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Background The Value-Based Healthcare (VBH) concept is designed to improve individual healthcare outcomes without increasing expenditure, and is increasingly being used to determine resourcing of and reimbursement for medical services. Radiology is a major contributor to patient and societal healthcare at many levels. Despite this, some VBH models do not acknowledge radiology's central role; this may have future negative consequences for resource allocation. Methods, findings and interpretation This multi-society paper, representing the views of Radiology Societies in Europe, the USA, Canada, Australia, and New Zealand, describes the place of radiology in VBH models and the health-care value contributions of radiology. Potential steps to objectify and quantify the value contributed by radiology to healthcare are outlined. Published under a CC BY 4.0 license.

Purpose: To compare nationwide trends in noninvasive diagnostic imaging (NDI) practice patterns of radiologists and of nonradiologists among the Medicare population during the 6 years from 1993 to 1999., Materials and Methods: Medicare Part B claims files from 1993, 1996, and 1999 were analyzed for all procedure codes related to NDI. NDI codes were classified into 22 diagnostic categories within seven imaging modality groups. For each NDI code, physicians performing the services were classified as radiologists or nonradiologists by using the provider specialty code designated in claims in the files. The data were analyzed to determine the overall utilization rates and relative value unit (RVU) rate changes between 1993 and 1999 among radiologists and nonradiologists., Results: In 1993, the overall NDI utilization rate per 100,000 Medicare fee-for-service beneficiaries was 215,652 for radiologists and 79,942 for nonradiologists. In 1999, the rate was 207,270 for radiologists and 100,059 for nonradiologists, which is a 3.9% decrease among radiologists and a 25.2% increase among nonradiologists. In the 6-year interval from 1993 to 1999, the overall RVU rate increased 6.9% among radiologists and 32.4% among nonradiologists. The percentage of NDI performed by radiologists decreased from 73.0% in 1993 to 67.4% in 1999., Conclusion: Overall, the utilization rate of advanced, high-technology imaging is increasing among both radiologists and nonradiologists. However, it is increasing at a considerably more rapid rate among nonradiologists.

Purpose: To determine current utilization rates and recent nationwide trends for noninvasive diagnostic imaging (NDI) among the Medicare population., Materials and Methods: Medicare Part B claims data files from 1993, 1996, and 1999 were analyzed for all procedure codes related to NDI. NDI codes were grouped into 22 imaging categories, as well as seven imaging modality groups. The data were analyzed to determine the overall nationwide utilization and relative value unit (RVU) volume and rates and changes in utilization rates and RVU rates between 1993 and 1999 for the Medicare fee-for-service population, which included approximately 33 million enrollees per year., Results: The overall utilization rate for all NDI in 1999 was 324,974 examinations per 100,000 enrollees. Conventional radiography was the most utilized imaging technology (55.5%), followed by ultrasonography (US) (20.5%), computed tomography (CT) (8.8%), mammography (6.0%), nuclear imaging (5.2%), magnetic resonance (MR) imaging (2.6%), and bone densitometry (1.5%) (percentages do not add up to 100% due to rounding). In the 6-year interval from 1993 to 1999, the rate of NDI utilization increased 3.8%. The utilization rate for conventional radiography decreased 13.7%, while that of all other modalities increased a combined total of 39.1%. During this 6-year period, RVU rates per 100,000 increased 14.6%, with RVUs for MR imaging increasing 76.6%; those for nuclear imaging, 38.7%; those for CT, 28.3%; and those for US, 24.2%., Conclusion: A 3.8% increase in the rate of NDI utilization occurred during the 6-year period between 1993 and 1999. A considerably larger increase in RVU rates (14.6%) occurred during the same time period.

Purpose: To evaluate spinal injection procedures for trends in volume, reimbursement, and physician specialty participation., Materials and Methods: By using the 1993, 1996, 1998, and 1999 Medicare Part B claims database, we studied Current Procedural Terminology revision 4 codes used for percutaneous spinal injection procedures, including cervical and lumbar discography, disk aspiration and/or injection, facet and/or perifacet joint injection, and epidural steroid injection. For each of these procedures, volume, reimbursement, and physician specialty participation (categorized as radiology, anesthesiology, surgery, physiatry, and other specialties) for each year were recorded., Results: Despite an overall increase in spinal injection procedure volume and reimbursement from 1993 to 1999, nonradiologists performed most of these procedures. Epidural steroid and facet joint injections had the highest volume and reimbursement during this time period and were performed almost exclusively by nonradiologists (predominantly anesthesiologists). Radiologists performed more discography procedures than did other specialists in 1993, but participation decreased each year, while anesthesiologist participation increased; as of 1999, anesthesiologists performed more discography procedures than did radiologists. Although radiologists performed more disk aspiration procedures than did other specialists, procedure volume remained low during the period studied., Conclusion: Spinal injection volume and reimbursement have increased substantially in the Medicare population from 1993 to 1999. During this interval, radiologist participation has decreased. Nonradiologists perform most spinal injection procedures.

Purpose: To determine the trends in utilization of non-neurologic (ie, body) magnetic resonance (MR) imaging and of MR angiographic examinations performed from 1993 to 1998, the trends in non-radiologist participation in MR imaging, and the relative reimbursements for these examinations compared with those for all other noninvasive imaging studies performed in 1998., Materials and Methods: By using the 1993, 1996, and 1998 nationwide Medicare Part B databases, utilization rates per 100,000 Medicare beneficiaries and physician reimbursements were determined for seven MR angiography and 14 body MR imaging CPT-4 (Current Procedural Terminology, version 4) codes. Medicare specialty codes were used to categorize physicians as radiologists or non-radiologists., Results: The utilization rate per 100,000 Medicare beneficiaries for all 21 MR angiography and body MR imaging codes increased from 649 in 1993 to 1,253 in 1996 and to 1,876 in 1998--a 189% increase. These rates represented 0.55% of the total noninvasive imaging volume in 1998 and 2.8% of physician reimbursements. Musculoskeletal MR imaging utilization increased 142% from 1993 to 1998 compared with a 58% increase in the utilization of other body MR imaging studies. Non-radiologist participation in musculoskeletal MR imaging increased from 2.9% in 1993 to 3.6% in 1996 and to 5.6% in 1998., Conclusion: MR angiography and body MR imaging utilization rates increased substantially from 1993 to 1998. However, these studies still account for a minor fraction of all noninvasive imaging examinations performed and fees reimbursed. MR angiography and musculoskeletal MR imaging utilization has increased rapidly. Non-radiologist participation in musculoskeletal MR imaging is increasing.

Purpose: To evaluate cardiac nuclear medicine practice patterns in different physician specialty groups to better understand a recent rapid increase in utilization of radionuclide myocardial perfusion imaging (MPI) and certain supplementary examinations., Materials and Methods: National Medicare Part B databases from 1996 and 1998 were used to evaluate utilization of four primary procedure codes for radionuclide MPI and two supplementary codes (add-on left ventricular wall motion or left ventricular ejection fraction). Utilization rates were calculated for cardiologists, radiologists, and other physicians. Other cardiac imaging for which radionuclide imaging might be substituted was similarly studied., Results: Overall utilization rate of radionuclide MPI per 100,000 Medicare beneficiaries increased 19.1%, from 4,046 in 1996 to 4,820 in 1998 (P <.001). However, for cardiologists the rate increased from 1,771 to 2,413 (36.3%), whereas for radiologists it increased from 1,958 to 2,031 (3.7%) (P <.001 for both changes). Overall utilization rate of add-on codes increased 264% from 1,006 to 3,657 (P <.001). By 1998, the ratio of these add-on examinations to primary MPI was 0.94 among cardiologists compared with 0.53 among radiologists (relative risk, 1.77; 95% CI: 1.76, 1.78). Cardiologist-performed stress echocardiography and cardiac catheterization and coronary angiography increased by 24.2% and 8.7%, respectively., Conclusion: Growth in utilization of radionuclide MPI between 1996 and 1998 was almost 10 times higher among cardiologists than radiologists. Utilization of the two add-on codes increased even more dramatically. The greater use of MPI is not a substitute for other cardiac imaging.

Purpose: To determine the extent to which emergency medicine physicians have assumed responsibility for performing and interpreting ultrasonographic (US) studies in emergency departments (EDs) in the United States., Materials and Methods: The national 1997 Medicare Part B database was searched by using standard US procedure codes, location codes, and physician specialty codes. The authors determined how many US studies were performed in EDs and what percentage of those studies were performed by emergency medicine physicians, radiologists, or other physicians., Results: During 1997, 234,820 ED US studies within nine major examination categories were performed in Medicare patients nationwide. Emergency medicine physicians performed 1,551 (0.7%) of these studies. When echocardiographic examinations were excluded, emergency medicine physicians performed 458 (0.2%) of the remaining total of 196,158 studies., Conclusion: Although emergency medicine physicians have claimed to be actively involved in ED US on a broad scale, the data reveal that their involvement in 1997 was minimal. This raises doubt as to whether they can properly train their residents to perform US or maintain their own competence at acceptable levels.

Purpose: To compare results of helical computed tomographic (CT) angiography with real-time interactive volume rendering (VR) to CT angiography with maximum intensity projection (MIP) for the detection of renal artery stenosis., Materials and Methods: Twenty-five patients underwent both conventional and CT angiography of the renal arteries. Images were blindly reviewed after rendering with MIP and VR algorithms. MIP images were viewed in conjunction with axial CT images; VR models were evaluated in real time at the workstation without CT images. Findings in 50 main and 11 accessory renal arteries were categorized as normal or by degree of stenosis., Results: All arteries depicted on conventional angiograms were visualized on MIP and VR images. Receiver operating characteristic (ROC) analysis for MIP and VIR images demonstrated excellent discrimination for the diagnosis of stenosis of at least 50% (area under the ROC curve, 0.96-0.99). Although sensitivity was not significantly different for VR and MIP (89% vs 94%, P > .1), specificity was greater with VR (99% vs 87%, P = .008 to .08). Stenosis of at least 50% was overestimated with CT angiography in four accessory renal arteries, but three accessory renal arteries not depicted at conventional angiography were depicted at CT angiography., Conclusion: In the evaluation of renal artery stenosis, CT angiography with VR is faster and more accurate than CT angiography with MIP. Accessory arteries not depicted with conventional angiography were depicted with both CT angiographic algorithms.

Purpose: To determine the level of participation of nonradiologists in computed tomography (CT) and magnetic resonance (MR) imaging of the brain, head and neck, and spine at hospitals and at private offices and imaging centers in the United States., Materials and Methods: The 1993 Part B Medicare Annual Database was used to determine the number of procedures performed by radiologists and nonradiologists at hospitals and at private offices or imaging centers. The fourth edition of the Physicians' Current Procedural Terminology was used to classify procedures., Results: Of the 3,883,391 neurologic CT and MR imaging studies billed to Medicare in 1993, 3,148,088 (81%) were obtained in a hospital setting; only 58,005 (2%) of these studies were interpreted by nonradiologists. Of the 735,303 imaging studies (19%) obtained at a private office or imaging center, only 63,115 (9%) studies were interpreted by nonradiologists. Overall, nonradiologists performed only 121,120 (3%) of the neuroimaging examinations billed to Medicare nationwide in 1993., Conclusion: The level of participation of nonradiologists in the interpretation of results from neurologic CT and MR imaging billed to Medicare is minimal.

The authors describe how to develop and manage a capitated outpatient radiology contract. Aspects of a capitated fee structure and the need to apportion fees between a hospital and its radiology group are discussed. During negotiations with a managed care organization (MCO), certain information and commitments should be obtained. Utilization data should also be obtained from the MCO, but if they are not available (or are thought to be unreliable), certain norms can be used. Once a utilization projection is arrived at, reimbursement calculations can be made and compared with assumed reimbursements under a known fee schedule, such as that of Medicare. This procedure allows one to estimate whether a capitated proposal is financially feasible. Once a contractual agreement is instituted, the radiology group must then track and manage utilization. An understanding of these principles should enable radiologists to deal effectively with both practice and fiscal concerns presented by managed care.

Purpose: To determine the relative degree of participation by radiologists and other specialists in percutaneous interventional procedures., Materials and Methods: By using 1992 Medicare Part B claims data that covered seven states, the specialty of the physician provider was determined for all services performed within various percutaneous vascular and nonvascular interventional procedure codes., Results: Radiologists' performance of interventional procedures in descending percentage of participation was as follows: renal cyst aspiration (92.7%), biliary decompression (90.5%), abdominal or retroperitoneal mass biopsy (87.7%), lung or mediastinal biopsy (84.2%), noncardiac angioplasty (76.8%), pancreatic biopsy (75.2%), upper urinary tract decompression (73.7%), liver biopsy (43.7%), renal biopsy (38.4%), certain types of abscess drainages (38.2%), and thoracentesis with tube insertion (29.4%). They had only small roles in thoracentesis for aspiration (4.7%) and tube thoracostomy (1.7%)., Conclusion: Despite controversy between radiologists and other specialists over who should perform percutaneous interventions, radiologists have maintained strong predominance in many types of these procedures. In others, they have a shared, but still major, role.

Purpose: To assess replacement of barium enema examination with colonoscopy in relation to age- and sex-related risk factors, place of service, physician specialty, and cost., Materials and Methods: Between 1985 and 1992, 894,777 insurance claims for barium enema examination and lower gastrointestinal endoscopy were retrospectively examined. Changes in use were investigated. Use of proctosigmoidoscopy and flexible sigmoidoscopy, two office-based endoscopic procedures, was also examined., Results: Use of diagnostic colonoscopy increased from 191 to 406 services per 100,000 persons; colonoscopy with biopsy, from 77 to 183 services; and colonoscopy with lesion removal, from 77 to 202 services. Barium enema examination use declined from 929 to 511 services per 100,000 persons; diagnostic proctosigmoidoscopy, from 854 to 193 services; and diagnostic flexible sigmoidoscopy, from 656 to 620 services. Increases in use of colonoscopy in patients aged younger than 40 years were greater than overall increases., Conclusion: Colonoscopy has been replacing barium enema examination as the initial colorectal examination since 1985. Increased use of colonoscopy in patients with lower risk of neoplasia suggests that indications have become overly broad.

Purpose: To describe a program for controlling intravenous use of low-osmolar contrast agents (LOCAs)., Materials and Methods: The department of radiology at the authors' institution adopted a policy of selective use of intravenously administered LOCAs. Clinical indications for LOCA use were specified after consultation with the administration, risk managers, legal department, and ethics committee of the hospital. The guidelines were then publicized throughout the department and hospital, and a contrast agent data form was developed to collect data on all cases. Monitoring mechanisms were instituted., Results: Over the next 23 months, 11,373 patients received intravenous iodinated contrast agents, of whom 28.1% were deemed to be at high risk and were given LOCAs. Monthly tracking showed no evidence of a trend toward increasing use of LOCAs., Conclusion: Clear definition of use guidelines, close monitoring, and feedback can stabilize LOCA use at acceptably low levels.

Purpose: To define the frequency of physician self-referral for diagnostic imaging studies., Materials and Methods: High-volume radiographic (n = 65) and ultrasound (US) (n = 29) procedural codes in claims filed by Pennsylvania Blue Shield subscribers were analyzed to determine private-office (nonhospital) utilization of these examinations by radiologists and nonradiologists during 1991. A total of 787,703 radiographic and 159,281 US claims were filed., Results: Nonradiologists self-referred 550,878 radiographic examinations (69.9%) and 99,931 US examinations (62.7%). Patterns of utilization varied considerably by anatomic category: The imaging studies with the highest rates of utilization by nonradiologists were skeletal radiography, vascular US, and obstetric and pelvic US. Aggregate reimbursement allowance by Pennsylvania Blue Shield for all examinations in these 94 codes was approximately $68 million, of which $44 million (65%) went to non-radiologists.

The authors examined global charges (incorporating both technical and professional components) and global reimbursement allowances for all radiographic and ultrasound (US) examinations performed on Pennsylvania Blue Shield subscribers in the Lehigh Valley area of Pennsylvania during 1990. Data for radiologists and nonradiologists were compared with respect to all procedure codes for which at least 25 claims were submitted, yielding a sample of 40,619 radiographic examinations (54 procedure codes) and 9,761 US examinations (11 procedure codes). Radiologists' mean charges were higher than those of nonradiologists for 38 of the 54 radiographic codes. However, nonradiologists received higher mean reimbursement allowances for 39 of the 54 codes. Among the 11 US codes, nonradiologists' mean charges were higher for 10 and they received higher mean reimbursement allowances for seven. The averages of the mean reimbursement allowances for individual codes were higher for nonradiologists in both the radiographic and US categories. Pennsylvania Blue Shield has begun steps to eliminate disparities in reimbursements to providers who submit claims for imaging examinations.

Radiation levels near an imaging chain commonly used in angiography were measured with both a 100- and a 200-mm-thick scatter phantom. The scatter was measured in lines parallel in space to the central ray of the x-ray beam, at lateral distances of 300, 500, and 800 mm. The effects of fluoroscopic kilovoltage and image intensifier magnification mode were also measured. The results indicate that the highest scattered radiation levels occur near the surface of the patient where the x-ray beam enters. Exposure rates were measured in both anteroposterior (AP) and posteroanterior (PA) geometries on a U-arm system. In PA geometry, the highest radiation levels occur below the angiographer's waist, an area well protected by the lead apron. The AP geometry increases the exposure rate to the neck, head, and upper extremities, areas where apron shielding is less effective.

A survey of nonacademic community hospitals was conducted to ascertain the degree of control radiologists have of 38 selected imaging or imaging-related interventional procedures. Responses from 187 hospitals showed that community hospital radiologists totally controlled or strongly dominated almost half of these procedures, including all computed tomographic and magnetic resonance imaging studies, bone radiography, breast needle localization, emergency department radiography, arthrography, obstetric ultrasound (US), renal and peripheral angioplasty, percutaneous abscess and biliary drainage, percutaneous nephrostomy, cerebral angiography, and interventional neuroangiography. Radiologists dominated in prostate and vascular US, myelography, urethrography, cardiac nuclear medicine, percutaneous lung biopsy, ureteral stent placement, and pulmonary angiography, but there was also significant participation in these studies by nonradiologists. Radiologists and nonradiologists had roughly equivalent roles in hysterosalpingography, peripheral atherectomy and laser angioplasty, and percutaneous inferior vena cava filter placement. Nonradiologists dominated in echocardiography, endoscopic retrograde cholangiopancreatography, biliary and kidney stone lithotripsy, percutaneous gastrostomy, coronary angiography and angioplasty, and pediatric angiocardiography.

The safety and efficacy of the Palmaz balloon-expandable vascular stent and its effect on the results of percutaneous transluminal angioplasty (PTA) were assessed in a prospective study. Technical success was achieved in the placement of 34 of 35 stents (97%) in 27 common and external iliac artery lesions in 19 patients (23 limbs) who presented with disabling claudication, rest pain, or gangrene. Stent placement improved the angiographic results achieved by PTA alone in all 19 patients. Seventeen of 23 limbs (74%) had significant (greater than 20%) elevation of the ankle-arm index after combined angioplasty and stent placement, including nine limbs with occlusive outflow lesions. All 10 patients with continuous runoff distal to the stent and one patient with discontinuous runoff had resolution of their symptoms, remaining unchanged at a mean follow-up time of 6 months. There were three complications: One significantly altered the patient's hospital course, but none detracted from the achieved stent result. Stent placement is effective and does not significantly increase the complication rate of conventional iliac PTA. The current delivery system, however, may limit its utility.

Coronary angiography is one of the few radiologic procedures which remains largely under the control of another medical specialty. There are several contributing reasons, none of which justify continuation of this situation. A more active role for radiologists in performing coronary angiography is urged.

The additive effect of two sequential stenoses on arterial flow and pressure was studied in five dogs, using an extracorporeal aorto-femoral shunt. It was determined that the concept of flow being governed by the more severe stenosis is imprecise. This is true only of one critical and one subcritical lesion: two critical stenoses have an additive effect. Otherwise subcritical stenoses can become critical in the presence of hyperemia. When evaluating patients with vascular insufficiency due to arterial narrowing, all stenoses should be carefully assessed and attention directed to their cumulative effect.

A frequent concern during angioplasty is the possibility of occluding important side branches that originate in arterial stenoses subjected to balloon dilatation. The effect of dilatation on 93 side branches (greater than or equal to 1 mm in diameter) was evaluated in 86 patients undergoing percutaneous transluminal coronary angioplasty (PTCA) in whom those branches arose directly in dilated segments of the left anterior descending, circumflex, or right coronary arteries. Seventy-six of the 93 side branches had minor (less than 50%) narrowing at their origin. Among these side branches, nine (12%) were compromised by PTCA. Seventeen of the 93 side branches had greater than 50% ostial stenosis. Significantly more of these side branches (seven of seventeen, or 41%) were compromised by PTCA (P less than .01). Even when compromise does occur, it usually takes the form of increased stenosis rather than total occlusion. The presence of side branches originating in stenotic lesions is not a contraindication to PTCA since serious compromise of such branches rarely results from this procedure.

Injection of fluid through catheters positioned selectively in arteries results in substantial increases in flow and pressure in those arteries for the duration of the injection. This produces certain artifacts which may lead to misinterpretation of the arteriograms. Apparent direction of flow in major vessels, extent of collateral circulation, distribution of contrast medium throughout various branches of the arterial tree, and density of accumulation of contrast material in organs or tumors can be altered significantly by the injection technique.

Two patients with clinically nonfunctioning pheochromocytomas of the adrenal gland were studied angiographically. The radiological characteristics were indistinguishable from those of functioning pheochromocytomas. In patients with hypervascular adrenal masses, the diagnosis of pheochromocytoma should be considered even in the absence of customary signs and symptoms.

The effects on cardiac hemodynamics and serum parameters of a standard contrast agent (sodium methylglucamine diatrizoate [Renografin 76]) were compared with the effects of a new nonionic agent (iohexol) in a double-blind study in 51 patients undergoing coronary angiography and left ventriculography. No significant alteration in measured blood parameters occurred with either contrast agent. Hemodynamic changes occurred with both, but were significantly greater with the standard Renografin than with the low-osmolality, nonionic iohexol. After left ventriculography, heart rate increased and peripheral arterial pressure fell with both agents, but less with iohexol. Following coronary artery injections, heart rate and arterial pressure decreased with both agents, but the changes were more marked and occurred earlier with the standard contrast material. It is concluded that iohexol causes less alteration in cardiac function than does the agent currently most widely used. Nonionic contrast material is likely to improve the safety of coronary angiography, particularly in those patients at greatest risk.

Three cases of jugular venous ectasia in children were diagnosed preoperatively by selective venography. These rare lesions appear to be congenital dilatations of the veins and should not properly be called aneurysms, as their histological structure is normal. A typical history and complex of physical findings are associated with this entity. It is important to include it in the differential diagnosis of neck masses in children.

The original Gruentzig coaxial catheter system for percutaneous transluminal coronary angioplasty (PTCA) utilized a blunt, closed-end, inner balloon catheter with a short guide wire attached to its tip. Options for safely crossing severe stenoses with this large, nonmaneuverable catheter were limited. More recently, over-the-wire systems have been developed in which the lesion initially is crossed with a small-caliber floppy or steerable guide wire, then by the balloon catheter advanced over the wire. Technical success was achieved in 78 of our first 100 PTCAs with this system. Significant cardiac complications occurred in ten patients, seven of whom required emergency coronary bypass surgery. A recently published survey of all PTCA techniques reported a technical success rate of 62%. Our higher success rate may be attributed to certain advantages of the over-the-wire system, which are discussed in detail. A learning curve is associated with this procedure: our success rate was 65% in the first 20 cases but 81% thereafter. These results can be considered typical of those expected at hospitals now beginning PTCA programs with advanced over-the-wire technology.

A case of metastatic malignant melanoma to the adrenal gland is presented. The radiographic appearance mimicked a benign cystic adrenal lesion because of the presence of curvilinear calcification of its border.

Percutaneous transcatheter embolization of the coronary arteries with autologous clot was performed in six dogs. The occlusions resolved completely within 14 days in the four surviving dogs. Postmortem examination revealed transmural myocardial infarction in two dogs and subendocardial infarcts in the other two. Histological sections showed no residual emboli in three dogs and a recanalized thrombus in an epicardial vessel in the fourth. These findings indicate that myocardial infarction can be produced by multiple occlusions of the distal coronary arterial branches, provided that common or contiguous myocardium is affected. The recanalized thrombus in one dog suggests that the thrombolytic process need not be complete for return to a normal angiographic appearance.