The Benefits of Not Being “Advanced Diagnostic Imaging”

For nearly two decades, ultrasound has had to struggle to gain equal footing in the eyes of imagers who have had much longer experience in cross-sectional imaging. With some exceptions, ultrasound was seen as a second-tier modality due to concerns about its sensitivity and specificity for many diagnoses. As the technology has improved, the quality of ultrasound imaging has risen to a level on par with CT and MRI for many more of the diagnoses throughout the body. As a result, even imagers with a strong bias toward CT/MRI are now forced to consider ultrasound more frequently in their current practice.

Factors that favor the consideration of ultrasound for initial imaging include its lack of ionizing radiation, portability, widespread access, and relative low costs. Considering these advantages, it is no wonder that healthcare policy thought leaders would be looking to ultrasound as a first-line imaging option when possible.

One of these interested groups is the government. The Center for Medicare & Medicaid Services (CMS) continues to focus on value-based aspects of medical imaging to provide high-quality clinical diagnoses and improved patient outcomes. As a result, the 2014 Protecting Access to Medicare Act (PAMA) legislation includes language that encourages physicians to consider studies that may be less costly or more beneficial to patients when they are choosing imaging for their Medicare patients, and it was PAMA that first defined ultrasound as a Non-Advanced Diagnostic Imaging Study (NADIS), along with radiography and fluoroscopy.

For those of you like me who bristle every time there is an obvious or glaring slight against ultrasound in favor of CT/MR, it was at first hard not to react with disbelief. However, in this rare case, it serves to benefit the sonography community. Because of ultrasound’s NADIS designation, there are reduced hurdles to ordering ultrasound versus “advanced imaging”, depending on the local clinical decision support mechanism (CDSM).

How does this affect ultrasound in a direct concrete way? The implications are significant. As one example, the American College of Radiology (ACR) Appropriateness Criteria (AC) Committee has evaluated the literature and generated appropriateness categorization for over 1900 clinical scenarios for CDSM distribution in over 700 medical institutions for decision support.

In these recommendations, the AC guidelines instruct that when ultrasound (US) can provide sufficient clinical information to manage the patient or achieve a similar patient outcome compared to an ADIS, the US procedure should be rated more appropriate than the ADIS procedure.

As ultrasound is actively recommended to ordering physicians when it is the most appropriate study, internal bias toward CT/MRI should decrease over time. I do not suggest and would not want ultrasound to be recommended when it is not the best choice; only that it should be recommended when it is. These changes are likely to help move us toward this ideal. I foresee a continued strong presence of ultrasound within the imaging toolbox for physicians for years to come.

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Mark Lockhart, MD, MPH, is Professor of Radiology at UAB Department of Radiology in Birmingham, Alabama.

Interesting in learning more from Mark Lockhart, MD, MPH? Check out the following resources from the American Institute of Ultrasound in Medicine (AIUM):

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