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Bilal Tahir, MD Gitasree Borthakur, MD Indiana University School of Medicine Department of Radiology & Imaging Sciences

November 15 , 2013 ACP 2013

Dr. Kumar Sandrasegaran Dr. Curtis Wright Beth Ward

Increased utilization of medical imaging:

introduction of new technologies (PET, MRA, CTA, etc.)

new uses for existing technologies

self-referral

patient demand

defensive medicine

0 20,000,000 40,000,000 60,000,000 80,000,000

1998

2010

Number of CT Scans Performed Annually Diagnostic Imaging has a growth rate of 8-16% annually

Estimated over 10 percent of these exams are not necessary or are duplicative

Landro L. Radiation risks prompt push to curb CT scans. The Wall Street Journal. Mar 2010.

Over 1 billion radiology exams annually. The overall cost of diagnostic imaging is

estimated over $100 billion annually in the United States alone.

According to the ACP, all unnecessary tests cost $200-$250 billion a year.

Sherman D. Stemming the tide of overtreatment in U.S. healthcare. Reuters. Feb 2012.

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Some providers boost utilization to pay off imaging technology investments

Physicians who own their own imaging equipment are 2-7 times more likely to order an imaging test.

Kouri BE, Parson RG. Physician self-referral for diagnostic imaging: review of the empiric literature. American Journal of Roentgenology. 2002;179: 843-850.

Physicians face increasing patient demands for specific diagnostic imaging tests. A survey of 7,7320 patients and 300 physicians

indicates that patients were more satisfied with physicians who used a “participatory style” of discussion options (Annals of Internal Medicine).

Kaplan S H, Greenfield S, Gandek B, Rogers W H, Ware J E J. Characteristics of physicians with participatory decision-making styles” Annals of Internal Medicine. 1996;124(5):497–504.

Physicians worry about malpractice lawsuits The Mount Sinai School of Medicine conducted a

survey of 2,416 physicians, which showed 91% of physicians believe that concerns over malpractice lawsuits result in “defensive” medicine.” Estimated cost is $60 billion annually.

18-28% of tests, procedures, referral and consultations were ordered to avoid lawsuits

Vast majority of physicians practice 'defensive medicine' according to physician survey.

Science Daily. Mount Sinai School of Medicine. July 2010.

Education on appropriate use of imaging

Patients

Physicians

Health care system administrators

Radiologists need to open doors of communication with ordering clinicians

ACR Appropriateness Criteria®

Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for a specific clinical condition.

186 topics with over 900 variants in the February 2013 version.

http://www.acr.org/Quality-Safety/Appropriateness-Criteria

Can be integrated with computerized ordering and electronic health record (EHR) systems.

Healthcare organizations can ensure that the right patient gets the right scan for the right indication.

http://www.acrselect.org

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Do I need imaging to answer question? Does a prior imaging study already answer

question? What imaging study do I need? What general imaging protocol to order? Is this really the best imaging study for THIS

patient? Contraindications? Have I used the tools at my disposable to

clarify any confusion?

Routine ICU chest x-rays Routine pre-operative chest x-rays Incidental pulmonary nodules Headache Low back pain Incidental thyroid nodules Incidental adrenal nodules Renal cysts Ovarian cysts Non-contrast vs contrast vs both CT

Meta-analysis of eight trials comprising 7,078 ICU patients, half of whom received daily chest and the other half who received chest radiographs for specific clinical indication.

Eliminating routine daily chest radiographs did not affect mortality, length of stay in the hospital or ICU, or ventilator days in either group.

Oba Y, Zaza T. Abandoning daily routine daily chest radiography in the intensive care unit: meta-analysis. Radiology 2010; 255 (2): 386-395.

Hejblum G. Comparison of routine and on-demand prescription of chest radiographs in mechanically ventilated adults: a multicentre, cluster-randomised, two-period crossover study. The Lancet. Nov 2009.

Routine daily chest radiographs are not indicated.

Follow up radiographs should be obtained only for specific clinical indications (increasing hypoxia, initial line or tube placement, etc.)

Morosa JK. Expert Panel on Thoracic Imaging. ACR Appropriateness Criteria® routine chest radiographs in ICU patients. American College of Radiology (ACR); 2011.

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Methodist Hospital: 140 ICU beds Wishard Hospital: 24 ICU beds, 29 PICU beds St. Vincent: 40 ICU beds, 16 Trauma/NICU beds. Community Hospital North: 24 ICU beds Community Hospital East: 12 ICU beds

Chest Xray: $42 (est. payment from insurance) Healthcare Blue Book 2013

Systematic review of 14 published articles

No association between preop CXR and morbidity or mortality

Postoperative pulmonary complications in those with preop CXR was 13% vs 16% in those without

Joo HS, Wong J, Naik VN, Savoldelli GL. The value of screening preoperative chest x-rays: a systematic review. Can J Anaesth 2005; 52(6):568-574.

Acute cardiopulmonary disease is suspected on the basis of history and physical exam.

History of stable chronic cardiopulmonary disease in a patient > 70 years old without a chest radiograph within the past 6 months.

Mohammed T. et al. Routine admission and preop chest radiography. ACR Appropriateness Criteria 2011.

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Rounded opacity <3 cm without other lung abnormalities.

Benign pattern of calcification or stability of nodule size for over 2 years for solid pulmonary nodules

http://www.acr.org/Quality-Safety/Appropriateness-Criteria

CT Chest without contrast: $312 CT Chest with contrast: $396

(est. payment from insurance)

Healthcare Blue Book 2013

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19 yo woman presents to PCP office Frontal headache for 1 day Onset at rest, “pressure-like pain” Studying for finals this week Similar symptoms every few months

What is the next appropriate step?

A) CT head without contrast

B) MRI head without contrast

C) MRA head and neck

D) EEG

E) Patient reassurance

Chronic headache, no new features: None

Chronic headache, new features: MRI head without +/- with IV contrast

Sudden onset severe headache: CT head without contrast

Sudden onset unilateral headache, ipsilateral Horner’s syndrome, suspected carotid/vertebral dissection: CTA or MRA head and neck

Suspected complication of sinusitis: CT paranasal sinuses without IV contrast

http://www.acr.org/Quality-Safety/Appropriateness-Criteria

CT head without contrast: $340 CT head with and without contrast: $676 MRI head without contrast: $660 MRI head without and with contrast: $779

(est. payment from insurance)

Healthcare Blue Book 2013

36 year old male with increasing low back pain x 10 days

No trauma No fevers, chills, neurological deficit Past medical history unremarkable

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Next step

A) Pain management and physical therapy

B) X-ray lumbar spine

C) CT lumbar spine

D) MRI lumbar spine

E) Fluoroscopic myelogram

http://www.acr.org/Quality-Safety/Appropriateness-Criteria

56-year-old male. Low back pain especially on left side for 6

weeks. History of prostate cancer.

Next step:

A) X-ray lumbar spine

B) CT lumbar spine

C) MR lumbar spine

D) Pain management and physical therapy

http://www.acr.org/Quality-Safety/Appropriateness-Criteria

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Imaging considered if no improvement within 6 weeks

Or red flags:

Cauda equina syndrome

Cancer- insidious onset, weight loss

Fracture- age >50, osteoporosis, cumulative trauma

Neurologic deficit

Symptomatic spinal stenosis

Infection- IV drug use, immunosuppression, diabetes

http://www.acr.org/Quality-Safety/Appropriateness-Criteria

Indications for IV contrast:

Cancer

Infection

Prior surgery

Reassess if GFR <35

X-ray lumbar spine: $200-$300 CT lumbar spine: $549 MRI lumbar spine: $780

(est. payment from insurance*) Healthcare Blue Book 2013

5% thyroid nodules are malignant. On CT, thyroid nodules with size > 1 cm,

calcifications, or septations should be further evaluated for malignancy with US.

Risk factors: age <15 or >60, male sex, history of head/neck radiation, family history

Ahmed S. Incidental Thyroid Nodules on Chest CT: Review of the Literature and Management Suggestions. American Journal of Roentgenology. Nov 2010.

Thyroid calcification with possible soft tissue, US evaluation confirmed benign parenchymal calcification

Dense calcification

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Heterogenous thyroid nodule, Ca ++, > 1 cm

Thyroid Nodule, over 1 cm, calcifications. US evaluation with biopsy = cancer

Neck Ultrasound: $113 (est. payment from insurance) Healthcare Blue Book 2013

Up to 5% of thoracic and abdominal CT may reveal an adrenal incidentaloma

83% are non functioning benign lesions Differentiate benign from mass that warrants

treatment (metastasis, pheochromocytoma, adrenal carcinoma)

Sahdev A. The Indeterminate Adrenal Lesion. Cancer Imaging. 18 March 2010.

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Less than 1 cm, ignore Stable 6 – 12 months = benign <10 HU = benign <4cm nodule without known malignancy

<0.2% likelihood of malignancy 1-4 cm may be followed up in 1 year > 4 cm biopsy, surgery, or PET-CT

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Abdomen CT without contrast: $314 Abdomen CT with contrast: $398 Abdomen CT with and without contrast: $465 Abdomen and Pelvis without contrast: $393 Abdomen and Pelvis with contrast: $618 Abdomen and Pelvis with and without

contrast: $782 (est. payment from insurance*) Healthcare Blue Book 2013

Simple cyst (Bosniak Type I) imperceptible wall

rounded

Work up: none

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Mildly complex (Bosniak type 2)

Thin septa

Thin calcification

Work up: none

Simple or hemorrhagic cysts < 5 cm No follow-up

Simple cysts 5 - 7 cm Annual US follow up to ensure lesion stability

Hemorrhagic cysts 5-7 cm 6–12-week follow-up US to ensure resolution

Simple cysts > 7 cm Further imaging (e.g., MRI) or surgery

Levine D. et al. Management of asymptomatic ovarian and other adnexal cysts Imaged at US. Society of Radiologists in Ultrasound Consensus Conference Statement. Ultrasound Quarterly 2010;26:121-131.

Simple cysts < 1 cm

No follow-up

Simple cysts 1 – 7 cm mention on report

Annual US

After 2 years or if size i a longer interval follow

up

Simple cysts > 7 cm – as in premenopausal

women

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Aortic dissection Adrenal mass workup (may only need non-

contrast) Renal mass workup HCC follow-up status post non-surgical

treatment AAA status post endovascular stent graft

repair CT Urogram CT Cystogram

Metastatic cancer work-up / follow-up Trauma (head & C/T/L-spine without) Abdominal / pelvic / chest pain, weight loss,

infection, inflammatory processes, most other indications

For artery evaluation, CTA Some indications require multiple post

contrast phases (HCC screening dual or triple phase, pancreatic dual phase)

Gastrografin --- if pt < 150 lbs, recent GI surgery/enteric leak

Water --- pancreatic protocol Volumen --- enterography

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59 year old man with history of heroin abuse complaining of excruciating chest pain radiating to his back.

HTN- medication non-compliance, presenting with BP of 214/110.

Prior ischemic stroke without current neurological deficits, diabetes mellitus.

EKG and Chest X-ray are normal. Next step?

A) CTA Chest with IV contrast

B) CT Chest without IV contrast, CTA chest with IV contrast

C) CT Chest with IV contrast

D) MRI Chest without and with IV contrast

E) CT Chest without IV contrast

F) No imaging

65 yo AAM on hemodialysis, needs imaging for renal mass work-up. Order what?

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63 year old man with history of alcohol abuse, hepatitis C, elevated AFP

What is the next imaging modality to order?

A) Abdominal ultrasound

B) MRI abdomen without contrast

C) CT abdomen single phase

D) CT abdomen triple phase

E) MRI abdomen without and with IV contrast

A) US guided core biopsy B) Abdomen MRI without & with IV contrast C) Abdomen Ultrasound D) No further imaging to confirm diagnosis E) CT guided FNA & core biopsy

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Adrenal mass in recent immigrant from Burma.

65 yo man s/p endovascular stent graft repair for AAA. No acute symptoms. Presents for AAA stent graft evaluation.

Calcifications Type II endoleak

Ask if imaging is really needed? Use radiologist as a consultant rather than

lab service. Radiologists can add value to patient care and help eliminate extra imaging, costs and anxiety.

Eliminate routine ICU chest x-rays, only post procedure or specific indications

Eliminate preoperative chest x-rays in patients without cardiopulmonary disease

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For incidental pulmonary nodules, follow Fleishner society guidelines. Ignore 4 mm pulmonary nodules in low risk patients.

Chronic headaches without new features generally do not need imaging.

Most low back pain without red flags will respond to conservative management without imaging intervention.

Incidental adrenal nodules under 1 cm can be ignored. Those 1-4 cm may be followed up in 1 year.

Incidental thyroid nodules on CT can usually be ignored if under 1 cm without calcifications or septations.

Most renal cysts are simple or mildly complex (thin septa or calcification) and require no further imaging.

For simple or hemorrhagic ovarian cysts under 5 cm in premenopausal women, no follow-up. Simple ovarian cysts under 1 cm in postmenopausal women can be ignored.

Avoid unnecessary CT precontrast or postcontrast phases when possible.

Some indications require precontrast and postcontrast imaging to avoid repeat imaging.

If confused or uncertain, call or email radiology colleagues

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2. Ahmed S. Horton KM. Jeffrey RB. Sheth S. Fishman E. Incidental Thyroid Nodules on Chest CT: Review of the Literature and Management Suggestions. American Journal of Roentgenology. Nov 2010. Volume 195. Number 5.

3. Basi SK, Marrie TJ, Huang JQ, Majumdar SR. Patients admitted to hospital with suspected pneumonia and normal chest radiographs: epidemiology, microbiology, and outcomes. Am J Med 2004; 117(5):305-311.

4. Coursey CA, Nelson RC, Patel MB, et al. Making the diagnosis of acute appendicitis: do more preoperative CT scans mean fewer negative appendectomies? A 10-year study. Radiology 2010

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7. De Hert S, Imberger G, Carlisle J. The value of screening preoperative chest x-rays: a systematic review. June/July 2005, Volume 52, Issue 6, pp 568-574

8. Kaplan S H, Greenfield S, Gandek B, Rogers W H, Ware J E J. “Characteristics of Physicians with Participatory Decision-Making Styles” Annals of Intern Medicine. 1996;124(5):497–504.

9. Kouri BE, Parson RG. Physician Self-Referral for Diagnostic Imaging: Review of the Empiric Literature. American Journal of Roentgenology. 2002;179: 843-850.

10. Landro L. Radiation Risks Prompt Push to Curb CT Scans. The Wall Street Journal. Mar 2010. 11. Macmahon H et al. Guidelines for Management of Small Pulmonary Nodules Detected on CT Scans: A

Statement from Fleishner Society. Radiology 2005.; 237: 395-400. 12. Morosa JK, Bramwit MP, Mohammed TL, Reddy GP, Brown K, Dyer DS, Ginsburg ME, Heitkamp DE, Jeudy J,

Kirsch J, MacMahon H, Ravenel JG, Saleh AG, Shah RD. Expert Panel on Thoracic Imaging. ACR Appropriateness Criteria® routine chest radiographs in ICU patients. American College of Radiology (ACR); 2011.

13. Niess M. Preoperative Chest Xrays: A Teachable Moment. JAMA Intern Med. Sep 2013. 14. Rao PM, Rhea JT, Novelline RA, Mostafavi AA, McCabe CJ. Effect of computed tomography of the appendix

on treatment of patients and use of hospital resources. N Engl J Med 1998;338(3):141-146. 15. Sahdev A. Willatt J. Francis I. Reznek RH. The indeterminate adrenal lesion. Cancer Imaging. 18 March 2010. 10

(1): 102-113. 16. Sherman D. Stemming the tide of overtreatment in U.S. healthcare. Reuters. Feb 2012. 17. Schwartz. Prevalence and Importance of Small Hepatic Lesions Found at CT in Patients with Cancer. January

1999. Radiology. 210. 71-74 18. Vast majority of physicians practice 'defensive medicine,' according to physician survey. ScienceDaily. Mount

Sinai School of Medicine. July 2010. 19. van Randen A, Bipat S, Zwinderman AH, Ubbink DT, Stoker J, Boermeester MA. Acute appendicitis: meta-

analysis of diagnostic performance of CT and graded compression US related to prevalence of disease. Radiology 2008; 249(1):97-106.

20. WB, Jr. Abdominal CT scanning in reproductive-age women with right lower quadrant abdominal pain: does its use reduce negative appendectomy rates and healthcare costs? Am Surg 2007;73(6):580-584.

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Please feel free to email with questions: btahir@iupui.edu

Look forward to speaking on similar/other topics in future.

http://bit.ly/19nijAs