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OBJECTIVE: To characterize provider-parent vaccine communication and determine the influence of specific provider communication practices on parent resistance to vaccine recommendations. METHODS: We conducted a cross-sectional observational study in which we videotaped provider-parent vaccine discussions during health supervision visits. Parents of children aged 1 to 19 months old were screened by using the Parent Attitudes about Childhood Vaccines survey. We oversampled vaccine-hesitant parents (VHPs), defined as a score >50. We developed a coding scheme of 15 communication practices and applied it to all visits. We used multivariate logistic regression to explore the association between provider communication practices and parent resistance to vaccines, controlling for parental hesitancy status and demographic and visit characteristics. RESULTS: We analyzed 111 vaccine discussions involving 16 providers from 9 practices; 50% included VHPs. Most providers (74%) initiated vaccine recommendations with presumptive (eg, "Well, we have to do some shots") rather than participatory (eg, "What do you want to do about shots?") formats. Among parents who voiced resistance to provider initiation (41%), significantly more were VHPs than non-VHPs. Parents had significantly higher odds of resisting vaccine recommendations if the provider used a participatory rather than a presumptive initiation format (adjusted odds ratio: 17.5; 95% confidence interval: 1.2-253.5). When parents resisted, 50% of providers pursued their original recommendations (eg, "He really needs these shots"), and 47% of initially resistant parents subsequently accepted recommendations when they did. CONCLUSIONS: How providers initiate and pursue vaccine recommendations is associated with parental vaccine acceptance. [ABSTRACT FROM AUTHOR]

Purpose: Incorporating coronary CT angiographic (CCTA) imaging into emergency department (ED) workflows has been limited by the need for 24/7 real-time postprocessing. The aim of this study was to determine whether interpretation of transaxial CCTA images alone (limited axial interpretation [LI]) is noninferior to interpretation of combined transaxial and multiplanar reformation images (full interpretation [FI]) in assessing patients with acute chest pain in the ED., Methods: CCTA examinations from 74 patients were evaluated by two radiologists, one without dedicated CCTA training and one with basic CCTA experience. Each examination was evaluated three times in separate sessions, once by LI and twice by FI, in random order. Nineteen coronary artery segments were rated as having significant stenoses (≥50%) or not. Interreader agreement was assessed using Cohen's κ statistic. The primary analysis was whether the accuracy of LI for detecting significant stenosis was noninferior to that of FI at the patient level (margin = -10%). Secondary analyses included similar analyses of sensitivity and specificity, at both the patient and vessel levels., Results: Interreader agreement for significant stenosis was good for both LI and FI (κ = 0.72 vs 0.70, P = .74). Average accuracy for significant stenosis at the patient level was 90.5% for LI and 91.9% for FI, with a difference of -1.4%. The accuracy of LI was noninferior to FI, because the confidence interval did not include the noninferiority margin. Noninferiority was also found for patient-level sensitivity and for accuracy, sensitivity, and specificity at the vessel level., Conclusions: LI of the coronary arteries using transaxial CCTA images may be sufficient for the detection of significant coronary artery disease in the ED setting., (Copyright © 2023 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Objective: We sought to confirm, refute, or modify a 4-step process for implementing shared decision-making (SDM) in pediatrics that involves determining 1) if the decision includes >1 medically reasonable option; 2) if one option has a favorable medical benefit-burden ratio compared to other options; and 3) parents' preferences regarding the options; then 4) calibrating the SDM approach based on other relevant decision characteristics., Methods: We videotaped a purposive sample of pediatric inpatient and outpatient encounters at a single US children's hospital. Clinicians from 7 clinical services (craniofacial, neonatology, oncology, pulmonary, pediatric intensive care, hospital medicine, and sports medicine) were eligible. English-speaking parents of children who participated in inpatient family care conferences or outpatient problem-oriented encounters with participating clinicians were eligible. We conducted individual postencounter interviews with clinician and parent participants utilizing video-stimulated recall to facilitate reflection of decision-making that occurred during the encounter. We utilized direct content analysis with open coding of interview transcripts to determine the salience of the 4-step SDM process and identify themes that confirmed, refuted, or modified this process., Results: We videotaped 30 encounters and conducted 53 interviews. We found that clinicians' and parents' experiences of decision-making confirmed each SDM step. However, there was variation in the interpretation of each step and a need for flexibility in implementing the process depending on specific decisional contexts., Conclusions: The 4-step SDM process for pediatrics appears to be salient and may benefit from further guidance about the interpretation of each step and contextual factors that support a modified approach., (Copyright © 2023 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Delay or refusal of childhood vaccines is common and may be increasing. Pediatricians are parents' most trusted source for vaccine information, yet many struggle with how to communicate with parents who resist recommended vaccines. Evidence-based communication strategies for vaccine conversations are lacking. In this manuscript, we describe the development and perceived usefulness of a curriculum to train clinicians on a specific vaccine communication strategy as part of the PIVOT with MI study, a cluster randomized trial testing the effectiveness of this communication strategy on increasing childhood vaccination uptake among 24 pediatric practices in Colorado and Washington. The communication strategy is based on the existing evidence-based communication strategies of a presumptive format for initiating vaccine conversations and use of motivational interviewing if hesitancy persists. Focus groups and semi-structured interviews with pediatric clinicians helped inform the development of the training curriculum, which consisted of an introductory video module followed by 3 training sessions. Between September 2019 and January 2021, 134 pediatric clinicians (92 pediatricians, 42 advanced practice providers) participated in the training as part of the PIVOT with MI study. Of these, 92 % viewed an introductory video module, 93 % attended or viewed a baseline synchronous training, 82 % attended or viewed a 1st refresher training, and 77 % attended or viewed a 2nd refresher training. A follow-up survey was administered August 2020 through March 2021; among respondents (n = 100), >95 % of participants reported that each component of the training program was very or somewhat useful. These data suggest that the PIVOT with MI training intervention is a useful vaccine communication resource with the potential for high engagement among pediatric clinicians., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Introduction: Trauma center radiologists vary widely in the degree to which they provide secondary interpretations for transferred patients' advanced imaging. A general perception of uncertainty over reimbursement for these exams often results in reluctance to provide routine overreads. The purpose of this study is to assess the difference in reimbursement rates between primary interpretations and secondary interpretations in the emergency department (ED) setting., Materials and Methods: Billing records for the three CT procedures most commonly performed in a single, major level 1 trauma center ED from January 1, 2021, to December 31, 2021, constituted the dataset. Gross charges, total receipts, and payer status were recorded for each exam, and reimbursement rates calculated., Results: In total, 19,754 exams met the inclusion criteria. Primary interpretation was performed on 16,507 (83.6%) exams and secondary interpretation on 3247 (16.4%). For the three CPT codes examined, the average reimbursement percentage was 32.9% for primary interpretation and 43.5% for secondary interpretation. The average reimbursement percentage for commercial payers was 56.5% for primary interpretation and 65.9% for secondary interpretation. The average reimbursement percentage for Health Insurance Exchange payers was 58.5% for primary interpretation and 59.5% for secondary interpretation. The average reimbursement percentage for Medicaid was 24.7% for primary interpretation and 39.9% for secondary interpretation. The average reimbursement percentage for Medicare was 31.1% for primary interpretation and 30.2% for secondary interpretation. The average reimbursement percentage for self-paying patients was 2.3% for primary interpretation and 3.5% for secondary interpretation., Conclusion: Regardless of payer status, reimbursement for secondary interpretation of the three most common transfer patients' CT exams is near or greater than that of primary interpretations., (© 2022. The Author(s), under exclusive licence to American Society of Emergency Radiology (ASER).)

Purpose: Advanced imaging examinations of emergently transferred patients (ETPs) are overread to various degrees by receiving institutions. The practical clinical impact of these second opinions has not been studied in the past. The purpose of this study is to determine if emergency radiology overreads change emergency medicine decision making on ETPs in the emergency department (ED)., Methods: All CT and MRI examinations on patients transferred to a level I trauma center during calendar year 2018 were routinely overread by emergency radiologists and discrepancies with the outside report electronically flagged. All discrepant reports compared with the outside interpretations were reviewed by one of four emergency medicine physicians. Comparing the original and final reports, reviewers identified changes in patient management that could be attributed to the additional information contained in the final report. Changes in patient care were categorized as affecting ED management, disposition, follow-up, or consulting services., Results: Over a 12-month period, 5,834 patients were accepted in transfer. Among 5,631 CT or MRI examinations with outside reports available, 669 examinations (12%) had at least one discrepancy in the corresponding outside report. In 219 examinations (33%), ED management was changed by discrepancies noted on the final report; patient disposition was affected in 84 (13%), outpatient follow-up in 54 (8%), and selection of consulting services in 411 (61%), and ED stay was extended in 544 (81%). Discrepant findings affected decision making in 613 of 669 of examinations (92%)., Conclusion: Emergency radiology overreading of transferred patients' advanced imaging examinations provided actionable additional information to emergency medicine physicians in the care of 613 of 669 (92%) examinations with discrepant findings. This added value is worth the effort to design workflows to routinely overread CT and MRI examinations of ETPs., (Copyright © 2022 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Background: At our level 1 trauma center, we overread cross-sectional scans on all transferred patients, initially reported by community radiologists (CR). We designed a unique peer feedback learning model to address discrepancies encountered with outside overreads with the goal of practice improvement on the part of the CRs. Although there is ample literature on internal peer review and peer learning programs, no publications address errors committed by peers outside institutional boundaries. In this paper we describe our model and report a survey analyzing the perception of the program by the CRs., Materials and Methods: Outside CT and MR exams and reports of patients transferred to our level 1 trauma center were imported into PACS and prospectively overread by specialist trauma radiologists. Our report contained a summary of the outside findings as well as our findings. In the case of a significant discrepancy, a paper copy of our final report was sent by US mail to the originating CR. When the program had been active for 18 months, an invitation to participate in a survey was sent to all radiologists who had been sent reports., Results: Eight thousand three hundred forty patients were transferred, of which 4331 (52%) had 9175 exams with outside reports (8666 CT scans and 509 MRI). One hundred seventy six final report letters containing significant discrepancies were sent to 139 individual radiologists. These 139 radiologists also later received our survey letter. Thirty-eight (27%) responses were received. Thirty-two respondents (84%) recalled receiving the report and reviewed the exam in question. Twenty-eight of them (85%) agreed with the overread and 30 (88%) believed that our feedback program should be continued., Conclusion: We have designed a novel peer feedback learning model to address discrepancies in outside overreads which is administratively simple and well received by the CRs getting feedback. Those CR who responded to the survey rated the experience favorably and wanted the practice continued, although the overall response rate did not allow statistical analysis. Also, institutions trying to design similar or new peer learning models can benefit from our experience., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: To evaluate receipt fidelity of communication training content included in a multifaceted intervention known to reduce antibiotic over-prescribing for pediatric acute respiratory tract infections (ARTIs), by examining the degree to which clinicians implemented the intended communication behavior changes., Methods: Parents were surveyed regarding clinician communication behaviors immediately after attending 1026 visits by children 6 months to < 11 years old diagnosed with ARTIs by 53 clinicians in 18 pediatric practices. Communication outcomes analyzed were whether clinicians: (A) provided both a combined (negative + positive) treatment recommendation and a contingency plan (full implementation); (B) provided either a combined treatment recommendation or a contingency plan (partial implementation); or (C) provided neither (no implementation). We used mixed effects multinomial logistic regression to determine whether these 3 communication outcomes changed between baseline and the time periods following each of 3 training modules., Results: After completing the communication training, the adjusted probability of clinicians fully implementing the intended communication behavior changes increased by an absolute 8.1% compared to baseline (95% Confidence Interval [CI]: 2.4%, 13.8%, p = .005)., Conclusions: Our findings support the receipt fidelity of the intervention's communication training content., Practical Implications: Clinicians can be trained to implement communication behaviors that may aid in reducing antibiotic over-prescribing for ARTIs., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Purpose: To determine the rate and nature of significant discordances between community and subspecialist emergency radiologists' interpretations of cross-sectional exams performed on patients transferred to our trauma center., Methods: Outside hospital CT and MRI exams performed on transfer trauma patients are routinely overread by subspecialist emergency radiologists, specifying either concordance or discordance with the interpretation by the community radiologist. We evaluated the discordant reports for clinical significance, defined as an additional finding or difference in interpretation which was likely to affect patient management. The total rate of significant discordances, rate by modality, rate by body region, and rate per patient transferred were calculated. The most common errors were identified, and the distribution of errors among individual community radiologists was examined., Results: 9175 exams were reviewed. Significant discordances were encountered in 4.1% of exams: 3.9% for CT and 6.7% for MRI; 5.1% for head and neck exams, 3.3% for spine, 3.8% for torso, and 2.9% for extremities. The discordance rate per patient transferred was 7.7%. The most common discordances involved missing injuries to the cranio-cervical junction, missing or misinterpreting vascular injuries in the neck, and incompletely characterizing facial fractures. Discordances were evenly spread among 220 community radiologists., Conclusion: There is frequent discordance between community and emergency radiologists' interpretations of CT and MRI exams, leading to a change in transferred patient management. Thus, trauma center radiologists provide added value overreading these patients' exams. It is difficult to predict which patients or exams will contain discordances, justifying routine overreading of all such exams., (© 2022. American Society of Emergency Radiology.)

The ACR Council passed Resolution 47 at its 2020 annual meeting establishing a representative task force (TF) to explore the concept of the "multispecialty radiologist," previously proposed in 2012. The TF held eight virtual meetings over 8 months, considered data from a 2020 ACR Membership Tracking Survey, conducted a review of current literature, and collected anecdotal experience from TF members and ACR leadership. ACR legal counsel and a cross-section of ACR Commissions and Committees also provided input. The TF concluded that there is scant interest from the radiology community in the multispecialty radiologist title and no agreed-upon definition for the term. Radiologists may identify as diagnostic or subspecialty radiologists; however, the roles they fill in clinical practice include general, multispecialty, and subspecialized radiology. The TF proposes definitions for each of these terms to support radiologist recruitment aligned with optimal patient care in the practice community and to improve the quality of data collection about the field. To reduce ambiguity, the TF proposes adoption of the defined terms by the radiology community, including radiologist recruiters and employers, and suggests ways in which resident training and the ABR board examination can be adapted to support this new structure. Additionally, as part of an exploration of hyperspecialization and trainee preparedness for clinical practice, the TF discussed the challenges faced by community-based practices seeking to provide a full range of high-quality, radiologist-delivered diagnostic and interventional services to their patient populations., (Copyright © 2021 American College of Radiology. All rights reserved.)

OBJECTIVE. To reduce staff exposure to infection and maintain operational efficiency, we have developed a protocol to image patients using portable chest radiography through the glass of an isolation room. This technique is safe and easy to implement. Images are of comparable quality to standard portable radiographs. CONCLUSION. This protocol, used routinely by our department during the COVID-19 pandemic, can be applied to any situation in which the patient is placed in isolation.

Purpose: To evaluate whether volumetric measurements of segmental vascular injuries (SVIs) based on computed tomography (CT) imaging obtained during an initial trauma survey correlate with future nuclear medicine (NM) split renal function., Methods: A retrospective review was performed of renal trauma patients treated at a level 1 trauma center between 2008 and 2015. Patients with unilateral SVIs on initial CT imaging with follow-up NM renal scans were evaluated. CT-based split renal function was calculated by assessing the ratio of ipsilateral uninjured kidney volume to bilateral total uninjured kidney volume by two separate radiologists., Results: Eight patients with unilateral SVIs on initial CT trauma evaluation underwent follow-up NM renal scans at a mean of 4 months (range 2-6) after injury. Mean NM split renal function of the injured kidney was 43% (range 22-57). Based on the CT volumetric measurements of the affected kidney, mean percent injured was 23% (range 7-62) with a calculated mean split renal function of 44% (range 23-60). Calculated mean CT split function correlated with NM split function (R = 0.89). Intraclass correlation measuring inter-rater reliability for CT volumetric measurements was 0.94 (95% confidence interval 0.72-0.99)., Conclusion: Volumetric measurements based on CT imaging obtained during the initial trauma evaluation correlated with future NM split renal function after SVIs with high inter-rater reliability. This method utilizes pre-existing imaging and avoids additional radiation exposure, work burden, and financial cost from a NM scan. Further evaluation is required to assess feasibility with more complex injuries.

Purpose: Occasionally, a patient requiring computed tomography (CT) with poor venous access or in an unstable condition may have a sheath as their only form of IV access. Many institutions prohibit contrast power injection through the side ports, for concern for rupture. We hypothesize that under conditions encountered in CT scanning, the side arm of the sheath introducer is safe for power injection of contrast material., Methods: In this in vitro study, we injected contrast at different flow rates varying from 2 to 8 ml/s, through the side port of the sheath. Time-pressure graphs were obtained for each injection from the injector display. The assembly was observed for any signs of leakage or material failure., Results: There was not a single event of leak, rupture, or displacement. Maximum pressures were within the range of conventional contrast administrations., Conclusion: This study suggests that iodinated contrast can safely be injected through the side port of a venous sheath.

Purpose: While several studies analyze radiology malpractice lawsuits, none specifically examines the site of service. The purpose of this study is to estimate the relative likelihood of a lawsuit arising from a radiology study performed in emergency (ED), inpatient (IP) and outpatient (OP) settings., Methods: Referrals from a malpractice review consulting company over a six year period were compared to the 2016 Medicare Part B file and stratified by site of service. The proportion of exams for each site of service was estimated, and using absolute differences in proportions and odds ratios (ORs), differences in the place of service were calculated., Results: The Cleareview cohort contained 25 (17%) IP, 56 (38%) OP, and 68 (46%) ED exams. In 2016, Medicare assigned benefits for 27,009,053 (20%) IP, 84,075,848 (62%) OP and 23,964,794 (18%) ED exams. The ORs (Cleareview: Medicare) of the ED to IP, OP, and IP+OP were 3.07 (95% CI: 1.56-6.03), 4.26 (95% CI: 2.76-6.59), 3.89 (95% CI: 2.60-5.83), respectively. By contrast, the OR for IP:OP between Cleareview and Medicare was not significantly different than 1 (OR: 1.39, 95% CI: 0.68-2.83, P = .38)., Discussion: Radiological studies performed in the ED accounted for a disproportionate number of liability claims against radiologists. Further study is warranted to confirm this finding with a more robust data set., (Copyright © 2019 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Core Curriculum Illustration: [blunt thoracic aortic pseudo aneurysm]. This is the [40th] installment of a series that will highlight one case per publication issue from the bank of cases available online as part of the American Society of Emergency Radiology (ASER) educational resources. Our goal is to generate more interest in and use of our online materials. To view more cases online, please visit the ASER Core Curriculum and Recommendations for Study online at: http://www.aseronline.org/curriculum/toc.html.

The escalation of imaging volumes in the emergency department and intensifying demands for rapid radiology results have increased the demand for emergency radiology. The provision of emergency radiology is essential for nearly all radiology practices, from the smallest to the largest. As our radiology specialty responds to the challenge posed by the triple threat of providing 24-7 coverage, high imaging volumes, and rapid turnaround time, various questions regarding emergency radiology have emerged, including its definition and scope, unique operational demands, quality and safety concerns, impact on physician well-being, and future directions. This article reviews the current challenges confronting the subspecialty of emergency radiology and offers insights into preparing for continued growth., (Copyright © 2019 American College of Radiology. All rights reserved.)

Purpose: Growing numbers of patient with advanced imaging being transferred to trauma centers has resulted in increased numbers of outside CT scans received at trauma centers. This study examines the degree of agreement between community radiologists' interpretations of the CT scans of transferred patients and trauma center radiologists' reinterpretation., Methods: All CT scans of emergency transfer patients received over a 1 month period were reviewed by an emergency radiologist. Patients were classified as trauma or non-trauma and exams as neuro or non-neuro. Interpretive discrepancies between the emergency radiologist and community radiologist were classified as minor, moderate, or major. Major discrepancies were confirmed by review of a second emergency radiologist. Discrepancy rates were calculated on a per-patient and per exam basis., Results: Six hundred twenty-seven CT scans of 326 patients were reviewed. Major discrepancies were encountered in 52 (16.0%, 95% CI 12.2-20.5) patients and 53 exams (8.5%, 95% CI 6.5-10.5). These were discovered in 46 trauma patients (21.6%, 95% CI 16.4-27.9) compared to six non-trauma patients (5.3%, 95% CI 2.2-11.7) (P < 0.001). A significant difference in the major discrepancy rate was also found between non-neuro and neuro exams (12.4 vs 3.3%, respectively, P < 0.001), primarily due to discrepancies in trauma patients, rather than non-trauma patients., Conclusions: Potentially management-changing interpretive changes affected 16% of transferred patients and 8.5% of CT exams over a 1 month period. Trauma center reinterpretations of community hospital CT scans of transferred patients provide valuable additional information to the clinical services caring for critically ill patients.

Objective: To examine how clinicians communicate with parents about influenza vaccination and the effect of these communication behaviors on parental vaccine decision-making., Study Design: We performed a secondary analysis of data obtained from a cross-sectional observational study in which health supervision visits between pediatric clinicians and English-speaking parents of young children were videotaped. Eligible visits occurred during the 2011-2012 and 2013-2014 influenza seasons, included children ≥6months, and contained an influenza vaccine discussion. A coding scheme of 10 communication behaviors was developed and applied to each visit. Associations between clinician communication behaviors and parental verbal vaccine acceptance and parental visit experience were examined using bivariate analysis and generalized linear mixed models., Results: Fifty visits involving 17 clinicians from 8 practices were included in analysis. The proportion of parents who accepted influenza vaccine was higher when clinicians initiated influenza vaccine recommendations using presumptive rather than participatory formats (94% vs. 28%, p<0.001; adjusted odds ratio 48.2, 95% CI 3.5-670.5). Parental acceptance was also higher if clinicians pursued (vs. did not pursue) original recommendations when parents voiced initial resistance (80% vs. 13%, p<0.05) or made recommendations for influenza vaccine concurrent with (vs. separate from) recommendations for other vaccines due at the visit (83% vs. 33%, p<0.01). Parental visit experience did not differ significantly by clinician communication behaviors., Conclusion: Presumptive initiation of influenza vaccine recommendations, pursuit in the face of resistance, and concurrent vaccine recommendations appear to increase parental acceptance of influenza vaccine without negatively affecting visit experience., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Objective: Peer review is an important and necessary part of radiology. There are several options to perform the peer review process. This study examines the reproducibility of peer review by comparing two scoring systems., Materials and Methods: American Board of Radiology-certified radiologists from various practice environments and subspecialties were recruited to score deidentified examinations on a web-based PACS with two scoring systems, RADPEER and Cleareview. Quantitative analysis of the scores was performed for interrater agreement., Results: Interobserver variability was high for both the RADPEER and Cleareview scoring systems. The interobserver correlations (kappa values) were 0.17-0.23 for RADPEER and 0.10-0.16 for Cleareview. Interrater correlation was not statistically significantly different when comparing the RADPEER and Cleareview systems (p = 0.07-0.27). The kappa values were low for the Cleareview subscores when we evaluated for missed findings (0.26), satisfaction of search (0.17), and inadequate interpretation of findings (0.12)., Conclusion: Our study confirms the previous report of low interobserver correlation when using the peer review process. There was low interobserver agreement seen when using both the RADPEER and the Cleareview scoring systems.

Objective: The purpose of this article is to illustrate the use of the American College of Radiology Dose Index Registry data with a novel measurement of exposure to guide quality improvement efforts., Materials and Methods: Using information from the Dose Index Registry report covering July through December 2012, we examined our relative ranking compared with the national median CT dose for the 20 most frequently performed examinations at our institution. The total exposure variance, defined as the difference between institutional and median national dose multiplied by the local examination frequency and expressed in units of mGy-persons, was calculated. Using this metric, two examinations were selected for investigation: pulmonary and thoracic CT angiography (CTA). Protocol modifications were implemented, and postintervention dose data were assessed from the report 1 year later., Results: As indicated by size-specific dose estimates (SSDEs), the 2012 pulmonary CTA was within the national interquartile range; however, total exposure variance analysis showed that it presented the greatest opportunity for improvement on a population basis. Thoracic CTA was a top quartile examination and offered the second highest potential savings. After protocol modification, the average pulmonary CTA SSDEs decreased by 16%, for a population exposure savings of 1776 mGy-persons in the 2013 report. Average thoracic CTA SSDEs decreased by 44%, for a population exposure savings of 1050 mGy-persons., Conclusion: Total exposure variance analysis can increase the usefulness of Dose Index Registry data by relating per-examination dose differences to the local examination frequency. This study exhibited reduction of dose metrics for two commonly performed examinations.

Objective: Soliciting patients' complete agendas of concerns (aka. 'agenda setting') can improve patients' health outcomes and satisfaction, and physicians' time management. We assess the distribution, content, and effectiveness of physicians' post-chief-complaint, agenda-setting questions., Methods: We coded videotapes/transcripts of 407 primary-, acute-care visits between adults and 85 general-practice physicians operating in 46 community-based clinics in two states representing urban and rural care. Measures are the incidence of physicians' questions, their linguistic format, position within visits, likelihood of being responded to, and the nature of such responses., Results: Physicians' questions designed to solicit concerns additional to chief concerns occurred in only 32% of visits (p<.001). Compared to questions whose communication format explicitly solicited 'questions' (e.g., "Do you have any questions?"), those that were formatted so as to allow for 'concerns' (e.g., "Any other concerns?") were significantly more likely to generate some type of agenda item (Chi(2) (1, N=131)=11.96, p=.001), and to do so more frequently when positioned 'early' vs. 'late' during visits (Chi(2) (1, N=73)=4.99, p=.025)., Conclusions: Agenda setting is comparatively infrequent. The communication format and position of physicians' questions affects patients' provision of additional concerns/questions., Practice Implications: Physicians should increase use of optimized forms of agenda setting., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

In the more than 1 billion primary-care visits each year in the United States, the majority of patients bring more than one distinct concern, yet many leave with "unmet" concerns (i.e., ones not addressed during visits). Unmet concerns have potentially negative consequences for patients' health, and may pose utilization-based financial burdens to health care systems if patients return to deal with such concerns. One solution to the problem of unmet concerns is the communication skill known as up-front agenda setting, where physicians (after soliciting patients' chief concerns) continue to solicit patients' concerns to "exhaustion" with questions such as "Are there some other issues you'd like to address?" Although this skill is trainable and efficacious, it is not yet a panacea. This article uses conversation analysis to demonstrate that patients understand up-front agenda-setting questions in ways that hamper their effectiveness. Specifically, we demonstrate that up-front agenda-setting questions are understood as making relevant "new problems" (i.e., concerns that are either totally new or "new since last visit," and in need of diagnosis), and consequently bias answers away from "non-new problems" (i.e., issues related to previously diagnosed concerns, including much of chronic care). Suggestions are made for why this might be so, and for improving up-front agenda setting. Data are 144 videotapes of community-based, acute, primary-care, outpatient visits collected in the United States between adult patients and 20 family-practice physicians.

Rationale and Objectives: This study explored four common sequences of interaction between providers and a collaborative, nondenial model preauthorization program to assess the extent to which the collaborative consultation impacted care delivered to a patient in the 30 days after a neuroimaging consult. In each of the sequences examined, providers interacted with the preauthorization program's consulting radiologist and modified their imaging study requests during the interaction. If providers did not subsequently reinitiate the original study requests, then it suggests that the study resulting from the collaborative consultation fulfilled the providers' clinical objective., Materials and Methods: Four years of retrospective authorization and clinical data were analyzed to determine the rate at which requests modified through peer-to-peer consultation were reinitiated in the following four sequences: 1) request for head computed tomography (CT) modified to head magnetic resonance imaging (MRI), 2) request for both head CT and intracranial CT angiography (CTA) or both head MRI and intracranial MRA modified to a request for a single study, 3) request for both a CT of the head and sinuses modified to a request for a single study, and 4) request for an MRI of the head and orbits modified to a request for a single study., Results: In three of the sequences, no provider reinitiated a study within 30 days. In the fourth sequence, only 4 of 64 (6%) withdrawn requests for head CT/MRI or head CTA/MRA were reinitiated within 30 days., Conclusions: Modifications after collaborative consultations rarely lead to repeat imaging requests, confirming the utility of the consultations., (Copyright © 2015 AUR. Published by Elsevier Inc. All rights reserved.)

Objectives: We investigated how provider vaccine communication behaviors influence parental vaccination acceptance and visit experience., Methods: In a cross-sectional observational study, we videotaped provider-parent vaccine discussions (n = 111). We coded visits for the format providers used for initiating the vaccine discussion (participatory vs presumptive), parental verbal resistance to vaccines after provider initiation (yes vs no), and provider pursuit of recommendations in the face of parental resistance (pursuit vs mitigated or no pursuit). Main outcomes were parental verbal acceptance of recommended vaccines at visit's end (all vs ≥ 1 refusal) and parental visit experience (highly vs lower rated)., Results: In multivariable models, participatory (vs presumptive) initiation formats were associated with decreased odds of accepting all vaccines at visit's end (adjusted odds ratio [AOR] = 0.04; 95% confidence interval [CI] = 0.01, 0.15) and increased odds of a highly rated visit experience (AOR = 17.3; 95% CI = 1.5, 200.3)., Conclusions: In the context of 2 general communication formats used by providers to initiate vaccine discussions, there appears to be an inverse relationship between parental acceptance of vaccines and visit experience. Further exploration of this inverse relationship in longitudinal studies is needed.

To assess the sensitivity of detecting the most commonly encountered foreign bodies in Emergency Radiology using all imaging modalities (conventional radiography, computed tomography, ultrasound, and magnetic resonance imaging). The following materials were inserted into a pig-leg phantom and imaged using conventional radiography, computed tomography, ultrasound, and magnetic resonance imaging: Plastics #1, 2, 3, 5, and compostable plastic; dry and wet wood, aluminum, gravel, glass (tinted and non-tinted), and Salmon and Halibut fish bones. The visibility of plastic is variable on both conventional radiography and computed tomography, depending on composition, but all types of plastic are well visualized on ultrasound. Wood is most easily identified and localized on both computed tomography and ultrasound, is only faintly visible on conventional radiography, and is not well visualized on magnetic resonance imaging. Gravel, glass, and aluminum are well visualized on all modalities, with the exception of magnetic resonance imaging, where there is significant artifact surrounding the foreign body. Fish bones (Halibut and Salmon) are well visualized on conventional radiography, computed tomography, and ultrasound. Conventional radiography and computed tomography are great modalities for detecting foreign bodies of various compositions. Computed tomography is particularly useful at localizing the foreign body and determining its relationship to surrounding structures and its depth of involvement. All foreign bodies are visualized on ultrasound if the location is known and the foreign body is in the plane of the transducer. Magnetic resonance imaging is not helpful in detecting foreign bodies.

Purpose: This study examined relationships between provider communication practices, antibiotic prescribing, and parent care ratings during pediatric visits for acute respiratory tract infection (ARTI)., Methods: A cross-sectional study was conducted of 1,285 pediatric visits motivated by ARTI symptoms. Children were seen by 1 of 28 pediatric providers representing 10 practices in Seattle, Washington, between December 2007 and April 2009. Providers completed post-visit surveys reporting on children's presenting symptoms, physical examination findings, assigned diagnoses, and treatments prescribed. Parents completed post-visit surveys reporting on provider communication practices and care ratings for the visit. Multivariate analyses identified key predictors of prescribing antibiotics for ARTI and of parent visit ratings., Results: Suggesting actions parents could take to reduce their child's symptoms (providing positive treatment recommendations) was associated with decreased risk of antibiotic prescribing whether done alone or in combination with negative treatment recommendations (ruling out the need for antibiotics) [adjusted risk ratio (aRR) 0.48; 95% CI, 0.24-0.95; and aRR 0.15; 95% CI, 0.06-0.40, respectively]. Parents receiving combined positive and negative treatment recommendations were more likely to give the highest possible visit rating (aRR 1.16; 95% CI, 1.01-1.34)., Conclusion: Combined use of positive and negative treatment recommendations may reduce the risk of antibiotic prescribing for children with viral ARTIs and at the same time improve visit ratings. With the growing threat of antibiotic resistance at the community and individual level, these communication techniques may assist frontline providers in helping to address this pervasive public health problem., (© 2015 Annals of Family Medicine, Inc.)

Objective: As the use of medical images in applications other than direct patient care increases, the need for deidentified images grows. Federal regulations govern the requirements for deidentification, and software developers offer several methods for deidentification., Conclusion: However, there are numerous ways for protected health information to be included in images other than in DICOM headers. Either such information must be obscured or the images containing the information must be deleted to comply with deidentification requirements.

Purpose: Seeking to control advanced diagnostic imaging costs, health insurance plans have instituted broad-based utilization management systems. Most processes ultimately contain denial provisions, meaning that the health plans will refuse to pay for requested studies if performed. The aim of this analysis was to determine whether removal of a denial provision would result in increased utilization of imaging services., Methods: A major US health plan used a no-denial preauthorization system in all but 4 geographic markets for all CT, MRI, PET, and nuclear cardiac imaging studies, constituting the experimental group. This study consisted of a retrospective review of 247,117 advanced imaging requests 21 months before and 16 months after the elimination of the denial provision in the experimental group. A matched population with no such change in the review process served as the control group. Population-normalized utilization rates were measured for both pooled groups before and after the change., Results: Utilization decreased slightly more in the experimental group than in the control group (-0.10 requests per 1,000 covered lives; 95% confidence interval, -0.20 to 0.00; P = .050) after elimination of the denial provision. The rates of request approval, examination modification, withdrawal, and no consensus after peer-to-peer consultation did not significantly change., Conclusions: Eliminating denial provisions in utilization management for advanced diagnostic imaging does not result in increased utilization of such imaging., (Copyright © 2013 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Objective: Although weight-based contrast agent injection protocols can improve contrast-enhanced CT, one disadvantage is waste caused by differences between the amount of contrast material required for a weight-based algorithm and full-package protocols used with single-use packaging of contrast material. The availability of 500-mL multiple-use packaging of contrast material should facilitate the implementation of weight-based contrast bolus protocols for CT because arbitrary volumes of contrast agent can be loaded without significant waste. Our hypothesis was that multiple-use packaging when used with a weight-based contrast bolus protocol would reduce costs compared with single-use packaging., Materials and Methods: Contrast agent volume loaded and volume actually delivered to 1304 patients undergoing abdominal and pelvic CT were recorded. Model 1 used volume loaded to estimate contrast material cost, model 2 used volume delivered, and model 3 assumed that patients received either 100 or 150 mL from a single-use package, depending on weight., Results: Model 1 required 368 packages of 500 mL contrast material ($23,000). Model 2 required 353 packages of 500 mL contrast material ($22,062.50). Model 3 required 863 and 478 packages of 100 and 150 mL contrast material, respectively ($22,120)., Conclusion: Cost containment can be realized while improving the quality of contrast opacification by employing 500-mL multiple-use packaging of contrast materials. Care must be taken by the technologists to load only the volume of contrast agent that is needed, or the resulting contrast agent waste will negate the savings and even result in cost increases.

Patients transferred for higher levels of care often arrive with medical imaging from the outside facility, with or without accompanying radiology reports. The handling of pretransfer studies by receiving radiologists introduces several concerns regarding resource utilization, medicolegal risk, and technical quality control. The authors review the current status of transfer patient imaging, with an emphasis on the role of the receiving emergency radiologist. Practice solutions developed at the authors' level I trauma center are described., (Copyright © 2013 American College of Radiology. Published by Elsevier Inc. All rights reserved.)