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December 23, 2010

ARDMS Updates and Headlines in the News:

*Pay Your 2011 ARDMS Annual Renewal Fee on or before December 31, 2010

*2011 Clinical Verification (CV) forms now available

Collaboration to Develop Guidelines for Point-Of-Care Ultrasound Applications Spearheaded by AIUM

Most Endometrial Cancers Caught by Ultrasound

Nonradiologists Power Musculoskeletal Ultrasound Growth

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Collaboration to Develop Guidelines for Point-Of-Care Ultrasound Applications Spearheaded by AIUM

The AIUM recently hosted Ultrasound Practice Forum: Point-of-Care Use of Ultrasound in Orlando, Florida. This ground-breaking conference brought together a cross section of the ultrasound community, drawing representatives from 46 medical and other health-related societies to explore professional issues related to emerging point-of-care ultrasound technologies.

"The AIUM Forum aimed to facilitate an open dialogue among the entire ultrasound community regarding performance and training issues for point-of-care applications", said AIUM President Harvey L. Nisenbaum, MD. "With ultrasound playing an expanding role in several settings, the ultrasound community must collaborate to ensure the most effective use of the technology."

Participants at the Forum were divided into 3 tracks focusing on point-of-care ultrasound in obstetrics and gynecology, ultrasound-guided procedures, and emergency medicine/ critical care. Attendees included obstetricians, gynecologists, emergency physicians, radiologists, sports medicine physicians, osteopathic physicians, maternal-fetal medicine specialists, sonographers, nurses, nurse midwives, physician assistants, physical therapists and others.

A range of professional concerns were discussed in each track. The obstetrics and gynecology track deliberated the definition of limited obstetric ultrasound and the corresponding education and training requirements. The discussion about ultrasound-guided procedures focused on the need for performance and training guidelines for joint injections, aspirations, nerve blocks, and biopsies. In the emergency medicine/critical care group, topics included currently available guidelines, emergent uses of ultrasound, competency issues, challenges to training, and the common ground among specialists.

The forum resulted in collaborative initiatives and educational objectives that will help promote the most effective use of ultrasound imaging and the highest quality patient care as point-of-care applications continue to advance. The AIUM looks forward to making further developments from the Forum available to the ultrasound community as they are completed.

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Article written by staff at medicalnewstoday.com and adapted for the purposes of this newsletter.

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Most Endometrial Cancers Caught by Ultrasound

Transvaginal ultrasound screening can pick up most cases of endometrial cancer in postmenopausal women before symptoms appear, researchers reported. Such testing could identify more than 80% of cases but would have a false-positive rate of nearly 15%, according to Ian Jacobs, MD, of University College London, and colleagues.

The sensitivity and specificity could be improved if the ultrasound screening was restricted to a high-risk population, Jacobs and colleagues reported online in The Lancet Oncology. On the other hand, many experts argued that the method is unlikely to be cost-effective. "It's still a very crude screening test and nonspecific," said William Cliby, MD, of the Mayo Clinic in Rochester, Minn. He noted that even a 3% false-positive rate would translate into 3,000 unnecessary tests if 100,000 women were screened.

And "it's highly unlikely to be cost-effective," argued Jonathan Berek, MD, of Stanford University School of Medicine in Stanford, California. Almost all women with endometrial cancer will develop symptoms -- typically vaginal bleeding -- before the cancer begins to spread, he said in an e-mail. At that point, an endometrial biopsy will be used to make the diagnosis, he said. Endometrial cancer, Jacobs and colleagues wrote, is the most common gynecological cancer, and it usually has a good prognosis. But for that reason, there is little information on the role of screening in women without symptoms, the researchers noted.

The issue needs to be revisited, they argued, because increasing obesity and falling fertility "suggest that incidence of endometrial cancer will continue to rise in postmenopausal women and will become a substantial public health problem worldwide." To examine the topic, Jacobs and colleagues conducted a nested case-control study within the United Kingdom Collaborative Trial of Ovarian Cancer Screening. As part of the trial, transvaginal ultrasound was performed on 48,230 women, but more than 11,000 were ineligible for this analysis either because they had had a hysterectomy or they did not have endometrial thickness recorded, leaving a cohort of 37,038 women.

Of those, the researchers found, 136 women developed endometrial cancer or atypical endometrial hyperplasia within a year of their ultrasound. The median follow-up was 5.11 years. Of those women, Jacobs and colleagues found, 81% had an endometrial thickness of at least five millimeters, while 83% of those without disease had a thickness of less than five millimeters. At the optimum cutoff for endometrial thickness of 5.15 millimeters, the transvaginal ultrasound would detect 80.5% of cancer cases and would falsely indicate that a healthy woman had cancer 13.8% of the time, Jacobs and colleagues found.

The false-positive rate could be lowered by increasing the thickness cutoff, they found, but in that case fewer cancers would be detected. A logistic regression model -- including factors such as weight, age, cancer history and use of contraceptive pills -- found that 39.5% of the cases would fall in the 25% of the population that was identified as being at high risk.

If screening were restricted to those women, Jacobs and colleagues reported, the sensitivity and specificity were 84.3% and 89.9%, respectively, if the thickness cutoff were set at 6.75 millimeters. "A targeted screening approach might help reduce the overall number of false-positive findings while maintaining a high sensitivity," they argued. The study "provides very important information" on screening for endometrial cancer and is probably the largest such study to date, commented Ignace Vergote, MD, PhD, and colleagues from University Hospitals Leuven in Leuven, Belgium.

On the other hand, it falls short of proving "a benefit for screening for endometrial cancer because of an absence of survival data," Vergote and colleagues argued in an accompanying comment article. According to Diane Harper, MD, of the University of Missouri, "The test characteristics are not good enough" and the ultrasound process may be less acceptable to many women than a biopsy, which is more accurate in the first place.

"Having a transvaginal probe inserted and moved around is quite invasive for the patient," Harper said in an e-mail. On the other hand, while an endometrial biopsy can cause painful cramping, it's relatively quick and involves only the woman and her doctor, she argued.

"This investigation will not change clinical practice," said Sean Dowdy, MD, also of the Mayo Clinic in Rochester. The procedure has been used for many years in patients with postmenopausal bleeding, he noted in an e-mail, "but both sensitivity and specificity are far too low" for it to be used as a screening method. Endometrial cancer is usually diagnosed early because of the vaginal bleeding experienced by most patients, so "there is far less to gain" from a screening test for this disease, Dowdy wrote, adding that a more effective intervention would be reducing obesity among women.

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Article written by staff at medpagetoday.com and adapted for the purposes of this newsletter.

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Nonradiologists Power Musculoskeletal Ultrasound Growth

Musculoskeletal ultrasound usage nearly quadrupled between 2000 and 2008, driven primarily by increased utilization by nonradiologists, according to a study presented Thursday at the 2010 RSNA meeting in Chicago. A team from Thomas Jefferson University in Philadelphia found that Medicare reimbursed 279.4% more musculoskeletal ultrasound studies in 2008 than they did in 2000. And nonradiologists, sparked by a surge in utilization by podiatrists, accounted for 71% of the more than 157,000 increase in utilization.

"Self-referral may be contributing to higher increases of nonradiologist musculoskeletal ultrasound utilization," said presenter Richard Sharpe, MD. "These studies, if that were the case, may then not represent an efficient allocation of healthcare dollars." Musculoskeletal ultrasound is an emerging radiology subspecialty, and utilization has increased rapidly. In fact, utilization has risen so sharply that insurers in four states -- Illinois, New Mexico, Oklahoma, and Texas -- for a time denied all claims for nonoperative spinal and musculoskeletal ultrasound, declaring the studies to be "experimental." That policy was rescinded in February 2010, however.

To document trends in musculoskeletal ultrasound utilization in the Medicare population, the researchers obtained source data from the U.S. Centers for Medicare and Medicaid Services (CMS) Part B Physician/Supplier Procedure Summary Master Files from 2000 to 2008. The data cover all Medicare fee-for-service beneficiaries and omit HMO enrollees.

Records for allowed primary claims for extremity nonvascular ultrasound (CPT code 76880) were extracted, and providers were classified using Medicare's provider specialty codes.

To determine imaging volume, the researchers tabulated global claims and professional-component-only claims. Technical-component-only claims were excluded due to the possibility of double counting, Sharpe said. The researchers found that 213,425 musculoskeletal ultrasound studies were primarily reimbursed by Medicare in 2008, up 279.4% from the 56,254 exams reimbursed in 2000. This also yields a 256.7% growth in utilization rate, which climbed from 171/100,000 Medicare beneficiaries in 2000 to 610/100,000 in 2008.

Of the 157,171 increase in studies over the time period, 111,268 (71%) were from nonradiologists. Radiologists did contribute the plurality of overall claims in 2008, submitting 86,780 claims (40.7%). Podiatrists generated 66,585 (31.2%) claims and rheumatologists produced 22,270 (10.4%) claims.

"The podiatrists, which began the study as a lower user, are now using nearly as many studies as radiologists -- in just the past eight years," Sharpe said. In other findings, the researchers noted that office (i.e., privately owned facilities) claims increased 635.8% in the study period, climbing from 19,372 in 2000 to 145,542 in 2008. Podiatrists submitted 66,103 (46.4%) of these claims, while rheumatologists contributed 22,220 (15.6%) and radiologists generated 19,390 (13.6%).

"The greatest increases in utilization occurred in private offices, and the nature of private offices is that some of these studies may be less scrutinized -- may be subject to less peer review, less validation, and less regulation," Sharpe said. "Consequently, these examinations may have wide ranges of quality." The study team also discovered significant geographic variation by CMS region in the use of musculoskeletal ultrasound. "In Kansas City, for example, about 20% of musculoskeletal studies are performed by nonradiologists," he said. "But in Atlanta, Dallas, New York, and San Francisco, that number is about 65%." In addition, nearly all regions experienced significant increases in nonradiologist use of ultrasound. "Only in Boston have nonradiologists used less [over the course of the study]," he said.

The researchers acknowledged a number of limitations of their research, including the lack of assessment of the quality or clinical appropriateness of individual ultrasound examinations. In addition, the study only evaluated the Medicare population, Sharpe said.

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Article written by staff at auntminnie.com and adapted for the purposes of this newsletter.

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