1. Steven Cotman, MD Lynn Shaffer, PhD Richard Fankhauser, MD
Role of the Radiologist’s Comments on Plain Radiographs in the Initiation of Advanced Imaging
Steven Cotman, MD
Lynn Shaffer, PhD
Richard Fankhauser, MD

2. Objectives
Understand the impact of the Radiologist’s Report on the ordering clinician.
Understand the financial impact of Advanced Imaging
Apply the correct scenario to rely on the Radiologist’s Report
Recommend future Studies

3. Disclosures
none

4. Case Presentation 70 year old male comes in with hip pain
Poor historian, no definite history of trauma
X-Rays obtained in the Emergency Department

5. Radiologist’s Report
No evidence of fracture or dislocation if concern for occult fracture would recommend MRI

6. Question 1
Do comments in the interpreting radiologist’s reports on plain radiographs of the hip, knee and ankle result in an increased proportion of subsequent advanced imaging studies?

7. Question 2
Could such comments made by the Radiologist, if they did result in more advance imaging studies, have an economic impact to our healthcare system?

8. IRB
Mount Carmel West institutional review board
IRB#

9. Power Analysis 340 reports in both groups
15% difference between the two groups
type 1 error of 5% and a selected type 2 error of 20%. 

10. Data Acquisition 340 consecutive records Recommended Advanced Imaging
Recommendation was defined as the presence of MRI or CT mentioned in the report

11. Data Acquisition 340 consecutive records Matched to 340 controls
101 hips
184 knees
55 ankles
Matched to 340 controls

12. Rate of Advanced Imaging Among Patients with Hip, Knee or Ankle X-Ray by Radiologist Recommendation
Patient Group
Radiologist Recommendation
No Advanced Imaging N (%)
Advanced Imaging Obtained1 N (%)
p-value
Odds Ratio (CI)
All joints No
Yes
327 (96.2%)
261 (76.8%)
13 (3.8%)
79 (23.2%)
<0.0001
( )
Hips
98 (97.0%)
67 (66.3%)
3 (3.0%)
34 (33.7%)
( )
Knees
177 (95.2%)
151 (82.1%)
7 (3.8%)
33 (17.9%)
( )
Ankles
53 (96.4%)
42 (76.4%)
2 (3.6%)
13 (23.6%)
0.0041
( )

13. Estimated Additional Expense of Advanced Imaging Due to Radiologist Recommendation
Joint
Modality
AR in Exposed1
Expense per 1000 exposed pts
Lower Confidence Limit
Upper Confidence Limit
Hips CT
0.2574
$102,703
$72,698
$139,850
MRI
0.0396
$47,401
$18,553
$116,588
CT + MRI
$150,104
$91,251
$256,437
Knees
0.0707
$27,502
$16,260
$45,552
0.0652
$47,466
$27,446
$80,444
$74,968
$43,706
$125,996
Ankles
0.1818
$70,720
$39,639
$117,984
0.0182
$13,231
$2,326
$69,865
$83,951
$41,965
$187,849

14. Recommendation Impact
X-Ray Hips
16.4 times more likely to obtain advanced Imaging
151% increase in cost
X-Ray Knees
5.5 times more likely to obtain advanced Imaging
87% increase in cost
X-Ray Ankles
8.1 times more likely to obtain advanced Imaging
114% increase in cost

15. Future of Medicine
Beginning January 2017, Medicare requires the application of appropriate use criteria for ordering advanced imaging.
Shift in philosophy from volume to value.

16. Area for Cost Savings Emergency Department Visits (2013) 130.4 million
33% obtained X-Rays
15.5 % obtained CT scans

17. ADV + ADV - XR + 34 12 73.9% PPV XR - 10 23 69.7% NPV 77.3% 65.7% SN
Sensitivity, Specificity, Positive and Negative Predictive Value of the Interpreting Radiologist's Recommendation
ADV +
ADV -
XR + 34 12
73.9%
PPV
XR - 10 23
69.7%
NPV
77.3%
65.7% SN SP

18. Positive and Negative Predictive Value of the Interpreting Radiologist's Recommendation as a function of prevalence of occult hip fractures

19. Clinical Results 100 patients True Negatives – 62 False Negatives – 1
True Positives – 5
False Positives – 32

20. Interpretation
Relying exclusively on the report of the radiologist to guide treatment
Very good at ruling out specific etiology
Concern for occult hip fracture
Poor at finding unsuspecting pathology
Significant amount of false positives
i.e. pathology on advanced imaging that is not clinically relevant

21. Conclusions
The mention of advanced imaging in the Radiologist’s Report results in a significant increase in advanced imaging ordered.

22. Conclusions
This recommendation has a significant cost to the healthcare system with increases in cost from %.

23. Future Studies
This topic does not address the clinical impact in its entirety.
Whether the recommendation is appropriate
Whether the additional imaging would be made by an orthopedic surgeon
Larger numbers of recommended imaging reports to determine true PPV and NPV

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