-561.

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John Rodney - psot.com · Web viewThis chapter is a reaffirmation of the role played by non-radiologists in the interpretation of images. Assuming similar proportions for non-radiologists’