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Radiologists are losing control of musculoskeletal US

By Kate Madden Yee, AuntMinnie.com staff writer

December 19, 2017 -- Radiologists had a market share of less than 40% for musculoskeletal (MSK) ultrasound exams in the U.S. in 2015, down from 65% in 2003, indicating they could be losing control of the modality, according to a study published online December 13 in the Journal of the American College of Radiology.

Dr. Riti Kanesa-thasan from Thomas Jefferson University.

Although radiologists still have an important place in MSK imaging -- their share of musculoskeletal MRI remains stable, at 93% -- it's important to keep the big picture in mind, especially in a changing reimbursement environment, said lead study author Dr. Riti Kanesa-thasan from the Center for Research on Utilization of Imaging Services (CRUISE) at Thomas Jefferson University.

"MRI is considered an MSK imaging workhorse, and it's financially more profitable than ultrasound," she told AuntMinnnie.com. "But looking at our data, if the trend toward increased use of musculoskeletal ultrasound continues -- and if insurers start limiting payments for MRI, in an effort to curb costs -- radiologists could conceivably lose market share for all musculoskeletal imaging if they don't take ultrasound seriously."

Is US replacing MRI?

Musculoskeletal ultrasound is known to be an effective complementary -- or even alternative -- modality to MRI for the diagnostic evaluation of extremities. It's accurate, low-cost, and easier on patients, and more and more nonradiology specialties have started using it over the past decade, Kanesa-thasan and colleagues wrote.

In fact, in response to the increased use of musculoskeletal ultrasound, in 2011 Medicare initiated two new and more specific codes to reflect the different levels of effort required by each: a complete ultrasound exam (76881) and a limited exam (76882). A complete exam images the muscles, tendons, and soft-tissue structures and is reimbursed at $118, while a limited exam images one of these specific structures and is reimbursed at $36.

But has the increased uptake of musculoskeletal ultrasound affected the use of MRI? And which physicians are performing musculoskeletal ultrasound the most? To address these questions, Kanesa-thasan and colleagues used Medicare Part B Physician/Supplier Procedure Summary Master File data, analyzing use trends in musculoskeletal ultrasound and MRI between 2003 and 2015 and identifying the provider specialty for the procedures.

Over the study time frame, while the volume of MRI and ultrasound grew, the number of ultrasound scans grew far more rapidly. In addition, radiologists were performing a much lower share of MSK ultrasound scans at the end of the period compared to the beginning, while in MRI the percentage changed little.

Change in MSK MRI vs. US from 2003-2015
Modality	2003 No. of studies	2003 radiologist share	2015 No. of studies	2015 radiologist share
MRI	738,509	93%	1,131,503	93%
Ultrasound	96,235	65%	429,695	37%

"Although ultrasound grew at a faster rate in recent years, the volume of MRI studies remained at least double that of ultrasound in 2015," the researchers wrote. "[Our] data do not provide evidence that ultrasound is substituting for MRI in large enough numbers to decrease overall MRI volume. ... However, it is possible that musculoskeletal MRI growth has been restrained by greater use of MSK ultrasound in recent years."

Which types of physicians were taking over from radiologists in musculoskeletal radiology? Podiatrists had the highest market share after radiologists, but various other specialists were also performing the scans.

Total 2015 market share of MSK US exams by provider
Provider	Percent of total market share
Radiologists	37%
Podiatrists	18%
Orthopedic surgeons	12%
Rheumatologists	11.1%
Primary care physicians	8.3%
Physical medicine and rehabilitation physicians	5.6%
All other providers	8.1%

The researchers also found that nonradiologists used the code for complete exams to bill for studies far more than radiologists did -- which is surprising, since one would expect radiologists to do more of these exams than nonradiologists, they wrote.

"[Many] musculoskeletal conditions can be evaluated by a limited ultrasound without the need of a complete evaluation of the whole joint," they wrote. "Examples include such things as carpal tunnel syndrome, joint effusion, ganglion cysts, tenosynovitis, or lateral ankle sprain. However, by 2015, multiple specialties exceeded radiology in total volume of complete ultrasounds performed ... [raising] the possibility of overuse of the more costly complete examination."

Currently, there is no mechanism being used to assess the appropriateness of complete versus limited MSK ultrasound exams, according to Kanesa-thasan and colleagues.

"The only possible way to control overuse of complete ultrasound examinations is for payors to track each provider's use patterns and establish benchmarks," they wrote.

Hold on

The study findings affirm that musculoskeletal MRI is here to stay, and that radiologists are the primary interpreters of these studies. But nonradiology specialties have the upper hand in musculoskeletal ultrasound, in part because training has been incorporated into the curriculum, Kanesa-thasan said. It would behoove radiologists to incorporate this training as well.

"Our training on musculoskeletal ultrasound could be more methodical and thorough," she said. "Our rheumatology and sports medicine colleagues have dedicated musculoskeletal ultrasound training in their curricula, and we could follow this example."

Radiologists can also lead the way in helping their colleagues decide when to use a complete versus a limited musculoskeletal ultrasound exam, Kanesa-thasan concluded.

"We need to work not just with each other, but also with our colleagues in other specialties to help them understand which type of exam is most appropriate," she said.

JACR: Rads want more help with point-of-care ultrasound

By Kate Madden Yee, AuntMinnie.com staff writer

December 21, 2017 -- Radiologists would like more support from the American College of Radiology (ACR) for point-of-care ultrasound, according to an analysis of data from the ACR's 2017 workforce survey published December 19 in the Journal of the American College of Radiology.

Why is point-of-care ultrasound such a concern? Because it's complicated, according to co-authors Dr. Jay Harolds of Michigan State University in Grand Rapids and Dr. Edward Bluth of the Ochsner Clinic Foundation in New Orleans.

"[Point-of-care ultrasound] is complex -- potentially involving educational and reimbursement issues, standard setting, leadership development, marketing, and lobbying -- and does not have an easy solution," they wrote. "The ACR's study of this problem and development of a recommended comprehensive strategy ... would be of value."

This year, the ACR's workforce survey asked about areas in which Practice of Radiology Environment Database (PRED) group leaders would like more help. The survey was conducted between January and March. Out of 1,800 group leaders, 477 responded, for a response rate of 26%.

In response to the question about what areas survey participants would like additional help with from ACR leadership, 52% identified point-of-care ultrasound as a "somewhat high" to "high" priority, Harolds and Bluth wrote. Turf issues were the second most important issue to survey respondents, and the development of a patient satisfaction survey was the third.

Areas where radiologists want support from the ACR
Issue	Somewhat high to high priority
Point-of-care ultrasound	52%
Turf issues	36%
Development of a patient satisfaction survey	28%
Development of a referring physician satisfaction survey	22%
Documenting non-relative value unit (RVU) added-value activities	14%

The researchers also found that the majority of participants (67%) were satisfied with their involvement in managing allied health professionals. However, almost a third (28%) were dissatisfied or very dissatisfied with their level of involvement in the management of radiology IT activities.

"A potential cause of this dissatisfaction is highlighted by the survey result showing that only 29% of radiology IT resources report directly to radiology leaders compared to 49% that report to institutional IT departments," they wrote.

When asked about their influence within their own institution, 26% of survey respondents said they believe it has decreased, Harolds and Bluth noted.

"The fact that more than one-quarter of responding radiology department leaders feel their influence is diminishing is concerning and should be carefully monitored to determine if this is a developing trend," they wrote. "Perhaps the use of ACR resources such as the Radiology Leadership Institute should be further emphasized and made more easily available."

Liver Int. 2013 Sep;33(8):1138-47. doi: 10.1111/liv.12240. Epub 2013 Jul 16.

Meta-analysis: ARFI elastography versus transient elastography for the evaluation of liver fibrosis.

Bota S1, Herkner H, Sporea I, Salzl P, Sirli R, Neghina AM, Peck-Radosavljevic M.

Author information

Abstract

AIMS:

This meta-analysis aims to compare the diagnostic performance of acoustic radiation force impulse (ARFI) elastography and transient elastography (TE) in the assessment of liver fibrosis using liver biopsy (LB) as 'gold-standard'.

METHODS:

PubMed, Medline, Lilacs, Scopus, Ovid, EMBASE, Cochrane and Medscape databases were searched for all studies published until 31 May 2012 that evaluated the liver stiffness by means of ARFI, TE and LB. Information abstracted from each study according to a fixed protocol included study design and methodological characteristics, patient characteristics, interventions, outcomes and missing outcome data.

RESULTS:

Thirteen studies (11 full-length articles and 2 abstracts) including 1163 patients with chronic hepatopathies were included in the analysis. Inability to obtain reliable measurements was more than thrice as high for TE as that of ARFI (6.6% vs. 2.1%, P< 0.001). For detection of significant fibrosis, (F ≥ 2) the summary sensitivity (Se) was 0.74 (95% CI: 0.66-0.80) and specificity (Sp) was 0.83 (95% CI: 0.75-0.89) for ARFI, while for TE the Se was 0.78 (95% CI: 0.72-0.83) and Sp was 0.84 (95% CI: 0.75-0.90). For the diagnosis of cirrhosis, the summary Se was 0.87 (95% CI: 0.79-0.92) and Sp was 0.87 (95% CI: 0.81-0.91) for ARFI elastography, and, respectively, 0.89 (95% CI: 0.80-0.94) and 0.87 (95% CI: 0.82-0.91) for TE. The diagnostic odds ratio of ARFI and TE did not differ significantly in the detection of significant fibrosis [mean difference in rDOR = 0.27 (95% CI: 0.69-0.14)] and cirrhosis [mean difference in rDOR = 0.12 (95% CI: 0.29-0.52)].

CONCLUSION:

Acoustic radiation force impulse elastography seems to be a good method for assessing liver fibrosis, and shows higher rate of reliable measurements and similar predictive value to TE for significant fibrosis and cirrhosis.

© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

KEYWORDS:

ARFI; acoustic radiation force impulse elastography; fibroscan®; liver fibrosis; liver stiffness; transient elastography

Which are the cut-off values of 2D-Shear Wave Elastography (2D-SWE) liver stiffness measurements predicting different stages of liver fibrosis, considering Transient Elastography (TE) as the reference method?

Ioan SporeaCorrespondence information about the author Ioan SporeaEmail the author Ioan Sporea

, 

Simona Bota^1,Email the author Simona Bota

, 

Oana Gradinaru-Taşcău^2,Email the author Oana Gradinaru-Taşcău

, 

Roxana Şirli^2,Email the author Roxana Şirli

, 

Alina Popescu^2,Email the author Alina Popescu

, 

Ana Jurchiş^2,Email the author Ana Jurchiş

Department of Gastroenterology and Hepatology, “Victor Babeş” University of Medicine and Pharmacy, Timişoara, Romania

¹Address: 2, Str. Intrarea Martir Angela Sava, 300742 Timisoara, Romania. Tel.: +40 256488003; fax: +40 256488003.

²Address: 10, Bd. Iosif Bulbuca, 300736 Timisoara, Romania. Tel.: +40 256488003; fax: +40 256488003.

Mobile

European Journal of Radiology, March 2014, Volume 83, Issue 3, Pages e118–e122

Abstract

Introduction

To identify liver stiffness (LS) cut-off values assessed by means of 2D-Shear Wave Elastography (2D-SWE) for predicting different stages of liver fibrosis, considering Transient Elastography (TE) as the reference method.

Methods

Our prospective study included 383 consecutive subjects, with or without hepatopathies, in which LS was evaluated by means of TE and 2D-SWE. To discriminate between various stages of fibrosis by TE we used the following LS cut-offs (kPa): F1-6, F2-7.2, F3-9.6 and F4-14.5.

Results

The rate of reliable LS measurements was similar for TE and 2D-SWE: 73.9% vs. 79.9%, p = 0.06. Older age and higher BMI were associated for both TE and 2D-SWE with the impossibility to obtain reliable LS measurements. Reliable LS measurements by both elastographic methods were obtained in 65.2% of patients. A significant correlation was found between TE and 2D-SWE measurements (r = 0.68). The best LS cut-off values assessed by 2D-SWE for predicting different stages of liver fibrosis were: F ≥ 1: >7.1 kPa (AUROC = 0.825); F ≥ 2: >7.8 kPa (AUROC = 0.859); F ≥ 3: >8 kPa (AUROC = 0.897) and for F = 4: >11.5 kPa (AUROC = 0.914).

Conclusions

2D-SWE is a reliable method for the non-invasive evaluation of liver fibrosis, considering TE as the reference method. The accuracy of 2D-SWE measurements increased with the severity of liver fibrosis.

Keywords:

Liver stiffness, Transient Elastography, Shear Waves Elastography, Liver fibrosis

Siêu âm tần số cao khảo sát phân nhánh thần kinh vận động của thần kinh cơ bì chi phối cơ nhị đầu cánh tay

Siêu âm  tần số cao khảo sát phân nhánh thần kinh vận động của thần kinh cơ bì chi phối cơ nhị đầu cánh tay: từ vị trí tách nhánh đến phân bố trong cơ

High-frequency ultrasonography of the motor branches of the musculocutaneous nerve innervating biceps brachii: from the branching location to the distribution in the muscle.

BS Lê Tự Phúc

Medic Medical Center HCM

Abstract

Purpose

The aim of this study was to investigate the ability of high-frequency ultrasonography in examing the motor branches of the musculocutaneous nerve innervating biceps brachii in the correlation with anatomical and histological knowledge. We analysed the location where they exit the main nerve trunk, penetrate the muscle epimysium and distribute inside the muscle.

Methods

Sixteen healthy volunteers (eight males and eight females, ages 20-60, mean age 35) were examined on both sides of the musculocutaneous nerves and their branches innervating biceps brachii. The 5-18 MHz and 16-23 Mhz multi-frequency transducers along with the latest high-resolution ultrasound systems were used to examine the musculocutaneous nerves slowly and continuously in cross section from the coracoid process of the scapula to the elbow. By analyzing the nerve bundles inside the musculocutaneous nerve and the epimysium of biceps brachii, we observed the position where one nerve branch separated from the main trunk of the  nerve, penetrated the epimysium and distributed inside the muscle. Blood vessels were distinguished with nerves by Doppler ultrasound and compression  method.

Results

One right arm of a 28-year-old woman was found with the absence of the musculocutaneous nerve and the median nerve give the motor branches to the biceps brachii.

Thirty one musculocutaneous nerves and their motor branches to biceps brachii muscles were detected on ultrasound. Inside the muscle, the nerve branches were located in the hyperechoic bands while the surrounding muscular tissue was hypoechoic. In these hyperechoic bands, the nerves were identified because of hypoechoic structure and thicker than the thickness of the bands. The blood vessels were also found in these bands. The minimum diameter of the nerve branches inside the muscles can be seen as 0.3 mm.

Conclusion

High-frequency ultrasonography can examine very small nerve structure, detemine the position where the motor branches exit from the main trunk of the nerve, penetrate the muscle epimysium and branching inside the muscle.

Keywords: ultrasound, motor branch of the nerve, intramuscular nerve distribution, musculocutaneous nerve, biceps brachii muscle

Tóm tắt

Mục đích

Mục đích của nghiên cứu này là để đánh giá khả năng của siêu âm với tần số cao trong khảo sát phân nhánh thần kinh vận động của thần kinh cơ bì chi phối cơ nhị đầu cánh tay trong sự tương quan với kiến thức giải phẫu học và mô học. Chúng tôi phân tích các phân nhánh này từ vị trí tách ra khỏi thân thần kinh chính, xuyên qua bao ngoài cơ và phân bố bên trong bó cơ.

Phương pháp

Mười sáu người lớn khỏe mạnh tình nguyện (gồm tám nam và tám nữ; tuổi từ 20-60; trung bình 35 tuổi) được khám siêu âm hai bên khảo sát dây thần kinh cơ bì và các phân nhánh dây thần kinh cơ bì chi phối cơ nhị đầu cánh tay. Hai đầu dò đa tần số 5-18 MHz và 16-23 MHz cùng với các hệ thống máy siêu âm mới nhất với độ phân giải cao được dùng để khảo sát dây thần kinh cơ bì một cách chậm rãi và liên tục trên mặt cắt ngang từ mỏm quạ xương vai đến vùng khuỷu. Bằng cách phân tích các bó thần kinh nhỏ bên trong dây thần kinh cơ bì và lớp bao ngoài của cơ nhị đầu cánh tay, chúng tôi xác định vị trí một phân nhánh thần kinh tách ra khỏi thân thần kinh chính, xuyên qua bao ngoài cơ và phân bố trong cơ. Các mạch máu được phân biệt với thần kinh bởi siêu âm Doppler và phương pháp đè ép.

Kết quả

Một cánh tay phải của một phụ nữ 28 tuổi được xác định không có thần kinh cơ bì và thần kinh giữa tách nhánh thần kinh vận động chi phối cơ nhị đầu cánh tay.

Ba mươi mốt dây thần kinh cơ bì và phân nhánh dây thần kinh chi phối cơ nhị đầu cánh tay đều được xác định trên siêu âm. Trong bó cơ, các phân nhánh thần kinh nằm trong các dải hồi âm dày trong khi mô cơ xung quanh hồi âm kém. Tại các dải hồi âm dày này, phân nhánh thần kinh được nhận diện vì hồi âm kém và tăng độ dày so với độ dày của dải hồi âm dày này. Kế cận các phân nhánh thần kinh là các cấu trúc mạch máu được phân biệt với dây thần kinh bằng cách đè ép đầu dò và nhờ vào tín hiệu mạch trên Doppler. Đường kính phân nhánh dây thần kinh nhỏ nhất trong cơ có thể thấy là 0,3 mm.

Kết luận

Siêu âm với tần số cao có thể khảo sát các cấu trúc thần kinh rất nhỏ, xác định được vị trí phân nhánh thần kinh vận động tách ra khỏi thân dây thần kinh chính, vị trí nhánh thần kinh vận động đi vào bó cơ và phân bố thần kinh trong bó cơ.

Từ khoá: siêu âm, thần kinh vận động cơ, sự phân bố thần kinh trong cơ, thần kinh cơ bì, cơ nhị đầu