JOURNAL CLUB: Advanced Imaging Interpretation by Radiologists and Nonradiologist Physicians: A Training Issue

Point-of-care ultrasonography (POCUS) is a useful imaging technique for the emergency medicine (EM) physician. Because of its growing use in EM, this article will summarize the historical development, the scope of practice, and some evidence supporting the current applications of POCUS in the adult emergency department. Bedside ultrasonography in the emergency department shares clinical applications with critical care ultrasonography, including goal-directed echocardiography, echocardiography during cardiac arrest, thoracic ultrasonography, evaluation for deep vein thrombosis and pulmonary embolism, screening abdominal ultrasonography, ultrasonography in trauma, and guidance of procedures with ultrasonography. Some applications of POCUS unique to the emergency department include abdominal ultrasonography of the right upper quadrant and appendix, obstetric, testicular, soft tissue/musculoskeletal, and ocular ultrasonography. Ultrasonography has become an integral part of EM over the past two decades, and it is an important skill which positively influences patient outcomes.

To assess possible differences in physicians' practices with respect to diagnostic imaging, we compared the frequency and costs of imaging examinations as performed by primary physicians who used imaging equipment in their offices (self-referring) and as ordered by physicians who always referred patients to radiologists (radiologist-referring). Using a large, private insurance-claims data base, we analyzed 65,517 episodes of outpatient care by 6419 physicians for acute upper respiratory symptoms, pregnancy, low back pain, or (in men) difficulty urinating. The respective imaging procedures studied were chest radiography, obstetrical ultrasonography, radiography of the lumbar spine, and excretory urography, cystography, or ultrasonography. For all four clinical presentations, the self-referring physicians obtained imaging examinations 4.0 to 4.5 times more often than the radiologist-referring physicians (P less than 0.0001 for all four). For chest radiography, obstetrical ultrasonography, and lumbar spine radiography, the self-referring physicians charged significantly more than the radiologists for imaging examinations of similar complexity (P less than 0.0001 for all three). The combination of more frequent imaging and higher charges resulted in mean imaging charges per episode of care that were 4.4 to 7.5 times higher for the self-referring physicians (P less than 0.0001). These results were confirmed in a separate analysis that controlled for the specialty of the physician. Physicians who do not refer their patients to radiologists for medical imaging use imaging examinations more frequently than do physicians who refer their patients to radiologists, and the charges are usually higher when the imaging is done by the self-referring physician. From our results it is not possible to determine which group of physicians uses imaging more appropriately.

To retrospectively compare the frequency with which patients underwent diagnostic medical imaging procedures during episodes of outpatient medical care according to whether their physicians referred patients for imaging to themselves and/or physicians in their same specialty or to radiologists. Institutional review board approval was not necessary for this HIPAA-compliant study. An insurance claims database from a large national employer-based health plan was obtained. Claims data from 1999-2003 were grouped into episodes of care for six conditions: cardiopulmonary disease, coronary and/or cardiac disease, extremity fracture, knee pain, intraabdominal malignancy, and stroke. For each condition, each referring physician's behavior was categorized as either "same-specialty referral" or "radiologist referral" on the basis of that physician's entire history of imaging referrals for the condition. The frequency with which patients underwent diagnostic medical imaging procedures during episodes of care was compared according to whether their physicians referred patients for imaging to themselves and/or same-specialty physicians or to radiologists. Rates were compared by using chi(2) tests, and logistic regression was used to compare utilization rates, with patient age and number of comorbidities as covariates. For the conditions evaluated, physicians who referred patients to themselves or to other same-specialty physicians for diagnostic imaging used imaging between 1.12 and 2.29 times as often, per episode of care, as physicians who referred patients to radiologists (P < .005 for all comparisons). Adjusting for patient age and comorbidity, the likelihood of imaging was 1.196-3.228 times greater for patients cared forby same-specialty-referring physicians. Same-specialty-referring physicians tend to utilize imaging more frequently than do physicians who refer their patients to radiologists. These results cannot be explained by differences in case mix (because analyses were performed within six specific conditions of interest), patient age, or comorbidity.