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• W3084209218 abstract "HomeRadiologyVol. 297, No. 2 PreviousNext Reviews and CommentaryFree AccessEditorialValue in Interventional Radiology: Achieving High Quality Outcomes at a Lower CostSarah B. White Sarah B. White Author AffiliationsFrom the Department of Radiology, Division of Vascular and Interventional Radiology, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53226.Address correspondence to the author (e-mail: [email protected]).Sarah B. White Published Online:Sep 8 2020https://doi.org/10.1148/radiol.2020203407MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In See also the article by Trivedi et al in this issue.Sarah White, MD, MS, is an associate professor of radiology and surgical oncology and serves as vice chair of radiology research at the Medical College of Wisconsin. Dr White has served as the chair of the clinic research and registries for the Society of Interventional Radiology (SIR) Foundation since 2014. She has received national and international awards for her research, including the 2016 SIR Gary J. Becker Young investigator award for her work.Download as PowerPointOpen in Image Viewer On January 16, 1964, when Charles Dotter, MD, performed the first percutaneous angioplasty, image-guided therapeutic interventions became possible (1). Interventional radiology has seen many challenges in the past 56 years; however, interventional radiology has always been plagued by having to prove its value to referring physicians, hospital administrators, and at times even diagnostic colleagues. Interventional radiology is integral to the hospital and is required for a hospital to be designated as a level I trauma center by the American College of Surgeons, to be a regional transplant center, certified stroke center, clinical cancer center, and to provide services that are necessary for pediatrics, urology, and palliative care.The value of interventional radiology was demonstrated nicely in a study (2) performed at a large tertiary care center. It demonstrated that 41% of outside-hospital transfers to the trauma surgery department were transferred for interventional radiology services rather than for surgical services. However, interventional radiology is not the only specialty to perform image-guided procedures. Cardiologists, interventional nephrologists, interventional neurologists, and vascular surgeons also perform image-guided endovascular procedures. Therefore, now more than ever, interventional radiology must prove its worth. Many studies have shown that minimally invasive procedures decrease health care costs by improving recovery times and decreasing duration of hospitalizations (3–5). However, these studies compared minimally invasive therapies such as vertebroplasty and ablation with the open surgical options. Unlike these previous studies, LaRoy et al (6) published data comparing the cost of chest port insertion by physician specialty, in this case surgery and interventional radiology. This study was unique because it compared different specialties that performed the same procedure, unlike the previous studies that compared different approaches (eg, ablation vs resection). The results demonstrated that interventional radiology and surgical outcomes and morbidities were similar; however, the cost of chest port insertion was 193% higher when placed by a surgeon. Despite this provocative article, practice patterns have not changed dramatically. With the current emphasis on decreasing health care expenditures and the rising number of people who are beneficiaries of Medicare, it is imperative to provide high-quality cost-effective care.In this issue of Radiology, Trivedi et al (7) report a cost analysis of dialysis maintenance across physician specialties in U.S. Medicare beneficiaries. Similar to the study by LaRoy et al (6), they evaluated the cost of the same procedure when performed by different specialties. They used the Medicare Limited Data Set to evaluate all patients who had a new arteriovenous fistula or graft surgically placed for hemodialysis access in 2009 (n = 4127). The authors excluded 1151 patients who had a previous arteriovenous fistula or graft, 283 patients with Health Maintenance Organization status, and 1138 patients who required no maintenance interventions in the first 5 years following access creation. The authors followed the remaining patients longitudinally for 5 years (until 2014) and assessed all costs associated with maintenance of access patency. Cost was defined as societal cost, meaning the Medicare payment, which included technical and professional fees. To keep their data consistent, they also excluded all patients in whom access interventions were performed in the inpatient setting or at ambulatory surgery centers (n = 68). A total of 1479 patients were included in the study and 8166 interventions were performed over the 6-year follow-up. The interventions were then assigned to the billing physician by specialty, which included interventional radiology (43.6%; n = 3562), nephrology (33.2%; n = 2709), surgery (23.2%; n = 1895), and other (0.1%; n = 9). Physician data were missing for 1.2% (n = 106). Patient demographics, specific maintenance interventions, location of services provided (ambulatory or office vs hospital outpatient), and postintervention primary access patency were collected.Similar to the results published by La Roy et al (6), the study by Trivedi et al (7) demonstrated that outcomes were similar irrespective of the specialty performing the procedure. However, for the same patency gain, the procedure was approximately 50% more costly if performed by nephrology or surgery (P < .001). The unadjusted cost for procedures performed by interventional radiology, nephrology, and surgery was $71 000, $89 000, and $179 000, respectively.Regression analysis, however, teased out the drivers for the cost differences. High costs associated with surgeons performing interventions were driven by the use of the operating room, which resulted in a fourfold increase in Medicare cost. The use of anesthesia also drove up the cost of surgeons performing interventions. Surgeons were found to use anesthesia six times more often than their nephrology counterparts and four times more often than radiologists. High costs were associated with nephrologists performing procedures because 82% of the procedures they performed were in the ambulatory or office setting, which increased the cost by 69%. It can therefore be extrapolated that interventional radiology is more cost-effective in part because of hospital outpatient setting (82% of interventions), the use of a dedicated angiography suite located outside of the operating room, and nursing-administered sedation versus the involvement of anesthesia. Procedures performed in the Northeast region were also associated with higher costs. Perhaps what is equally interesting is that not a single patient factor—not age, sex, ethnicity, metropolitan status, comorbid conditions, or median incomes—played a role in the cost of health care.There were also differences in the practice patterns between the specialists. Surgeons placed stents significantly more often than the other two specialties (surgery, interventional radiology, and nephrology, 17%, 14%, and 10%, respectively), which were associated with a twofold increase in cost. Interventional radiologists performed more thrombolysis (surgery, interventional radiology, and nephrology, 24%, 30%, and 29%, respectively). These data indicate that the specialties either have different approaches to access interventions or that interventional radiologists and surgeons are seeing more complex patients than are their nephrology colleagues.The study was limited because it is retrospective in nature. Understanding referral patterns for Medicare beneficiaries cannot be assessed with data from this national Medicare database. It is also unclear whether surgeons and nephrologists were performing dialysis maintenance procedures because interventional radiologists were not available, they did not provide these services, or if referring providers had built relationships with other specialists. Provider practice patterns also could not be determined with this analysis, which only allowed a broad overview of maintenance interventions. The complexity of cases performed by interventional radiologists can only be extrapolated from the data presented in the study by Trivedi et al. Therefore, the true benefit of dialysis interventions performed by interventional radiologists may not be appreciated in their study (7).What is to be learned from this large data analysis? Interventional radiologists provide high-quality care to patients; this high-quality care is not unique to interventional radiology. However, when care was provided by interventional radiology versus the other specialties, the cost was half. The cost differences are inherent to how the different specialties provide services. The surgeons work in the operating room with anesthesia, nephrologists work in outpatient centers, and interventional radiologists most often practice in a hospital outpatient setting. Because of the current model in which interventional radiologists perform procedures, interventional radiology is able both to achieve faster turnaround times than the operating room and to use nursing sedation. Therefore, for surgeons and nephrologists to offer services at a cost similar to interventional radiology, they need to adopt the interventional radiology model, which has demonstrated significant financial benefits and decreased the financial burdens of dialysis maintenance. Until other specialties can match the cost of care provided by interventional radiologists, referring physicians and patients themselves should consider seeking care from interventional radiologists. However, for interventional radiologists to ultimately prove their value, a better understanding of the unique care delivered by interventional radiology is needed.Disclosures of Conflicts of Interest: S.B.W. Activities related to the present article: disclosed no relevant relationships. Activities not related to the present article: disclosed board membership of the Society of Interventional Radiology Foundation; disclosed money paid to author for consultancies from Guerbet and Cook; disclosed grants from Focused Ultrasound Foundation; disclosed travel/accommodations/meeting expenses from Cook; disclosed research support from Siemens and Insightec. Other relationships: disclosed no relevant relationships.References1. Friedman SG. Charles Dotter and the fiftieth anniversary of endovascular surgery. J Vasc Surg 2015;61(2):556–558. Crossref, Medline, Google Scholar2. Britt R, Davis P, Gresens A, et al. The Implications of Transfer to an Acute Care Surgical Tertiary Service. Am Surg 2017;83(12):1422–1426. Crossref, Medline, Google Scholar3. Epstein AJ, Groeneveld PW, Harhay MO, Yang F, Polsky D. Impact of minimally invasive surgery on medical spending and employee absenteeism. JAMA Surg 2013;148(7):641–647. Crossref, Medline, Google Scholar4. Itagaki MW, Talenfeld AD, Kwan SW, Brunner JW, Mortell KE, Brunner MC. Percutaneous vertebroplasty and kyphoplasty for pathologic vertebral fractures in the Medicare population: safer and less expensive than open surgery. J Vasc Interv Radiol 2012;23(11):1423–1429. Crossref, Medline, Google Scholar5. Kwan SW, Mortell KE, Hippe DS, Brunner MC. An economic analysis of sublobar resection versus thermal ablation for early-stage non-small-cell lung cancer. J Vasc Interv Radiol 2014;25(10):1558–1564; quiz 1565. Crossref, Medline, Google Scholar6. LaRoy JR, White SB, Jayakrishnan T, et al. Cost and Morbidity Analysis of Chest Port Insertion: Interventional Radiology Suite Versus Operating Room. J Am Coll Radiol 2015;12(6):563–571. Crossref, Medline, Google Scholar7. Trivedi PS, Jensen AM, Brown MA, et al. Cost analysis of dialysis access maintenance interventions across physician specialties in U.S. Medicare beneficiaries. Radiology 2020;297:474–481. Link, Google ScholarArticle HistoryReceived: Aug 12 2020Revision requested: Aug 17 2020Revision received: Aug 19 2020Accepted: Aug 20 2020Published online: Sept 08 2020Published in print: Nov 2020 FiguresReferencesRelatedDetailsCited ByA novel labeling modality of intra-abdominal lesions with Magseed magnetic marker and extirpation by Sentimag probe navigationDanielToman, IlkerSengul, OtakarKubala, TomášJonszta, JiříProkop, LubomírTulinský, PeterIhnát, PetraGuňková, AntonPelikán, DemetSengul2023 | Revista da Associação Médica Brasileira, Vol. 69, No. 1Access to beds for interventional radiology patients: improving patient careT.Bryant, R.Ahmad, A.Diamantopoulos, R.Lakshminarayan, C.Bent, J.Taylor, R.A.Morgan2023 | Clinical RadiologyComplication Management and Prevention in Vascular and non-vascular InterventionsDanielWeiss, Lena MarieWilms, Vivien LorenaIvan, MariusVach, ChristinaLoberg, FaridZiayee, JulianKirchner, LarsSchimmöller, GeraldAntoch, PeterMinko2022 | RöFo - Fortschritte auf dem Gebiet der Röntgenstrahlen und der bildgebenden Verfahren, Vol. 194, No. 10Precision interventional radiologyJiansongJi, ShijiFang, Minjiang chen, Liyun zheng, WeiqianChen, ZhongweiZhao, YongdeCheng2021 | Journal of Interventional Medicine, Vol. 4, No. 4Accompanying This ArticleCost Analysis of Dialysis Access Maintenance Interventions across Physician Specialties in U.S. Medicare BeneficiariesSep 8 2020RadiologyRecommended Articles Cost Analysis of Dialysis Access Maintenance Interventions across Physician Specialties in U.S. Medicare BeneficiariesRadiology2020Volume: 297Issue: 2pp. 474-481Hemodialysis Arteriovenous Fistula and Graft Stenoses: Randomized Trial Comparing Drug-eluting Balloon Angioplasty with Conventional AngioplastyRadiology2018Volume: 289Issue: 1pp. 238-247Updates and New Frontiers in Interventional Radiology The 2022 RadioGraphics Monograph IssueRadioGraphics2022Volume: 42Issue: 6pp. 1577-1578Medical Error, Adverse Events, and Complications in Interventional Radiology: Liability or Opportunity?Radiology2020Volume: 298Issue: 2pp. 275-283Long-term Graft and Patient Survival after Balloon Dilation of Ureteric Stenosis after Renal Transplant: A 23-year Retrospective Matched Cohort StudyRadiology2016Volume: 281Issue: 1pp. 301-310See More RSNA Education Exhibits Overview of FDA Approved Endovascular Techniques for Creating Arteriovenous Fistulas for Hemodialysis AccessDigital Posters2020The Role of CT/CTA in Attempted Salvage of the Threatened or Mangled Extremity: From Secondary Survey to Damage Control Radiology  Digital Posters2020Engaging Medical Students in Interventional Radiology: In the Era of the New Integrated IR ResidencyDigital Posters2018 RSNA Case Collection Stent placement for transplant hepatic artery stenosisRSNA Case Collection2020Buried Bumper Peg SyndromeRSNA Case Collection2021Superior Vena Cava SyndromeRSNA Case Collection2020 Vol. 297, No. 2 Metrics Altmetric Score PDF download" @default.
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