ED Imaging’s Diagnostic Cascade

“We recognize that radiology practices across the United States are facing increasing pressure to abandon the private practice of medicine.”

Covalent Radiology president, Peter Ricci, MD, on the consolidation pressures facing radiology practices, while alluding to the physician-led angle Covalent will take as it works to build a national network of partner practices.


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The Imaging Wire

ED Imaging’s Diagnostic Cascade
Israeli researchers found that increased imaging orders and specialist consultations in emergency departments are leading to a “diagnostic cascade” of unnecessary care, that’s draining hospital resources, prolonging ED wait times, and increasing rates of patient hospitalization. The researchers studied ED cases at their own hospital (Rambam Health Care in Haifa) between 2014 and 2017 and then 22 additional Israeli hospitals in early 2018 finding that specialist consultations grew by 14%, all types of CT scans increased by 5% (while X-ray fell by 11% and ultrasound remained flat), and patients who underwent CT scans had a 90% likelihood of admission (yes, 90%). Emergency department CT overuse has been a hot topic lately. This study follows research from Oregon Health & Science University that found that the vast majority of scans for seizure patients (mainly CT) were unnecessary and a separate report from Brigham and Women’s Hospital suggesting that adopting appropriate use criteria may curb ED imaging overuse (using renal colic CT scans in the study).

Covalent Radiology Looks Nationally
Denver-based Radiology Imaging Associates (RIA) and San Antonio-based South Texas Radiology Group (STRG) integrated to form “Covalent Radiology, a professional services company; and Covalent Healthcare Management, a full-service management services organization.” The combination of RIA and STRG makes Covalent Radiology a relatively large practice (180 radiologists, 56 hospitals, six states). However, this is not a typical practice merger, as Covalent Radiology/Covalent Healthcare Management appears to be primarily focused on creating a national network of “member partner” radiology practices, offering these partners the benefits enjoyed by larger practices (broader capabilities, tech infrastructure, scale, funding, governance/operational models) while remaining independent, physician-led, and in control of their revenue. The model also allows for a pathway to a full merger with Covalent should members want to legally merge their practice. Covalent Healthcare Management will support member practices with management services (revenue cycle, financial services, data analytics, HR, IT, group purchasing, etc.) and Covalent Radiology will provide professional services (24/7 subspecialty reading coverage, best practice development, informatics solutions, etc.). There are few themes more dominant than practice consolidation in radiology, and at the very least Covalent appears to give practices another option to consider as they try to stay on the right side of this trend (or whatever’s right for them).


MRI in 15 Minutes or Less
University of Arizona engineers are beginning development of an MRI capable of performing scans in 15 minutes or less (vs. 40-60min in current MRIs) in an effort to better support patient populations that have difficulties staying still for long periods (e.g. stroke and Parkinson’s disease patients, children), while also producing higher-resolution images with richer information. The neurology-focused MRI is based on already-established MUSE technology, which reduces motion artifacts and incorporates multiple types of MRI data (e.g. iron levels, gray matter volume, and white matter), and diffusion tensor imaging technology. The new MRI’s speed breakthrough is largely due to enhancements to the MUSE technology, including a new “denoising” process (can reduce noise-related errors by up to 90%) and a new scan process that alternates between top-down and bottom-up movement (canceling-out distortions). The five-year project will initially test healthy patients, followed by a longitudinal study of Parkinson’s patients to compare image accuracy versus healthy patients, before becoming clinically available.

3D Print Guidance
New research reveals that 3D-printed navigational templates are as accurate as CT-guidance for locating small lung nodules before surgery, while streamlining procedures and decreasing patient radiation exposure. The researchers created the 3D templates based on patients’ CT scans and surgeons’ planned localizer insertion routes, using this template-guided approach with half the study’s 190 participants (other half was CT-guided). The template-guided approach achieved similar results for localizer deviation (mean: 8.7mm template vs. 9.6mm CT), faster procedures (mean: 7.4min template vs. 9.5min CT), and lower radiation dosage (mean: 229mGy×cm template vs. 313mGy×cm CT), while situating the localizer in fewer attempts than the CT-guided approach.

Teamwork Makes the CMS QPP Dream Work
New research reveals that radiologists participating as a group in CMS pay-for-performance programs faired better than radiologists participating as individuals in 2016. The quantity advantage of group reporting was very clear, with groups reporting an average of 4.6 quality measures (vs. 2.3 avg. measures by individuals), 31.5% of groups reporting at least six measures (vs. just 1% of individuals), and only 5.4% of groups reporting one measure (vs. 33% of individuals). Radiologist groups’ quality advantage was not as pronounced, achieving a 3% higher average score than individuals on 8 of 11 measures and similar average scores as individuals on the remaining three measures. Based on these results, the report’s recommendation that “radiology practices seeking success under Medicare’s new Quality Payment Program should carefully explore group participation” seems like good advice.


The Wire

  • New research reveals that international CT protocols and radiation doses vary greatly, almost entirely because of “how institutions used the machines” (not patient, practice scan volume, or machine brand/model factors), suggesting that a global CT dosage standard is possible with sufficient cooperation by hospitals and countries. The research leveraged data from over 2 million CT examinations from 151 institutions across seven countries, finding significant variations by country (e.g. mean effective dose for abdominal CT ranged from 7.0 mSv in the Netherlands to 25.7 mSv in Japan), while the above-mentioned patient/practice/machine factors led to minimal dosage variations.





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