Disparities over Time in Volume, Day of the Week, and Patient Complexity between Paracentesis and Thoracentesis Procedures Performed by Radiologists versus Those Performed by Nonradiologists

Clinical question
Does complexity or day of the week affect whether a radiologist or non-radiologist performs a paracentesis or thoracentesis?

Take-away point
Radiologists are performing an increasingly larger portion of paracenteses and thoracenteses over time, however the proportion is higher on weekdays.

Reference
Gottumukkala, RV et al. Disparities over Time in Volume, Day of the Week, and Patient Complexity between Paracentesis and Thoracentesis Procedures Performed by Radiologists versus Those Performed by Nonradiologists. Journal of Vascular and Interventional Radiology. Nov, 2019: 30; 11, 1769-1778

Click here for abstract

Study design
Retrospective

Funding source
Self-funded or unfunded

Setting
Patient-level 5% Medicare Part B Research Identifiable Files





Figure 1. Proportion of total weekend and weekday volumes of paracenteses performed by radiologists compared with those performed by nonradiologists from 2004 to 2016. The vertical axis scale on the left reflects the percentages of the weekday volume performed by radiologists and nonradiologists (solid lines). The vertical axis scale on the right reflects the percentages of weekend volume performed by radiologists and nonradiologists (dashed lines).

Summary

Paracenteses and thoracenteses are common procedures that can be performed by radiologists and non-radiologists. Many radiologists have surmised that these procedures are being disproportionally referred to radiology after hours and on weekends. A 5% Medicare beneficiary cohort was evaluated over a 12 year period of time. The proportion of radiology performed paracenteses increased from 70% in 2004 to 80% in 2016. Likewise, the proportion of radiology performed thoracenteses increased from 45% to 65% over the same time period. Weekday paracenteses performed by radiologists increased from 71% to 80%, while weekend proportion increased from 57% to 68%. Weekday thoracentesis performed by radiologists increased from 47% to 66%, while weekend proportion increased from 29% to 54%. There was no difference in patient comorbidities over the final three years of the study for the patients who underwent a procedure by radiology versus other services.

The authors hypothesize that the increasing referral of these procedures to radiologists could be secondary to atrophy of procedural skill amongst Internal Medicine physicians, duty hour restrictions, competing clinical responsibilities, poor reimbursement of the procedures, and lack of available ultrasounds. The study also concluded that while radiologists and performing and increasing larger proportion of procedures over time, a greater share is still performed on weekdays than weekends. This finding differs compared to similar study of diagnostic procedures with similar inter-specialty dynamics. The results imply that selective referral of procedures to radiologists after and on more complex patients does not apply to paracenteses and thoracenteses.

Commentary

While the authors concluded that there is not a selective referral bias on paracenteses and thoracenteses, proportional rate of growth was greater on weekends than weekdays, suggesting that if this trend continues, a referral bias could be proven in the future. The overall percentages and volume speaks to the need of small procedure rooms within radiology to perform small procedures in a timely and cost effective manner. Dynamics are incredibly variable between institutions, and how nationwide trends applies to a singular institution is unclear.

Post Author
David M Mauro, MD
Assistant Professor
Department of Radiology, Vascular and Interventional Radiology
University of North Carolina

@DavidMauroMD