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There are potential benefits and harms of screening ultrasound (US) to supplement mammographic screening of women with dense breast tissue. We conducted a comprehensive literature review of studies assessing the efficacy of screening US to supplement mammography among women with dense breasts. From a total of 189 peer-reviewed publications on the performance of screening US, 12 studies were relevant to our analysis. The reporting of breast cancer risk factors varied across studies; however, the study populations tended to be at greater than average risk for developing breast cancer. Overall, US detected an additional 0.3-7.7 cancers per 1000 examinations (median, 4.2) and was associated with an additional 11.7-106.6 biopsies per 1000 examinations (median, 52.2). Significant improvements in cancer detection in dense breasts have been achieved with the transition from film to digital mammography. Thus adjunctive screening with ultrasound should be considered in the context of current screening mammography performance. Clinicians should discuss breast density as 1 of several important breast cancer risk factors, consider the potential harms of adjunctive screening, and arrive at a shared decision consistent with each woman's preferences and values., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: Women commonly present to imaging departments with a palpable breast abnormality. However, widespread confusion remains regarding the most appropriate sequence and extent of imaging required. The purpose of this article is to discuss the evidence informing current management guidelines for the care of patients with palpable breast abnormalities., Conclusion: Ultrasound is a highly effective imaging tool for guiding effective evaluation of women with palpable breast abnormalities and should be used for all women with suspicious findings at clinical breast examination. The exception is cases in which mammography shows a clearly benign correlate or a normal, fatty area of breast tissue in the location of the palpable finding. Breast ultrasound should be the primary imaging tool for women with palpable lumps who are pregnant, lactating, or younger than 30 years. For women 40 years old and older, mammography, followed in most cases by ultrasound, is recommended. For women 30-39 years old, ultrasound or mammography may be performed first at the discretion of the radiologist or referring provider. There is little to no role for breast MRI or other advanced imaging technologies in the routine diagnostic evaluation of palpable breast abnormalities.

Rationale and Objectives: As breast magnetic resonance imaging (MRI) use grows, benchmark performance parameters are needed for auditing and quality assurance purposes. We describe the variation in breast MRI abnormal interpretation rates (AIRs) by clinical indication among a large sample of US community practices., Materials and Methods: We analyzed data from 41 facilities across five Breast Cancer Surveillance Consortium imaging registries. Each registry obtained institutional review board approval for this Health Insurance Portability and Accountability Act compliant analysis. We included 11,654 breast MRI examinations conducted in 2005-2010 among women aged 18-79 years. We categorized clinical indications as 1) screening, 2) extent of disease, 3) diagnostic (eg, breast symptoms), and 4) other (eg, short-interval follow-up). We characterized assessments as positive (ie, Breast Imaging Reporting and Data System [BI-RADS] 0, 4, and 5) or negative (ie, BI-RADS 1, 2, and 6) and provide results with BI-RADS 3 categorized as positive and negative. We tested for differences in AIRs across clinical indications both unadjusted and adjusted for patient characteristics and registry and assessed for changes in AIRs by year within each clinical indication., Results: When categorizing BI-RADS 3 as positive, AIRs were 21.0% (95% confidence interval [CI], 19.8-22.3) for screening, 31.7% (95% CI, 29.6-33.8) for extent of disease, 29.7% (95% CI, 28.3-31.1) for diagnostic, and 27.4% (95% CI, 25.0-29.8) for other indications (P < .0001). When categorizing BI-RADS 3 as negative, AIRs were 10.5% (95% CI, 9.5-11.4) for screening, 21.8% (95% CI, 19.9-23.6) for extent of disease, 17.7% (95% CI, 16.5-18.8) for diagnostic, and 13.3% (95% CI, 11.6-15.2) for other indications (P < .0001). The significant differences in AIRs by indication persisted even after adjusting for patient characteristics and registry (P < .0001). In addition, for most indications, there were no significant changes in AIRs over time., Conclusions: Breast MRI AIRs differ significantly by clinical indication. Practices should stratify breast MRI examinations by indication for quality assurance and auditing purposes., (Copyright © 2014 AUR. Published by Elsevier Inc. All rights reserved.)

Objective: The goals of this article are to provide an overview of controversial aspects of imaging-based screening and to elucidate potential risks that may offset anticipated benefits., Conclusion: Current controversial topics associated with imaging-based screening include false-positive results, incidental findings, overdiagnosis, radiation risks, and costs. Alongside the benefits of screening, radiologists should be prepared to discuss these additional diagnostic consequences with providers and patients to better guide shared decision making regarding imaging-based screening.

Our specialty is seeking to establish the value of imaging in the longitudinal patient-care continuum. We recognize the need to assess the value of our contributions rather than concentrating primarily on generating revenue. This recent focus is a result of both increased cost-containment efforts and regulatory demands. Imaging 3.0 is a value-based perspective that intends to describe and facilitate value-based imaging. Imaging 3.0 includes a broad set of initiatives addressing the visibility of radiologists, and emphasizing quality and safety oversight by radiologists, which are new directions of focus for us. Imaging 3.0 also addresses subspecialty imaging and off-hours imaging, which are existing areas of practice that are emblematic of inconsistent service delivery across all hours. Looking to the future, Imaging 3.0 describes how imaging services could be integrated into the framework of accountable care organizations. Although all these efforts may be essential, they necessitate manpower expenditures, and these efforts are not directly covered by revenue. If we recognize the urgency of need in developing these concepts, we can justify the manpower and staffing expenditures each organization is willing to shoulder in reaching Imaging 3.0., (Copyright © 2014 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

The creation of the Patient-Centered Outcomes Research Trust Fund and the Patient-Centered Outcomes Research Institute (PCORI) through the Patient Protection and Affordable Care Act of 2010 presents new opportunities for funding patient-centered comparative effectiveness research (CER) in radiology. We provide an overview of the evolution of federal funding and priorities for CER with a focus on radiology-related priority topics over the last two decades, and discuss the funding processes and methodological standards outlined by PCORI. We introduce key paradigm shifts in research methodology that will be required on the part of radiology health services researchers to obtain competitive federal grant funding in patient-centered outcomes research. These paradigm shifts include direct engagement of patients and other stakeholders at every stage of the research process, from initial conception to dissemination of results. We will also discuss the increasing use of mixed methods and novel trial designs. One of these trial designs, the pragmatic trial, has the potential to be readily applied to evaluating the effectiveness of diagnostic imaging procedures and imaging-based interventions among diverse patient populations in real-world settings., (Copyright © 2014 AUR. Published by Elsevier Inc. All rights reserved.)

Purpose: The breast imaging modalities of mammography, ultrasound, and MRI are widely used for screening, diagnosis, treatment, and surveillance of breast cancer. Geographic access to breast imaging services in various modalities is not known at a national level overall or for population subgroups., Methods: A retrospective study of 2004-2008 Medicare claims data was conducted to identify ZIP codes in which breast imaging occurred, and data were mapped. Estimated travel times were made for each modality for 215,798 census block groups in the contiguous United States. Using Census 2010 data, travel times were characterized by sociodemographic factors for 92,788,909 women aged ≥30 years, overall, and by subgroups of age, race/ethnicity, rurality, education, and median income., Results: Overall, 85% of women had travel times of ≤20 minutes to nearest mammography or ultrasound services, and 70% had travel times of ≤20 minutes for MRI with little variation by age. Native American women had median travel times 2-3 times longer for all 3 modalities, compared to women of other racial/ethnic groups. For rural women, median travel times to breast imaging services were 4-8-fold longer than they were for urban women. Black and Asian women had the shortest median travel times to services for all 3 modalities., Conclusions: Travel times to mammography and ultrasound breast imaging facilities are short for most women, but for breast MRI, travel times are notably longer. Native American and rural women are disadvantaged in geographic access based on travel times to breast imaging services. This work informs potential interventions to reduce inequities in access and utilization., (Copyright © 2014 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: To compare performance measures before, during, and after the transition from screen-film mammography (SFM) to full-field digital mammography (FFDM) in a population-based screening program., Materials and Methods: No institutional review board approval was required for this analysis involving anonymized data for women aged 50-69 years enrolled in the Norwegian Breast Cancer Screening Program during 1996-2010. The χ(2) test was used to examine the equality of proportions of recall rates, positive predictive value of recall examinations and of invasive procedures, in addition to rates of screening-detected and interval cancers in women initially screened with SFM and FFDM and for women subsequently screened with SFM after SFM, FFDM after SFM, and FFDM after FFDM., Results: The recall rate was 3.4% (47 091 of 1 391 188) for SFM and 2.9% (13 130 of 446 172) for FFDM (P < .001). The biopsy rate was 1.4% (19 776 of 1 391 188) for SFM and 1.1% (5108 of 446 172) for FFDM (P < .001). The rate of screening-detected ductal carcinoma in situ was higher (P = .019) while the rate of invasive breast cancer was lower (P < .001) for FFDM compared with those for SFM. The rate of both invasive screening-detected and interval breast cancer remained stable during the transition from SFM to FFDM (when the previous examination was SFM) and after FFDM was firmly established (when the previous examination was FFDM, >25 months after FFDM adoption) (P < .05). The positive predictive value of recall examinations and of invasive procedures increased from 19.3% (4559 of 23 598) and 48.3% (4651 of 9623) to 22.7% (681 of 2995) and 57.5% (689 of 1198), respectively, after adoption of FFDM (P < .001)., Conclusion: After the initial transitional phase from SFM to FFDM, population-based screening with FFDM is associated with less harm because of lower recall and biopsy rates and higher positive predictive values after biopsy than screening with SFM., (© RSNA, 2014.)

Emerging imaging technologies, including digital breast tomosynthesis, have the potential to transform breast cancer screening. However, the rapid adoption of these new technologies outpaces the evidence of their clinical and cost-effectiveness. The authors describe the forces driving the rapid diffusion of tomosynthesis into clinical practice, comparing it with the rapid diffusion of digital mammography shortly after its introduction. They outline the potential positive and negative effects that adoption can have on imaging workflow and describe the practice management challenges when incorporating tomosynthesis. The authors also provide recommendations for collecting evidence supporting the development of policies and best practices., (Copyright © 2013 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: Because benign biopsies resulting from false-positive mammographic findings are a known harm of breast cancer screening, physicians and test manufacturers are searching for ways to reduce their frequency. The aim of this study was to estimate potential costs and consequences associated with using an adjunct diagnostic test for triaging women with suspicious mammographic findings before biopsy., Methods: A decision model was developed to compare the use of an adjunct test before biopsy to the current standard of care for suspicious mammographic findings. The decision analysis was performed from the perspective of a national health payer, with a 1-year time horizon among women representative of the US screening population aged 40 to 79 years. Three primary outcomes were assessed: (1) incremental costs, (2) number of benign biopsies avoided, and (3) number of missed opportunities for diagnosing cancer per million women screened. Input parameters were obtained from the medical literature and expert opinion. Sensitivity analyses were performed to evaluate the effects of uncertainty in parameter estimates., Results: The base-case analysis demonstrated that the use of an adjunct diagnostic test with 95% sensitivity, 75% specificity, and a cost of $1,000 would eliminate 8,127 unnecessary breast biopsies per million women screened. However, this would cost the US health care system an additional $6,462,977 and result in 255 missed opportunities for diagnosing cancer per million women screened., Conclusions: The addition of an adjunct test for triaging women for breast biopsy after abnormal findings on screening mammography would likely eliminate many unnecessary biopsies but also increase overall health care costs. This exploratory analysis highlights the fact that mammography remains a relatively inexpensive and effective breast cancer screening and diagnostic modality., (Copyright © 2013 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: The ACR Education Center's Breast MR With Guided Biopsy course is designed to provide radiologists with an intensive, hands-on experience in interpreting breast MR. The aim of this study was to describe radiologists' performance in breast MR interpretation by case clinical indication, lesion type, and BI-RADS(®) assessment to inform future educational efforts., Methods: Data from 16 consecutive courses held from 2009 to 2012 at the ACR Education Center were analyzed. For each MR case, the clinical indication (screening vs diagnostic), background parenchymal enhancement, and lesion type (mass vs nonmass enhancement) were recorded. Participant case BI-RADS assessments were categorized as either correct or incorrect in relation to expert-opinion BI-RADS assessments. Participants' interpretive accuracy on the basis of study indication, lesion type, and background parenchymal enhancement is reported., Results: Data from 745 course participants over 3 years were analyzed. Of the 96 MR cases included in the analysis, 58% (n = 50) were indicated for screening and 42% (n = 46) for diagnostic purposes. Participants provided correct BI-RADS assessments for 79% of screening cases (32,399 of 41,249) and 74% of diagnostic cases (20,888 of 28,106). Participants more accurately assessed screening compared with diagnostic MR cases (P < .0001) and masses compared with nonmass enhancement (P < .0001). There was no statistically significant difference in performance on the basis of background parenchymal enhancement., Conclusions: Practicing radiologists perform more accurately on screening compared with diagnostic MR and when evaluating masses as opposed to areas of nonmass enhancement. Future case-based breast MR education efforts should emphasize strategies for interpreting diagnostic breast MR cases and evaluating nonmass enhancement., (Copyright © 2013 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Our objective was to characterize the tasks of emergency radiologists and emergency physicians and quantify the proportion of time spent on these tasks to assess their roles in patient evaluation. Our study involved emergency radiologists and emergency physicians at an urban academic level I trauma medical center. Participants were observed for continuous 2-h periods during which all of their activities were timed and categorized into the following tasks: patient history, patient physical findings, assessment/plan, procedures, technical/administration, paperwork, and personal time. We performed multivariate analyses to compare the proportion of time spent on task categories between specialties. Twenty physicians (10 emergency medicine and 10 radiology) were observed for a total of 146,802 s (2,446.7 min). Radiologists spent a significantly larger combined proportion of time on determining physical findings and paperwork than emergency physicians (61.9 vs. 28.3 %, p<0.0001). Emergency physicians spent a significantly larger proportion of time than radiologists on determining patient history (17.5 vs. 2.5 %, p=0.0008) and assessment/plan (42.3 vs. 19.3 %, p<0.0001). Both specialties devoted minimal time toward personal tasks. Radiologists play a major role in the diagnostic evaluation of a subset of acute patients, spending significantly more of their time determining physical findings than their emergency physician counterparts.

Merely suggesting that radiologists answer the call to bolster and secure the future of their own specialty has not resulted in increased activism. Therefore, the ACR Commission on Human Resources has developed a definition for the concept of citizenship in radiology and explicit descriptions of the activities associated with it. Furthermore, the authors introduce a methodology for the measurement and valuation of individual radiologists' contributions to group practices and to the specialty as a whole. These measures can in turn be used to promote, acknowledge, recognize, and incentivize citizenship activity among radiologists at the local, regional, and national levels., (Copyright © 2013 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

The objective of this study was to compare direct health care costs for two competing diagnostic strategies for probably benign breast lesions detected by ultrasound in young women. We developed a decision analytic model and performed a cost minimization analysis comparing ultrasound-guided vacuum-assisted core biopsy and conservative short-term diagnostic ultrasound follow-up. Relative probabilities for diagnostic outcomes were derived from pooled analysis of the medical literature. Direct health care costs were estimated using United States national average figures from calendar year 2010. Deterministic sensitivity analyses were conducted, as well as a first-order Monte Carlo simulation to confirm cost differences between the two strategies. The conservative short-term imaging follow-up strategy ($639.55 average cost per patient) was the most economical strategy compared to immediate vacuum-assisted core biopsy ($879.55 average cost per patient). Sensitivity analyses demonstrated that the preferred strategy is most dependent on the probabilities of detecting change in appearance on follow-up ultrasound, having a benign finding on immediate core biopsy, and finding cancer on a biopsy triggered by an interval change in ultrasound appearance. The model was also sensitive to the costs of vacuum-assisted core biopsy and diagnostic ultrasound. Conservative imaging follow-up of BIRADS 3 breast masses by ultrasound is cost saving compared to immediate vacuum-assisted core biopsy, with a potential of saving more than one-third of overall costs associated with the diagnostic work-up of such lesions. Watchful waiting with short-term interval follow-up ultrasounds will spare women from unnecessary procedures and spare the United States health care system from unnecessary direct health care costs., (© 2012 Wiley Periodicals, Inc.)

To characterize patients' willingness to donate a biospecimen for future research as part of a breast cancer-related biobank involving a general screening population. We performed a prospective cross-sectional study of 4,217 women aged 21-89 years presenting to our facilities for screening mammogram between December 2010 and October 2011. This HIPAA-compliant study was approved by our institutional review board. We collected data on patients' interest in and actual donation of a biospecimen, motivators and barriers to donating, demographic information, and personal breast cancer risk factors. A multivariate logistic regression analysis was performed to identify patient-level characteristics associated with an increased likelihood to donate. Mean patient age was 57.8 years (SD 11.1 years). While 66.0 % (2,785/4,217) of patients were willing to donate blood or saliva during their visit, only 56.4 % (2,378/4,217) actually donated. Women with a college education (OR = 1.27, p = 0.003), older age (OR = 1.02, p < 0.001), previous breast biopsy (OR = 1.23, p = 0.012), family history of breast cancer (OR = 1.23, p = 0.004), or a comorbidity (OR = 1.22, p = 0.014) were more likely to donate. Asian-American women were significantly less likely to donate (OR = 0.74, p = 0.005). The major reason for donating was to help all future patients (42.3 %) and the major reason for declining donation was privacy concerns (22.3 %). A large proportion of women participating in a breast cancer screening registry are willing to donate blood or saliva to a biobank. Among minority participants, Asian-American women are less likely to donate and further qualitative research is required to identify novel active recruitment strategies to insure their involvement.

Objective: The purpose of this study was to determine the accuracy and value of breast ultrasound for primary imaging evaluation of women 30-39 years of age who present with focal breast signs or symptoms., Methods: We identified all women 30-39 years of age who underwent imaging evaluation (ultrasound and mammography) at our institution between January 1, 2002, and August 31, 2006, for focal breast signs or symptoms. Each area of concern was designated a study case. Benign versus malignant outcomes were determined by biopsy or imaging surveillance and through linkage with a tumor registry with a minimum 24-month follow-up. Overall cancer yield, sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) of ultrasound and mammography were calculated., Results: We identified 1208 cases in 954 patients. Outcomes were benign in 1185 of 1208 (98.1%) and malignant in 23 of 1208 (1.9%) cases. Sensitivities for ultrasound and mammography were 95.7% and 60.9%, respectively. Specificities for ultrasound and mammography were 89.2% and 94.4%, respectively. NPV was 99.9% for ultrasound and 99.2% for mammography. PPV was 13.2% for ultrasound and 18.4% for mammography. Mammography detected one additional malignancy in an asymptomatic area in a 32-year-old woman who was subsequently found to have a BRCA2 gene mutation., Conclusion: Breast imaging is warranted in women 30-39 years of age with focal signs or symptoms because of the small (1.9%) but real risk of malignancy. Ultrasound has high sensitivity (95.7%) and high NPV (99.9%) in this setting and should be the primary imaging modality of choice. The added value of adjunct mammography is low.

Objective: Given the growing concern about CT overutilization, we provide a descriptive trend analysis of CT studies ordered in U.S. emergency departments by nonphysician health care providers and examine whether there is a significant difference in ordering patterns between nonphysicians and physicians., Materials and Methods: We used a nationally representative data sample for 2001-2008 to describe trends in CT studies ordered in U.S. emergency departments by nonphysician health care providers. We performed a multivariate logistic regression with hospital fixed effects on the most recently available data to determine whether there is a difference in ordering patterns between the two provider groups., Results: From 2001 to 2008, the number of emergency department visits associated with CT studies managed solely by nonphysician health care providers increased from 100,626 to 620,296. Over this same period, the proportion of emergency department visits associated with CT managed solely by nonphysician providers grew from 1.5% to 3.6%. Controlling for hospital-level and patient-level variables, patient visits managed solely by nonphysician providers had 0.38 times the odds of CT utilization compared with patient visits managed by physicians., Conclusion: Although both the total number and the proportion of emergency department visits managed independently by nonphysician providers and associated with CT have grown rapidly in the past decade, nonphysician health care providers are less likely to order CT compared with physicians. The types of ordering providers and their differing practices should become part of the discourse regarding appropriate CT utilization.

Because radiology has historically not measured its added value to patient care and thus not communicated it in easily understood terms to all stakeholders, the specialty must correct this to prepare for the eventual transition from the current fee-for-service payment schedule to new value-based reimbursement systems. Given the increasing risk for marginalization, radiologists need to engage clinicians and managers to map the processes and associated costs of episodes of patient care to identify areas for providing and improving integrated diagnostic information and to measure the value thereof. In such time-driven, activity-based costing practices, radiologists should highlight how proper investments in the information generated by imaging and how radiologists' associated consultative and coordination of services can save greater resources downstream, especially in the nonrenewable resource of physician time, an increasingly scarce health care resource. Using physician time in the most efficient way will be a key element for decreasing health care costs at the aggregate level. Therefore, expressing radiology's contribution in terms of downstream physician time saved is a metric that can be easily understood by all stakeholders. In a conceptual framework centered on value, the specialty of radiology must focus more on its most important product, actionable information, rather than on imaging technologies themselves. Information, unlike imaging technologies, does not depreciate with time but rather increases in value the more it is used., (Copyright © 2012 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

The Norwegian Breast Cancer Screening Program was rolled out county by county over the course of a decade, from 1996 to 2005, and now encompasses all Norwegian women aged 50-69 years. We aim to compare DCIS and stage-specific invasive breast cancer incidence rates among participants, non-participants, and women not yet invited to the screening program over this entire implementation period. We estimate stage-specific breast tumor incidence rates for 640,347 women 50-69 years of age invited to the screening program between 1996 and 2007. We compare incidence rates and stage distribution among women diagnosed with breast cancer who were invited and participated, invited but not participated, and women not yet invited to the screening program using two-sided Chi-squared tests to determine statistical significance between groups. The incidence of ductal carcinoma in situ (DCIS) was 3.0 times higher and invasive breast cancer was 1.5 times higher for invited participants compared to invited non-participants (p < 0.001). While the incidence of Stage I cancer was two times higher among participants compared to non-participants (p < 0.001), the incidences of Stages III and IV cancer were two and three times lower, respectively, among participants compared to non-participants (p < 0.001 for both). No significant differences in stage-specific incidence or treatment utilization rates were observed between invited non-participants and not yet invited women, except for stage IV cancers, which were detected at a higher rate among women who were not yet invited (7.5 vs. 4.6 %, p = 0.001). Compared with women invited who did not participate, participants in the screening program are more likely to be diagnosed with DCIS and early stage invasive breast cancer and are less likely to be diagnosed with advanced stage breast cancer. More research is required to determine whether these differences in stage-specific incidences among invited participants and non-participants are associated with differences in mortality rates.

Introduction: Medical imaging now accounts for most of the US population's exposure to ionizing radiation. A substantial proportion of this medical imaging is ordered in the emergency setting. We aim to provide a general overview of radiation dose from medical imaging with a focus on computed tomography, as well as a literature review of recent efforts to decrease unnecessary radiation exposure to patients in the emergency department setting., Methods: We conducted a literature review through calendar year 2010 for all published articles pertaining to the emergency department and radiation exposure., Results: The benefits of imaging usually outweigh the risks of eventual radiation-induced cancer in most clinical scenarios encountered by emergency physicians. However, our literature review identified 3 specific clinical situations in the general adult population in which the lifetime risks of cancer may outweigh the benefits to the patient: rule out pulmonary embolism, flank pain, and recurrent abdominal pain in inflammatory bowel disease. For these specific clinical scenarios, a physician-patient discussion about such risks and benefits may be warranted., Conclusion: Emergency physicians, now at the front line of patients' exposure to ionizing radiation, should have a general understanding of the magnitude of radiation dose from advanced medical imaging procedures and their associated risks. Future areas of research should include the development of protocols and guidelines that limit unnecessary patient radiation exposure.

Objective: This article will briefly describe the driving forces of radiology's changing landscape because of health care reform and outline opportunities for radiologists in training to use health services and policy research skills to help show the value of radiologists in patient care, define the future business model of radiology, and shape wide-reaching public policy., Conclusion: The ability of our specialty to continue to thrive will require the presentation of sound evidence showing our added value to patients' overall health and well-being.

Objective: In the era of health care reform, our value-added to patient care, its corresponding level of reimbursement, and the stature of radiology as a specialty will likely be grounded in the scientific evaluation methods of health services research., Conclusion: We need to create more opportunities for training, provide resources and incentives for the brightest candidates to enter this field, and cultivate enriching environments for health services research in all academic radiology departments.

Objective: The purpose of this study was to evaluate the prevalence of incidental extracardiac findings on coronary CT, to determine the associated downstream resource utilization, and to estimate additional costs per patient related to the associated diagnostic workup., Materials and Methods: This retrospective study examined incidental extracardiac findings in 151 consecutive adults (69.5% men and 30.5% women; mean age, 54 years) undergoing coronary CT during a 7-year period. Incidental findings were recorded, and medical records were reviewed for downstream diagnostic examinations for a follow-up period of 1 year (minimum) to 7 years (maximum). Costs of further workup were estimated using 2009 Medicare average reimbursement figures., Results: There were 102 incidental extracardiac findings in 43% (65/151) of patients. Fifty-two percent (53/102) of findings were potentially clinically significant, and 81% (43/53) of these findings were newly discovered. The radiology reports made specific follow-up recommendations for 36% (19/53) of new significant findings. Only 4% (6/151) of patients actually underwent follow-up imaging or intervention for incidental findings. One patient was found to have a malignancy that was subsequently treated. The average direct costs of additional diagnostic workup were $17.42 per patient screened (95% CI, $2.84-$32.00) and $438.39 per patient with imaging follow-up (95% CI, $301.47-$575.31)., Conclusion: Coronary CT frequently reveals potentially significant incidental extracardiac abnormalities, yet radiologists recommend further evaluation in only one-third of cases. An even smaller fraction of cases receive further workup. The failure to follow-up abnormal incidental findings may result in missed opportunities to detect early disease, but also limits the short-term attributable costs.

Objective: The purpose of this article is to characterize current informed consent practices for diagnostic CT scans at U.S. academic medical centers., Materials and Methods: We surveyed 113 radiology chairpersons associated with U.S. academic medical centers using a survey approved by our institutional review board. The need for informed consent for this study was waived. Chairpersons were asked if their institutions have guidelines for nonemergent CT scans (by whom; oral and/or written), if patients are informed of the purpose of their scans (by whom), what specific risks are outlined (allergic reaction, radiation risk and dose, others; by whom), and if patients are informed of alternatives to CT., Results: The study response rate was 81% (91/113). Of the respondents, two thirds (60/90) currently have guidelines for informed consent regarding CT scans. Radiology technologists were most likely to inform patients about CT (38/60, 63%) and possible risks (52/91, 57%), whereas ordering physicians were most likely to inform patients about CT's purpose (37/66, 56%). Fifty-two percent (30/58) of sites provided verbal information and 5% (3/58) provided information in written form. Possible allergic reaction to dye was explained at 84% (76/91) of sites, and possible radiation risk was explained at 15% (14/91) of sites. Nine percent (8/88) of sites informed patients of alternatives to CT., Conclusion: Radiology technologists are more likely to inform patients about CT and associated risks than their physician counterparts. Although most academic medical centers currently have guidelines for informed consent regarding CT, only a minority of institutions inform patients about possible radiation risks and alternatives to CT.

Purpose: To determine the awareness level concerning radiation dose and possible risks associated with computed tomographic (CT) scans among patients, emergency department (ED) physicians, and radiologists., Materials and Methods: Adult patients seen in the ED of a U.S. academic medical center during a 2-week period with mild to moderate abdominopelvic or flank pain and who underwent CT were surveyed after acquisition of the CT scan. Patients were asked whether or not they were informed about the risks, benefits, and radiation dose of the CT scan and if they believed that the scan increased their lifetime cancer risk. Patients were also asked to estimate the radiation dose for the CT scan compared with that for one chest radiograph. ED physicians who requested CT scans and radiologists who reviewed the CT scans were surveyed with similar questions and an additional question regarding the number of years in practice. The chi(2) test of independence was used to compare the three respondent groups regarding perceived increased cancer risk from one abdominopelvic CT scan., Results: Seven percent (five of 76) of patients reported that they were told about risks and benefits of their CT scan, while 22% (10 of 45) of ED physicians reported that they had provided such information. Forty-seven percent (18 of 38) of radiologists believed that there was increased cancer risk, whereas only 9% (four of 45) of ED physicians and 3% (two of 76) of patients believed that there was increased risk (chi(2)(2) = 41.45, P <.001). All patients and most ED physicians and radiologists were unable to accurately estimate the dose for one CT scan compared with that for one chest radiograph., Conclusion: Patients are not given information about the risks, benefits, and radiation dose for a CT scan. Patients, ED physicians, and radiologists alike are unable to provide accurate estimates of CT doses regardless of their experience level.