Claim-Based Method for IR Identification

A Claims-Based Method for Identification and Characterization of Practicing Interventional Radiologists

Clinical question

How to identify practicing interventional radiologists when most of them are listed as diagnostic radiologists on national claims data sets?

Take away point

A claims-based method, using percent IR-related work effort, may provide generalizability and comparability for identifying practicing interventional radiologists.

Reference

Waid, M.D., Rula, E.Y., Hawkins, C.M., Findeiss, L. and Liu, R., 2024. A Claims-Based Method for Identification and Characterization of Practicing Interventional Radiologists. Journal of Vascular and Interventional Radiology, 35(6), pp.909-917.

Click here for abstract

Study design

Healthcare policy and economics study

Funding Source

Society of Interventional Radiology (SIR), Workforce Research Division

Figure

Summary

The article discusses the challenges and proposed solutions for accurately identifying practicing interventional radiologists (IRs) using claims data. Despite many diagnostic radiologists (DRs) performing IR work, self-designated specialties often underrepresent the IR field, necessitating a reliable method to define and identify IRs for research purposes. The study found that a significant majority (around 80%) of IRs were listed as self-designated diagnostic radiologists in both Medicare and private insurance data. As the proportion of work devoted to IR-related services increased, more effort was allocated to surgical, invasive, and evaluation and management services, with less focus on noninvasive imaging.

The research aimed to develop and test an operational definition for identifying IRs based on claims data, using data from Medicare and commercial insurance claims. A major finding was that self-designated interventional radiologists comprised only a minority of those identified as practicing IRs at various work effort thresholds. The study demonstrated that as the percentage of IR-related work increased, the proportion of procedural and evaluation/management services rose, while noninvasive imaging efforts declined. This pattern was consistent across both Medicare and private insurance data.

Demographically, practicing IRs were more likely to be male, work in metropolitan areas, have fewer years since graduation, and be in smaller practice groups. The study proposed a methodology to improve the identification of IRs in claims data, which is important for advancing IR-related health services research. The authors emphasize that their approach aims to create consistent and replicable samples of IRs for research, rather than making judgments on specialty designations. This methodology is expected to facilitate better comparisons and conclusions in future IR-related studies.

Commentary

The demographic insights provided by the study, such as the higher likelihood of IRs being male, working in metropolitan areas, and being relatively early in their careers, offer valuable context for workforce planning and policy development. Additionally, the finding that IRs tend to work in smaller practice groups could inform strategic decisions in practice management and resource allocation.

But the most interesting finding in the article is the discrepancy between self-designated IRs and those identified through claims data, highlighting an underrepresentation of IR in national claims data. This underscores the potential significance of claims-based identification to capture the full IR workforce. The methodology's ability to discern IRs by analyzing the proportion of work devoted to IR-related services versus noninvasive imaging is a good framework that can enhance the accuracy of IR specialty identification.

Disc versus Bone? Osteomyelitis Discitis Biopsy

Percutaneous Disc Biopsy versus Bone Biopsy for the Identification of Infectious Agents in Osteomyelitis/Discitis

Clinical question

Which diagnostic approach is more effective for vertebral discitis and osteomyelitis: intervertebral disc biopsy or vertebral body biopsy?

Take away point

Disc biopsies may provide superior diagnostic accuracy for vertebral discitis and osteomyelitis when compared to bone biopsy.

Reference

Zamarud A, Kesten J, Park DJ, et al. Percutaneous Disc Biopsy versus Bone Biopsy for the Identification of Infectious Agents in Osteomyelitis/Discitis. J Vasc Interv Radiol. 2024;35(6):852-857.e1. doi:10.1016/j.jvir.2024.02.016

Click here for abstract

Study design

Retrospective, observational, cohort study

Setting

Academic setting

Figure

Figure 1. Representative images from a disc biopsy procedure. A 75-year-old man with back pain underwent (a–c) magnetic resonance (MR) imaging and (d–f) fluoroscopy-guided bone biopsy. Sagittal (a) T2, (b) T1, and (c) contrast-enhanced MR images showed findings suspicious for L4/L5 discitis (arrow) and osteomyelitis of L4 and L5 (arrowheads). Percutaneous biopsy of the L4/L5 was performed in an oblique (d, e) anteroposterior and (f) lateral view. (d) A safe trajectory was noted on the oblique anteroposterior view (hemostat marker), and (e) an introducer needle was advanced in plane on this view into the disc space (arrow). (f) The introducer stylet was then removed, and a biopsy needle was used to sample the disc space (arrow).

Summary

Vertebral discitis and osteomyelitis (VDO) are severe spinal infections, potentially leading to significant neurological deficits and structural spinal damage. In addition to non-invasive imaging (MRI) to localize and characterize the extent of the infection, biopsy of the affected disc and/or vertebral body is obtained via a percutaneous image-guided approach (fluoroscopy or CT) for identification of the causative organism to tailor antibiotic treatment. The decision to perform a biopsy of the affected disc or vertebral body is typically left to the discretion of the proceduralist. This retrospective cohort study aimed to compare the diagnostic yield of disc biopsies versus vertebral body biopsies in patients with suspected VDO. It was hypothesized that percutaneous sampling of the disc rather than the affected vertebra would be more likely to yield a positive tissue culture as infection of the disc is believed to be the inciting event in most patients.

Patients included in the study underwent biopsy procedures between 2019 and 2023 due to suspected VDO. Inclusion criteria required patients to be >= 18 years of age with presumed VDO based on MR imaging who undergone percutaneous biopsy. Data were extracted from EMR, focusing on biopsy procedure details, culture results, patient demographics, imaging findings, and treatment outcomes. 66 patients were included in the study–36 had disc biopsies, 30 had vertebral body biopsies, and 6 (3 in each group) underwent repeated procedures given initial negative tissue sampling result. Biopsies were performed by 5 different neurointerventional radiologists and 1 neurosurgeon. The decision to biopsy the disc or bone was at the discretion of the physician with varying techniques. The primary outcome measure was the culture yield (positive or negative) after percutaneous sampling. Statistical analyses included chi-square tests and Fisher’s exact tests to compare positivity rates between the biopsy methods.

Patient characteristics did not different significant between the two groups, except for the history of intravenous drug use (26.7% compared with 5.5% in patients who underwent bone biopsy and disc biopsy, respectively). Disc biopsies had a significantly higher rate of positive cultures compared to bone biopsies; 41% compared to 15% There were no statistically significant association between the biopsy culture results and pre-biopsy antibiotic administration. Neither were there any significant association between pre-biopsy blood cultures and biopsy culture results; in fact, 90% of the cases had a negative blood culture prior to the biopsy. No adverse events were noted after the procedure in either procedure group.

The authors discussed the positive implications for clinical practice, including improved pathogen identification and thus more tailored antibiotic therapy for VDO. The authors’ findings corroborated with previous studies that have reported low diagnostic yields from bone biopsies. Limitations of the study included its small scale and retrospective nature. Overall, the authors concluded that percutaneous biopsy of VDO should prioritize sampling of the disc to increase the likelihood of a positive tissue culture and allow tailored narrowed antibiotic coverage.

Commentary

This retrospective study addresses the clinically relevant question of whether percutaneous biopsy for VDO should prioritize sampling the disc or bone to increase the probability of a positive tissue culture, enabling more targeted antibiotic therapy. 

However, the small sample size, the single-center nature of the study, and the potential bias introduced with each physician choosing a biopsy type at their own discretion may limit the strength of these results. Additionally, there was a minor discrepancy in culture results and results from histologic analysis. Two disc biopsy patients and 4 bone biopsy patients with negative culture results had an infectious etiology during histologic analysis. This suggests that histologic analysis may be complementary to tissue culture in detecting certain infections and should be explored in future studies. The significant difference in intravenous drug use history between the two groups could have also introduced a confounding variable and thus may have influenced the difference in outcomes slightly. This study could have benefitted from a multivariate analysis or propensity score matching to account for this difference. 

Despite all of these limitations, this study presents encouraging findings regarding the benefits of prioritizing percutaneous disc biopsy over bone biopsy for VDO. To integrate this approach into clinical practice, additional studies with larger sample sizes studied at multiple institutions and a more uniform cohort are necessary. Overall, these findings are the first step in shifting the clinical decision making of physicians in this setting and may prompt new guidelines in favoring percutaneous disc biopsy for VDO.

  

Post Author
Danielle Millner Balagtas, BA
MD Candidate, Class of 2027
University of Massachusetts Chan Medical School
@daniellelmb

VR for IR Sedation?

Digital Sedation in Interventional Radiology: Reducing Pain and Anxiety Through Virtual Reality During Peripherally Inserted Central Catheter Placement and Fine Needle Aspiration Thyroid Biopsy

Clinical question

Does the use of virtual reality (VR) as a non-pharmacologic adjunct have analgesic and anxiolytic effects during Peripherally Inserted Central Catheter (PICC) placement and Fine Needle Aspiration (FNA) thyroid biopsy?

Take away point

Implementation of VR as a non-pharmacologic adjunct can reduce pain during some interventional radiology procedures; therefore, showing promise as an alternative to pharmacological approaches.

Reference

Schaake, R., Leopold, I., Sandberg, A., Zenk, B., Shafer, L., Yu, D., Lu, X., Theingi, S., Udongwo, A., Cohen, G. S., & Maresky, H. S. (2024). Virtual reality for the management of pain and anxiety for IR procedures: A prospective, randomized, pilot study on Digital Sedation. Journal of Vascular and Interventional Radiology, 35(6), 825–833. https://doi.org/10.1016/j.jvir.2024.03.004

Click here for abstract

Study design

Prospective, single-center randomized controlled trial with 107 patients.

Funding Source

This study was supported by the Lewis Katz School of Medicine at Temple University.

Setting

Academic setting, Lewis Katz School of Medicine at Temple University.

Figure

Figure 1(a) Image of virtual reality tropical island environment used in trials. (b) Image of study participant viewing virtual reality during peripherally inserted central catheter placement.


Figure 4(a) Estimation plots for paired data of individual VAS pain scores before and after thyroid biopsy for individuals randomized to SOC (n = 22) vs SOC+VR (n = 25). (b) Estimation plots for individual VAS anxiety scores for before and after thyroid biopsy for individuals randomized to SOC (n = 22) vs SOC+VR (n = 25). Tufte slope graphs are presented for each patient, connecting pre- and postprocedural VAS scores. Mean difference and 95% confidence intervals bars are plotted below each panel. PICC = peripherally inserted central catheter; SOC = standard of care; VAS = visual analog scale; VR = virtual reality.

Summary

Schaake et al. examined the use of virtual reality (VR) as a form of “digital sedation” to reduce pain and anxiety during Interventional Radiology (IR) procedures that typically do not require pharmacologic sedation, such as peripherally inserted central catheter (PICC) placement and fine-needle aspiration (FNA) thyroid biopsies. A prospective, single center randomized controlled trial was conducted with a sample size of 107 patients assigned to either a Standard of Care or Standard of Care plus Virtual Reality. The PICC cohort consisted of 59 patients with a median age of 53.1, while the thyroid biopsy cohort consisted of 48 patients with a median age of 60.1. Of note, the following groups of patients were excluded from the study: declining to participate, inability to provide consent, emergency procedures, administration of general anesthesia/moderate sedation, visual/hearing deficits, pregnancy, current prisoner status, nerve/sensory deficits over the area of procedure, or coronavirus disease 2019–positive status.

The VR procedure utilized the “Emmarye” (VRAL, Philadelphia, Pennsylvania) environment where the patient viewed a tropical environment with a sunset sky and ambient audio of the ocean and seagulls. A fairy would also appear engaging users in breathing exercises and giving reminders to remain still. Participants in the study completed an assessment of anxiety and pain using visual analog scales both pre- and post-procedure. Heart rate and blood pressure were also obtained during the procedure. Statistical analysis included a one-way ANOVA comparing the two groups with respect to pain and anxiety scores, ultimately indicating that VR significantly reduced pain scores during fine needle aspiration of the thyroid. Additionally, a trend was observed without statistical significance showing reduced anxiety during thyroid biopsies, as well as reduced pain and anxiety during peripherally inserted central catheter placement. Schaake et al. concluded that VR could be implemented to alleviate patient pain and anxiety during minimally invasive IR procedures, without increased procedural duration or risks of adverse events. They also contextualized these findings with other studies demonstrating the efficacy of using VR during simple procedural interventions in medicine, such as reducing pediatric patient’s anxiety and pain during orthopedic cast removal.

Commentary

As healthcare continues to integrate technological advancements, the use of virtual reality to improve patient comfort is an intriguing area worthy of exploration. Patients often experience pain and anxiety around procedures. While pharmacologic anxiolytics and analgesics play an important role in procedural care, their adverse effects, especially in an epidemic of pain medication misuse and overuse, should not be overlooked. Therefore, this study’s investigation on non-pharmacologic methods to improve patient comfort during interventional radiology procedures is illuminating. The methodology incorporated a unique healthcare-oriented VR environment, established scales for pain and anxiety measurements, and appropriate analytic statistics. The results, though limited by small sample size, two procedures typically not requiring sedation, and missed opportunities of capturing granular procedural details, are promising for the use of VR for pain and anxiety control peri-procedurally.

Nevertheless, there are several important considerations or even obstacles to potential wider clinical application of VR. First, the initial cost of VR equipment and need for continual updates may be expensive. Second, the scope of VR is limited by procedure type. Certain procedures require patient feedback, or the patient may need to be physically adjusted into a position that could be obstructed by the VR headsets. Wearing VR headsets for lengthy procedures can also be uncomfortable for some patients and issues like battery life and technological difficulties may arise. Finally, patients might experience VR-related eye strain, headaches, or motion sickness. With motivated investments from the industry and continued technological advancements, however, these issues will be of ever decreasing concern.

This study offers an insightful view on the potential for advanced technology in patient care. Virtual Reality offers exciting possibilities in medicine, but more research is needed to ensure maximization of the benefits and minimization of adverse events. Ultimately, Schaake et al. demonstrate a promising outlook on how technology advances in the reality-virtuality continuum can improve the tolerability of health care interventions.

Post Author
Shabaz Khan, B.A
M.D. Candidate, Class of 2027
University of Massachusetts Chan Medical School
@shabaz_khan11