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Mobile health (mHealth) technologies stand poised to find broad application in the radiology space. They hold considerable promise for millions of patients in the United States, enabling at-home imaging and augmenting clinical decision-making. However, they often lie outside the ambit of FDA regulation and process vast quantities of data largely unprotected by HIPAA. This article explores features of federal mHealth policy relevant to imaging practice and advocates for greater regulatory clarity to assist radiologists, developers, and ultimately, patients.

Artificial intelligence technology promises to redefine the practice of radiology. However, it exists in a nascent phase and remains largely untested in the clinical space. This nature is both a cause and consequence of the uncertain legal-regulatory environment it enters. This discussion aims to shed light on these challenges, tracing the various pathways toward approval by the US Food and Drug Administration, the future of government oversight, privacy issues, ethical dilemmas, and practical considerations related to implementation in radiologist practice., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Movement disorders and neurodegenerative diseases are a variety of conditions that involve progressive neuronal degeneration, injury, or death. Establishing the correct diagnosis of a movement disorder or neurodegenerative process can be difficult due to the variable features of these conditions, unusual clinical presentations, and overlapping symptoms and characteristics. MRI has an important role in the initial assessment of these patients, although a combination of imaging and laboratory and genetic tests is often needed for complete evaluation and management. This document summarizes the imaging appropriateness data for rapidly progressive dementia, chorea, Parkinsonian syndromes, suspected neurodegeneration with brain iron accumulation, and suspected motor neuron disease. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment., (Copyright © 2020 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Gadolinium-based contrast agents (GBCAs) have enjoyed wide use since their introduction some 30 years ago. Used in as many as 30% of MRIs performed in the United States, GBCAs have generally been associated with low rates of adverse events. However, the safety profile and attendant medicolegal liability associated with GBCAs changed in 2016 with the description of gadolinium deposition disease (GDD). Despite being unproven scientifically, a groundswell of GDD-related litigation and personal injury advertising targeting potential GDD patients has occurred. In this article, we describe what GDD is, why GDD has created medicolegal risk, and how this risk might be mitigated. This article advocates using a risk mitigation strategy focused on reducing brain gadolinium retention during the period of purported GDD development. As such, based on the currently available data, the authors recommend the preferential use of gadoteridol as the default GBCA for MRI imaging., (Copyright © 2019 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: Limited information exists about medical malpractice claims against physicians-in-training. Data on residents' involvement in malpractice actions may inform perceptions about medicolegal liability and influence clinical decision-making at a formative stage. This study aimed to characterize rates and payment amounts of paid malpractice claims on behalf of resident physicians in the United States., Method: Using data from the National Practitioner Data Bank, 1,248 paid malpractice claims against resident physicians (interns, residents, and fellows) from 2001 to 2015, representing 1,632,471 residents-years, were analyzed. Temporal trends in overall and specialty-specific paid claim rates, payment amounts, catastrophic (> $1 million) and small (< $100,000) payments, and other claim characteristics were assessed. Payment amounts were compared with attending physicians during the same time period., Results: The overall paid malpractice claim rate was 0.76 per 1,000 resident-years from 2001 to 2015. Among 1,194 unique residents with paid claims, 95.7% had exactly 1 claim, while 4.3% had 2-4 claims during training. Specialty-specific paid claim rates ranged from 0.12 per 1,000 resident-years (pathology) to 2.96 (obstetrics and gynecology). Overall paid claim rates decreased by 52% from 2001-2005 to 2011-2015 (95% confidence interval [CI]: 0.45, 0.59). Median inflation-adjusted payment amount was $199,024 (2015 dollars), not significantly different from payments made on behalf of attending physicians during the same period. Proportions of catastrophic (11.2%) and small (33.1%) claims did not significantly change over the study period., Conclusions: From 2001 to 2015, paid malpractice claim rates on behalf of resident physicians decreased by 52%, while median payment amounts were stable. Resident paid claim rates were lower than attending physicians, while payment amounts were similar.

Recent years have seen digital technologies increasingly leveraged to multiply conventional imaging modalities' diagnostic power. Artificial intelligence (AI) is most prominent among these in the radiology space, touted as the "stethoscope of the 21st century" for its potential to revolutionize diagnostic precision, provider workflow, and healthcare expenditure. Partially owing to AI's unique characteristics, and partially due to its novelty, existing regulatory paradigms are not well suited to balancing patient safety with furthering the growth of this new sector. The current review examines the historic, current, and proposed regulatory treatment of AI-empowered medical devices by the US Food and Drug Administration (FDA). An innovative framework proposed by the FDA seeks to address these issues by looking to current good manufacturing practices (cGMP) and adopting a total product lifecycle (TPLC) approach. If brought into force, this may reduce the regulatory burden incumbent on developers, while holding them to rigorous quality standards, maximizing safety, and permitting the field to mature., (Copyright © 2019 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.)

Objective: The aim of this study was to determine the association between the presence of chronic medical disease and mammography screening adherence. Materials and Methods: We performed a retrospective study on women between the ages of 50 and 64 who received screening mammography in 2005 and had at least 8 years of follow-up. Demographic and clinical information was obtained from our centralized patient data registry. Women diagnosed with one or more of the following diseases for at least 3 months before their index mammogram were considered to have a chronic disease, including atrial fibrillation, congestive heart failure, Chronic Obstructive Pulmonary Disease (COPD), diabetes mellitus type II, heart disease, and/or peripheral vascular disease. Generalized estimating equations were used to evaluate for correlated observations. Multivariable regression analyses were used to evaluate the effects of selected chronic medical diseases on longitudinal engagement with routine mammography. Results: Of 9575 women identified, 1669 (17.7%) had one or more of the selected chronic medical diseases. The presence of one or more of these diseases was associated with reduced mammography screening (-0.29; confidence interval [CI] = -0.36 to -0.14; p  < 0.01) compared with women without these diseases over the study period. Within this group, the presence of congestive heart failure (-0.88; CI = -0.84 to -0.45; p  ≤ 0.01), COPD (-0.39; CI = -0.57 to -0.21; p  ≤ 0.01), or diabetes mellitus type II (-0.37; CI = -0.57 to -0.17; p  ≤ 0.01) was individually associated with reduced screening compared with women without the respective disease. Compared with women without chronic medical disease, women with multiple chronic medical diseases (-0.62; CI = -0.93 to -0.30; p  ≤ 0.01) were significantly ( p  ≤ 0.05) less likely to receive routine screening, while no significant difference was seen in women with only one chronic medical disease (-0.18; CI = -0.39 to -0.02; p  ≤ 0.08). Conclusion: Despite experiencing longer life expectancies, women with specific chronic diseases may experience additional barriers to uptake of mammography screening, which is likely compounded by the comorbidity burden of being simultaneously treated for multiple chronic conditions. Increased health care interactions seen in this group may represent missed opportunities to improve screening adherence.

Purpose: Regular contact with a primary care physician (PCP) is associated with increased participation in screening mammography. Older studies suggested that PCP interaction may have a smaller effect on screening mammography uptake among racial and ethnic minorities compared with whites, but there is limited contemporary evidence about the effect of PCP interaction on screening mammography uptake across different racial and ethnic groups. The purpose of this study was to evaluate the association between PCP contact and longitudinal adherence with screening mammography guidelines over a 10-year period across different racial/ethnic groups., Methods: This HIPAA-compliant and institutional review board-approved retrospective single-institution study included women between the ages of 50 and 64 years who underwent screening mammography in the calendar year of 2005. The primary outcome of interest was adherence to recommended screening mammography guidelines (yes or no) at each 2-year interval from their index screening mammographic examination in 2005 until 2015. Patients were defined as having a high level of PCP interaction if their PCPs were listed in the electronic medical record within the top three providers with whom the patients had the most visits during the study period. Generalized estimating equation models were used to estimate the effect of high PCP interaction on screening mammography adherence while adjusting for correlated observations and patient characteristics., Results: Patients in the high PCP interaction group had increased longitudinal adherence to recommended screening mammography (adjusted odds ratio [OR], 1.51; 95% confidence interval [CI], 1.42-1.73; P < .001). This was observed in stratified analyses for all self-reported racial groups, including white (adjusted OR, 1.51; 95% CI, 1.36-1.68; P < .001), black (adjusted OR, 1.93; 95% CI, 1.31-2.86; P = .001), Hispanic (adjusted OR, 1.92; 95% CI, 1.27-2.87; P = .002), Asian (adjusted OR, 1.55; 95% CI, 1.01-2.39; P = .045), and other (adjusted OR, 2.18; 95% CI, 1.32-3.56; P = .002), with no evidence of effect modification by race/ethnicity (P = .342). Medicaid (adjusted OR, 0.41; 95% CI, 0.31-0.53) and self-pay or other (adjusted OR, 0.39; 95% CI, 0.27-0.56) insurance categories were associated with decreased longitudinal adherence to recommended screening mammography (P < .001 for both)., Conclusions: High levels of PCP interaction result in similar improvements in longitudinal screening mammography adherence for all racial/ethnic minority groups. Future efforts will require targeted outreach to assist Medicaid and uninsured patient populations overcome barriers to screening mammography adherence., (Copyright © 2018 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Ataxia can result from an abnormality in the cerebellum, spinal cord, peripheral nerves, and/or vestibular system. Pathology involving the brain, such as infarct or hydrocephalus, can also present with ataxia as part of the symptom constitution, or result in symptoms that mimic ataxia. Clinical evaluation by history and careful neurological examination is important to help with lesion localization, and helps determine where imaging should be focused. In the setting of trauma with the area of suspicion in the brain, a head CT without intravenous contrast is the preferred initial imaging choice. If vascular injury is suspected, CTA of the neck can be helpful. When the area of suspicion is in the spine, CT or MRI of the spine can be considered to assess for bony or soft-tissue injury, respectively. In the setting of ataxia unrelated to recent trauma, MRI is the preferred imaging modality, tailored to assess the brain or spine depending on the area of suspected pathology. The use of intravenous contrast is generally helpful. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment., (Copyright © 2019 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

There are a wide variety of diseases that affect the thyroid gland ranging from hyperplastic to neoplastic, autoimmune, or inflammatory. They can present with functional abnormality or a palpable structural change. Imaging has a key role in diagnosing and characterizing the thyroid finding for management. Imaging is also essential in the management of thyroid cancer. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment., (Copyright © 2019 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate a new system for processing and performing inpatient STAT diagnostic imaging with respect to utilization and time-based performance metrics., Materials and Methods: This HIPAA-compliant study had institutional review board approval; informed consent was not required. The radiology information system of a large academic medical center was queried for all inpatient diagnostic imaging exams performed and interpreted from August 1, 2010, to October 31, 2012. Using customized software, data were evaluated based on order priority (non-STAT or STAT) and exam modality with respect to exam volume and time-based performance metrics (time-to-performance and preliminary interpretation time). Data were compared over 3 periods: August 1, 2010, to October 31, 2010 (preimplementation period); November 1, 2010, to October 31, 2011 (year 1 postimplementation); and November 1, 2011, to October 31, 2012 (year 2 postimplementation)., Results: In the first year after implementation of the new STAT policy, the percentage of inpatient exams ordered STAT significantly decreased from 22.1% to 5.4% (P < 0.001). This represented a proportional decrease of 26% (CT), 16% (MRI), 20% (US), and 24% (radiographs) relative to pre-STAT policy levels. The median time-to-performance and median preliminary interpretation time significantly decreased for all modalities after implementation of the policy (P < 0.05 for all modalities), decreasing by an average of 104 and 162 minutes, respectively. These changes persisted throughout year 2 postimplementation., Conclusion: A new institutional system for handling inpatient STAT diagnostic imaging results in a decreased number of STAT exams ordered and improved time-based performance metrics, thereby increasing workflow efficiency.

Purpose: The aim of this study was to assess differences in interreader variability among radiologists after the implementation of a computer-assisted reporting (CAR) tool for the interpretation of degenerative disc disease on lumbar spine MRI., Methods: Thirty lumbar spine MRI examinations were selected from the radiology database. Five fellowship-trained musculoskeletal radiologists evaluated each L4-L5 disc in a blinded fashion and reported the findings using a traditional free dictation approach. One month later, they reinterpreted the same discs using a web browser-based CAR tool in the same blinded fashion. The degrees of central canal stenosis, neural foraminal stenosis, and facet joint osteoarthritis; presence or absence of lateral recess stenosis; types of disc bulge or herniation; and herniation location using both methods were recorded. Percentage disagreement among the radiologists for each variable was calculated and compared using the Wilcoxon signed rank test., Results: There was a statistically significant decrease among the five radiologists in percentage disagreement for neural foraminal stenosis (46% versus 35%, P = .0146) and facet joint osteoarthritis (45% and 22%, P < .0001) for reports created by free dictation compared with those created using the CAR tool. There was no statistically significant difference in interreader variability for the assessment of central canal stenosis, lateral recess effacement, disc herniation, disc bulge, or herniation location., Conclusions: Implementation of a CAR tool for the interpretation of degenerative changes on lumbar spine MRI decreases interreader variability in the assessment of neural foraminal stenosis and facet joint osteoarthritis., (Copyright © 2017 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: As health care payment systems transition from fee-for-service to bundled payments, there is an increasing opportunity for radiologists to collaborate to improve population-based health care outcomes. Our purpose was to estimate the extent to which patients engaged in mammography underwent other additional imaging- and non-imaging-based preventative health services using Centers for Disease Control National Population Health Surveys., Methods: Women aged 40 to 74 in the 2014 Behavioral Risk Factor Surveillance System cross-sectional survey without histories of breast cancer who reported having a mammogram within the past 2 years were included. Adherence to recommended preventative services was based on US Preventive Services Task Force Recommendations, relative to the time at which the survey participant responded to the survey. Among women reporting being engaged in mammography, proportions of eligible women obtaining recommended preventative health services were calculated and stratified by demographics., Results: Of 172,245 women, 122,434 (71.1%) reported mammography within 2 years. The following percentages obtained recommended flu vaccines (49.2%), pneumococcal vaccines (69.5%), colorectal cancer screening (74.8%), and Papanicolaou test (93.2%). Women reporting mammography within the last 2 years with lower levels of education and income and who lacked health insurance or personal doctors were less likely to report receiving recommended preventative services (P < .001)., Conclusions: National population-based survey results suggest that large proportions of women engaged in mammography report are not up to date with a wide variety of recommended preventative health services, suggesting ample opportunities for radiology practices to partner with providers to improve population-based health outcomes and add value to health care systems., (Copyright © 2018 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Visual loss can be the result of an abnormality anywhere along the visual pathway including the globe, optic nerve, optic chiasm, optic tract, thalamus, optic radiations or primary visual cortex. Appropriate imaging analysis of visual loss is facilitated by a compartmental approach that establishes a differential diagnosis on the basis of suspected lesion location and specific clinical features. CT and MRI are the primary imaging modalities used to evaluate patients with visual loss and are often complementary in evaluating these patients. One modality may be preferred over the other depending on the specific clinical scenario. Depending on the pattern of visual loss and differential diagnosis, imaging coverage may require targeted evaluation of the orbits and/or assessment of the brain. Contrast is preferred when masses and inflammatory processes are differential considerations. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment., (Copyright © 2018 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: The aim of this study was to investigate the impact of wait days (WDs) on missed outpatient MRI appointments across different demographic and socioeconomic factors., Methods: An institutional review board-approved retrospective study was conducted among adult patients scheduled for outpatient MRI during a 12-month period. Scheduling data and demographic information were obtained. Imaging missed appointments were defined as missed scheduled imaging encounters. WDs were defined as the number of days from study order to appointment. Multivariate logistic regression was applied to assess the contribution of race and socioeconomic factors to missed appointments. Linear regression was performed to assess the relationship between missed appointment rates and WDs stratified by race, income, and patient insurance groups with analysis of covariance statistics., Results: A total of 42,727 patients met the inclusion criteria. Mean WDs were 7.95 days. Multivariate regression showed increased odds ratio for missed appointments for patients with increased WDs (7-21 days: odds ratio [OR], 1.39; >21 days: OR, 1.77), African American patients (OR, 1.71), Hispanic patients (OR, 1.30), patients with noncommercial insurance (OR, 2.00-2.55), and those with imaging performed at the main hospital campus (OR, 1.51). Missed appointment rate linearly increased with WDs, with analysis of covariance revealing underrepresented minorities and Medicaid insurance as significant effect modifiers., Conclusions: Increased WDs for advanced imaging significantly increases the likelihood of missed appointments. This effect is most pronounced among underrepresented minorities and patients with lower socioeconomic status. Efforts to reduce WDs may improve equity in access to and utilization of advanced diagnostic imaging for all patients., (Copyright © 2018. Published by Elsevier Inc.)

Evaluation of cranial neuropathy can be complex given the different pathway of each cranial nerve as well as the associated anatomic landmarks. Radiological evaluation requires imaging of the entire course of the nerve from its nucleus to the end organ. MRI is the modality of choice with CT playing a complementary role, particularly in the evaluation of the bone anatomy. Since neoplastic and inflammatory lesions are prevalent on the differential diagnosis, contrast enhanced studies are preferred when possible. The American College of Radiology Appropriateness Criteria are evidencebased guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment., (Copyright © 2017 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: To test whether data elements available in the electronic medical record (EMR) can be effectively leveraged to predict failure to attend a scheduled radiology examination., Materials and Methods: Using data from a large academic medical center, we identified all patients with a diagnostic imaging examination scheduled from January 1, 2016, to April 1, 2016, and determined whether the patient successfully attended the examination. Demographic, clinical, and health services utilization variables available in the EMR potentially relevant to examination attendance were recorded for each patient. We used descriptive statistics and logistic regression models to test whether these data elements could predict failure to attend a scheduled radiology examination. The predictive accuracy of the regression models were determined by calculating the area under the receiver operator curve., Results: Among the 54,652 patient appointments with radiology examinations scheduled during the study period, 6.5% were no-shows. No-show rates were highest for the modalities of mammography and CT and lowest for PET and MRI. Logistic regression indicated that 16 of the 27 demographic, clinical, and health services utilization factors were significantly associated with failure to attend a scheduled radiology examination (P ≤ .05). Stepwise logistic regression analysis demonstrated that previous no-shows, days between scheduling and appointments, modality type, and insurance type were most strongly predictive of no-show. A model considering all 16 data elements had good ability to predict radiology no-shows (area under the receiver operator curve = 0.753). The predictive ability was similar or improved when these models were analyzed by modality., Conclusion: Patient and examination information readily available in the EMR can be successfully used to predict radiology no-shows. Moving forward, this information can be proactively leveraged to identify patients who might benefit from additional patient engagement through appointment reminders or other targeted interventions to avoid no-shows., (Copyright © 2017 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Decreasing unnecessary variation in radiology reporting and producing guideline-concordant reports is fundamental to radiology's success in value-based payment models and good for patient care. In this article, we present an open authoring system for point-of-care clinical decision support tools integrated into the radiologist reporting environment referred to as the computer-assisted reporting and decision support (CAR/DS) framework. The CAR/DS authoring system, described herein, includes: (1) a definition format for representing radiology clinical guidelines as structured, machine-readable Extensible Markup Language documents and (2) a user-friendly reference implementation to test the fidelity of the created definition files with the clinical guideline. The proposed definition format and reference implementation will enable content creators to develop CAR/DS tools that voice recognition software (VRS) vendors can use to extend the commercial tools currently in use. In making the definition format and reference implementation software freely available, we hope to empower individual radiologists, expert groups such as the ACR, and VRS vendors to develop a robust ecosystem of CAR/DS tools that can further improve the quality and efficiency of the patient care that our field provides. We hope that this initial effort can serve as the basis for a community-owned open standard for guideline definition that the imaging informatics and VRS vendor communities will embrace and strengthen. To this end, the ACR Assist™ initiative is intended to make the College's clinical content, including the Incidental Findings Committee White Papers, available for decision support tool creation based upon the herein described CAR/DS framework., (Copyright © 2017 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: To assess whether text-based appointment reminders are a cost-effective strategy to decrease patient no-shows and improve arrival punctuality in the setting of outpatient radiology imaging., Methods and Materials: From July 2016 through October 2016, all patients scheduled for MRI imaging at two outpatient locations were randomly assigned to a texting or nontexting arm based on the day. On texting days, patients scheduled for MRI received both the traditional phone call reminder as well as a text-based reminder of their MRI examination. On nontexting days, patients scheduled for MRI received only the traditional phone call reminder. All patients were evaluated based on whether they attended the MRI appointment and, if attended, whether they arrived 30 minutes before the MRI appointment as requested in the text message. Potential associations between the text reminder and examination attendance and punctuality were assessed by χ 2 test with associations considered significant at P ≤ .05., Results: A total of 6,989 patients were eligible for analysis, 3,086 in the texting group and 3,903 in the nontexting group. In the texting group, 67.5% (2,083/3,086) of patients were successfully texted with an appointment reminder, with the other 32.5% not having text accessibility. The percent of no-shows was significantly decreased for the texting group compared with the nontexting group (3.8% versus 5.1%, P = .02, odds ratio 0.75, 95% confidence interval 0.59 to 0.94). There was no significant difference between the percent of patients arriving the requested 30 minutes before the MRI appointment between the texting and nontexting groups (60.0% versus 58.5%, P = .25)., Conclusion: Text message appointment reminders are an effective strategy for decreasing radiology no-shows, even in the presence of traditional phone reminders, but do not improve patient arrival punctuality., (Copyright © 2017 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

The current fee-for-service system for health care reimbursement in the United Stated is argued to encourage fragmented care delivery and a lack of accountability that predisposes to insufficient focus on quality as well as unnecessary or duplicative resource utilization. Episode payment models (EPMs) seek to improve coordination by linking payments for all services related to a patient's condition or procedure, thereby improving quality and efficiency of care. The CMS Innovation Center has implemented a broadening array of EPMs. Early models with relevance to radiologists include Bundled Payment for Care Improvement (involving 48 possible clinical conditions), Comprehensive Care for Joint Replacement (involving knee and hip replacement), and the Oncology Care Model (involving chemotherapy). In July 2016, CMS expanded the range of EPMs through three new models with mandatory hospital participation addressing inpatient and 90-day postdischarge care for acute myocardial infarction, coronary artery bypass graft, and surgical hip and femur fracture treatment. Moreover, some of the EPMs include tracks that allow participating entities to qualify as an Advanced Alternative Payment Model under the Medicare Access and CHIP Reauthorization Act (MACRA), reaping the associated reporting and payment benefits. Even though none of the available EPMs are radiology specific, the models will nevertheless likely influence reimbursements for some radiologists. Thus, radiologists should partner with hospitals and other specialties in care coordination through these episode-based initiatives, thereby having opportunities to apply their imaging expertise to help lower spending while improving quality and overall levels of health., (Copyright © 2017 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

On 8 November 2016 the American electorate voted Donald Trump into the Presidency and a majority of Republicans into both houses of Congress. Since many Republicans ran for elected office on the promise to 'repeal and replace' Obamacare, this election result came with an expectation that campaign rhetoric would result in legislative action on healthcare. The American Health Care Act (AHCA) represented the Republican effort to repeal and replace the Affordable Care Act (ACA). Key elements of the AHCA included modifications of Medicaid expansion, repeal of the individual mandate, replacement of ACA subsidies with tax credits, and a broadening of the opportunity to use healthcare savings accounts. Details of the bill and the political issues which ultimately impeded its passage are discussed here., Competing Interests: Competing interests: ABR and RD are supported by research grants from the Harvey L Neiman Health Policy Institute., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Diseases of the cerebral vasculature represent a heterogeneous group of ischemic and hemorrhagic etiologies, which often manifest clinically as an acute neurologic deficit also known as stroke or less commonly with symptoms such as headache or seizures. Stroke is the fourth leading cause of death and is a leading cause of serious long-term disability in the United States. Eighty-seven percent of strokes are ischemic, 10% are due to intracerebral hemorrhage, and 3% are secondary to subarachnoid hemorrhage. The past two decades have seen significant developments in the screening, diagnosis, and treatment of ischemic and hemorrhagic causes of stroke with advancements in CT and MRI technology and novel treatment devices and techniques. Multiple different imaging modalities can be used in the evaluation of cerebrovascular disease. The different imaging modalities all have their own niches and their own advantages and disadvantages in the evaluation of cerebrovascular disease. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment., (Copyright © 2017 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

The quality of medical literature is increasingly threatened by irresponsible publishing, leading to rising retraction rates, irreproducible results, and a flood of inconsequential publications that distract readers from more meaningful scholarship. "Predatory publishers" offer rapid publication with loose peer review, exploiting a system in which faculty seek longer bibliographies to achieve academic promotion. In this Commentary, the authors highlight some of the evidence that this problem exists and suggest actions to address it. Recommendations for protecting the medical literature include preventing predatory journals from being indexed by the National Library of Medicine; encouraging academic promotions committees to ensure that they prioritize value over volume of publications and that faculty understand that priority; excluding publications from predatory journals on curricula vitae and requiring that retractions are included; developing sanctions for repeated retractions or duplicate publications; and convening an expert panel to better elucidate this problem and determine strategies to combat it.

Most patients presenting with uncomplicated acute low back pain (LBP) and/or radiculopathy do not require imaging. Imaging is considered in those patients who have had up to 6 weeks of medical management and physical therapy that resulted in little or no improvement in their back pain. It is also considered for those patients presenting with red flags raising suspicion for serious underlying conditions, such as cauda equina syndrome, malignancy, fracture, and infection. Many imaging modalities are available to clinicians and radiologists for evaluating LBP. Application of these modalities depends largely on the working diagnosis, the urgency of the clinical problem, and comorbidities of the patient. When there is concern for fracture of the lumbar spine, multidetector CT is recommended. Those deemed to be interventional candidates, with LBP lasting for > 6 weeks having completed conservative management with persistent radiculopathic symptoms, may seek MRI. Patients with severe or progressive neurologic deficit on presentation and red flags should be evaluated with MRI. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (the RAND/UCLA Appropriateness Method and the Grading of Recommendations Assessment, Development, and Evaluation) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment., (Copyright © 2016 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: The purpose of this study was to investigate the role of imaging in transfers between an island Critical Access Hospital (CAH) emergency department (ED) and a quaternary care hospital., Methods: Electronic medical records were reviewed to identify all patients who were transferred from an island CAH to our quaternary care hospital in 2012 and 2013. Medical history, transfer diagnosis, and the type of imaging performed at the CAH prior to transfer were reviewed., Results: During the study period, a total of 22075 ED visits were made to the CAH and 696 (3.2%) of these patients were transferred for higher level of care, with 424 (60.9%) of the patients transferred to our quaternary care hospital. The most common reasons for transfer were cardiac (121; 28.5%), trauma (82; 19.3%), gastrointestinal (63; 14.9%), and neurologic conditions (54; 12.7%). 349 patients (82.3%) had imaging prior to transfer (56.4% radiograph, 33.5% computed tomography, 4.7% magnetic resonance imaging, 8.0% ultrasound). Of patients that had imaging, 53.6% had positive imaging findings related to the transfer diagnosis, and patients transferred for noncardiac etiologies were significantly more likely to have imaging findings related to their transfer diagnosis compared with patients transferred for cardiac etiologies (72.9% vs 6.9%, respectively; P< .0001)., Conclusion: Approximately 3 of every 100 ED visits to the rural CAH required transfer for higher level of care, with nearly three-quarters of noncardiac transferred patients having a positive imaging finding related to the reason for transfer., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Purpose: The aim of this study was to assess the prevalence of appropriate neuroimaging on the basis of the ACR Appropriateness Criteria among pediatric patients presenting after head trauma to a level I emergency department., Methods: A retrospective emergency department record review was performed for patients <18 years of age undergoing head CT or MRI for the indication "head trauma" between January 2013 and December 2014. Clinical history and symptoms were compared with the ACR Appropriateness Criteria; the indication was deemed appropriate for ratings of ≥7. Patients were analyzed by age, gender, presentation, imaging obtained, follow-up, treatment, and outcomes., Results: Among 207 patients, 120 (58%) were imaged with CT and 107 (52%) with MRI; 20 patients underwent both CT and MRI. One hundred eighty-seven patients (90.3%) were appropriately imaged, with 90.0% of CT studies (108 of 120) deemed appropriate and 91.6% of MRI studies (98 of 107) deemed appropriate. Younger patients were more likely to be inappropriately imaged with CT or MRI than older patients (P = .02 and P < .01, respectively). Patients undergoing CT were older (mean age 9.9 ± 5.8 years) and more likely to be male (85.2%) than those undergoing MRI (5.6 ± 5.6 years and 55.1%, respectively) (P < .01 and P < .001, respectively). The diagnostic yield of positive imaging findings for intracranial trauma was significantly lower in the MRI group (P < .01), and patients undergoing MRI were significantly more likely to return to baseline with conservative management (P < .01)., Conclusions: Most pediatric patients undergoing neuroimaging for head trauma did so appropriately per ACR guidelines and had symptom resolution with conservative management. The minority not imaged appropriately represent a target for quality improvement efforts., (Copyright © 2016 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

The authors explore the benefits and risks of not reporting imaging findings that do not have clinical relevance, with the goal of developing recommendations to reduce their reporting. The authors review the example of incidentally detected, simple renal cysts (Bosniak category I), including medicolegal conditions required for such a shift in reporting practices to be acceptable. The authors propose four potential criteria for not reporting clinically unimportant findings and recommend that these criteria be debated in other contexts, so that they can be refined and implemented., (Copyright © 2016 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: Leakage (out-of-network referral) is undesirable because it limits ability to control costs of services. Clinical decision support (CDS) systems seek to ensure appropriate imaging of patients but theoretically could drive leakage if ordering providers attempt to circumvent CDS recommendations and obtain studies from other imaging providers. This study assessed the incidence of leakage of imaging studies that had low appropriateness scores., Methods: We queried our outpatient CDS system over a three-year period (2011-2013) for studies that received a low CDS appropriateness score and were canceled by the ordering physician. For patients meeting these criteria and participating in risk-shared contracts, we cross-referenced their imaging utilization reports in the risk-contract insurance payment database to determine if they received outpatient imaging within 60 days of the index order, contrary to the decision support recommendation., Results: The risk-shared insurance database contained an average of 63,378 patients who had 18,008 MRIs and 18,014 CTs. A total of 11,234 (31.2%) studies were leaked: 3,513 (9.8%) to affiliated institutions; 7,721 (21.4%) to unaffiliated imaging facilities. Overall, 111 imaging studies received a low appropriateness score in the risk-shared patient population and were performed within 60 days despite the low score. Of these studies, 106 of 111 (95.5%) were ultimately performed within our hospital system (104 at the home institution; 2 at affiliated institutions); only 5 of 111 (4.5%) were performed outside of our hospital system., Conclusions: Decision support systems for ordering providers do not seem to drive imaging referrals out of hospital systems to other institutions. Hospital systems can implement decision support without fear of this occurring., (Copyright © 2016 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: The objective of this study was to evaluate the feasibility of the consensus-oriented group review (COGR) method of radiologist peer review within a large subspecialty imaging department., Methods: This study was institutional review board approved and HIPAA compliant. Radiologist interpretations of CT, MRI, and ultrasound examinations at a large academic radiology department were subject to peer review using the COGR method from October 2011 through September 2013. Discordance rates and sources of discordance were evaluated on the basis of modality and division, with group differences compared using a χ(2) test. Potential associations between peer review outcomes and the time after the initiation of peer review or the number of radiologists participating in peer review were tested by linear regression analysis and the t test, respectively., Results: A total of 11,222 studies reported by 83 radiologists were peer reviewed using COGR during the two-year study period. The average radiologist participated in 112 peer review conferences and had 3.3% of his or her available CT, MRI and ultrasound studies peer reviewed. The rate of discordance was 2.7% (95% confidence interval [CI], 2.4%-3.0%), with significant differences in discordance rates on the basis of division and modality. Discordance rates were highest for MR (3.4%; 95% CI, 2.8%-4.1%), followed by ultrasound (2.7%; 95% CI, 2.0%-3.4%) and CT (2.4%; 95% CI, 2.0%-2.8%). Missed findings were the most common overall cause for discordance (43.8%; 95% CI, 38.2%-49.4%), followed by interpretive errors (23.5%; 95% CI, 18.8%-28.3%), dictation errors (19.0%; 95% CI, 14.6%-23.4%), and recommendation (10.8%; 95% CI, 7.3%-14.3%). Discordant cases, compared with concordant cases, were associated with a significantly greater number of radiologists participating in the peer review process (5.9 vs 4.7 participating radiologists, P < .001) and were significantly more likely to lead to an addendum (62.9% vs 2.7%, P < .0001)., Conclusions: COGR permits departments to collect highly contextualized peer review data to better elucidate sources of error in diagnostic imaging reports, while reviewing a sufficient case volume to comply with external standards for ongoing performance review., (Copyright © 2016 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

The Affordable Care Act is celebrating its fifth anniversary and remains one of the most significant attempts to reform healthcare in US history. Prior to the federal legislation, Accountable Care Organizations had largely been part of an academic discussion about how to control rising healthcare costs, but have since become a fixture in our national healthcare landscape. A fundamental shift is underway in the relationship between healthcare delivery and payment models. Some elements of Accountable Care Organizations may remain unfamiliar to most healthcare providers, including neurointerventional specialists. In this paper we review the fundamental concepts behind and the current forms of Accountable Care Organizations, and discuss the challenges and opportunities they present for neurointerventionalists., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Purpose: To describe our multiyear experience in incident reporting related to magnetic resonance imaging (MRI) in a large academic medical center., Materials and Methods: This was an Institutional Review Board (IRB)-approved, Health Insurance Portability and Accountability Act (HIPAA)-compliant study. Incident report data were collected during the study period from April 2006 to September 2012. The incident reports filed during the study period were searched for all reports related to MRI. Incident reports were classified with regard to the patient type (inpatient vs. outpatient), primary reason for the incident report, and the severity of patient harm resulting from the incident., Results: A total of 362,090 MRI exams were performed during the study period, resulting in 1290 MRI-related incident reports. The rate of incident reporting was 0.35% (1290/362,090). MRI-related incident reporting was significantly higher in inpatients compared to outpatients (0.74% [369/49,801] vs. 0.29% [921/312,288], P < 0.001). The most common reason for incident reporting was diagnostic test orders (31.5%, 406/1290), followed by adverse drug reactions (19.1%, 247/1290) and medication/IV safety (14.3%, 185/1290). Approximately 39.6% (509/1290) of reports were associated with no patient harm and did not affect the patient, followed by no patient harm but did affect the patient (35.8%, 460/1290), temporary or minor patient harm (23.9%, 307/1290), permanent or major patient harm (0.6%, 8/1290) and patient death (0.2%, 2/1290)., Conclusion: MRI-related incident reports are relatively infrequent, occur at significantly higher rates in inpatients, and usually do not result in patient harm. Diagnostic test orders, adverse drug reactions, and medication/IV safety were the most frequent safety incidents., (© 2015 Wiley Periodicals, Inc.)

Quality assurance (QA) is a fundamental component of every successful radiology operation. A radiology QA program must be able to efficiently and effectively monitor and respond to quality problems. However, as radiology QA has expanded into the depths of radiology operations, the task of defining and measuring quality has become more difficult. Key performance indicators (KPIs) are highly valuable data points and measurement tools that can be used to monitor and evaluate the quality of services provided by a radiology operation. As such, KPIs empower a radiology QA program to bridge normative understandings of health care quality with on-the-ground quality management. This review introduces the importance of KPIs in health care QA, a framework for structuring KPIs, a method to identify and tailor KPIs, and strategies to analyze and communicate KPI data that would drive process improvement. Adopting a KPI-driven QA program is both good for patient care and allows a radiology operation to demonstrate measurable value to other health care stakeholders., (Copyright © 2015 Mosby, Inc. All rights reserved.)

Purpose: The aim of this study was to compare the frequency and liability costs associated with radiology malpractice claims relative to other medical services and to evaluate the clinical context and case disposition associated with radiology malpractice claims., Methods: This HIPAA-compliant study was exempted from institutional review board approval. The Comparative Benchmarking System database, a repository of more than 300,000 medical malpractice cases in the United States, was queried for closed claims over a five-year period (2008-2012). Claims were categorized by the medical service primarily responsible for the claim and the paid total loss. For all cases in which radiology was the primary responsible service, the case abstracts were evaluated to determine injury severity, claimant type by setting, claim allegation, process of care involved, case disposition, modality involved, and body section. Intracategory comparisons were made on the basis of the frequency of indemnity payment and total indemnity payment for paid cases, using χ(2) and Wilcoxon rank-sum tests., Results: Radiology was the eighth most likely responsible service to be implicated in a medical malpractice claim, with a median total paid loss (indemnity payment plus defense cost plus administrative expense) per closed case of $30,091 (mean, $205,619 ± $508,883). Radiology claims were most commonly associated with high- and medium-severity injuries (93.3% [820 of 879]; 95% confidence interval [CI], 91.7%-94.95%), the outpatient setting (66.3% [581 of 876]; 95% CI, 63.0%-69.2%), and diagnosis-related allegations (ie, failure to diagnose or delayed diagnosis) (57.3% [504 of 879]; 95% CI, 54.0%-60.6%). A high proportion of claims pertained to cancer diagnoses (44.0% [222 of 504]; 95% CI, 39.7%-48.3%). A total of 62.3% (548 of 879; 95% CI, 59.1%-65.5%) of radiology claims were closed without indemnity payments; 37.7% (331 of 879; 95% CI, 34.5%-40.9%) were closed with a median indemnity payment of $175,000 (range, $112-$6,691,762; mean $481,094 ± $727,636)., Conclusions: Radiology malpractice claims most commonly involve diagnosis-related allegations in the outpatient setting, particularly cancer diagnoses, with approximately one-third of claims resulting in payouts to the claimants., (Copyright © 2016 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate the effect of a workstation-integrated, point-of-care, clinical decision support (CDS) tool on radiologist adherence to radiology department guidelines for follow-up of incidental pulmonary nodules detected on abdominal CT., Methods: The CDS tool was developed to facilitate adherence to department guidelines for managing pulmonary nodules seen on abdominal CT. In October 2012, the tool was deployed within the radiology department of an academic medical center and could be used for a given abdominal CT at the discretion of the interpreting radiologist. We retrospectively identified consecutive patients who underwent abdominal CT (in the period from January 2012 to April 2013), had no comparison CT scans available, and were reported to have a solid, noncalcified, pulmonary nodule. Concordance between radiologist follow-up recommendation and department guidelines was compared among three groups: patients scanned before implementation of the CDS tool; and patients scanned after implementation, with versus without use of the tool., Results: A total of 409 patients were identified, including 268 for the control group. Overall, guideline concordance was higher after CDS tool implementation (92 of 141 [65%] versus 133 of 268 [50%], P = .003). This finding was driven by the subset of post-CDS implementation cases in which the CDS tool was used (57 of 141 [40%]). In these cases, guideline concordance was significantly higher (54 of 57 [95%]), compared with post-implementation cases in which CDS was not used (38 of 84 [45%], P < .001), and to a control group of patients from before implementation (133 of 268 [50%]; P < .001)., Conclusions: A point-of-care CDS tool was associated with improved adherence to guidelines for follow-up of incidental pulmonary nodules., (Copyright © 2016 American College of Radiology. Published by Elsevier Inc. All rights reserved.)