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.

DCF 1.0

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):

Handle the Scan with Care

Anytime one begins an obstetrical scan, there is a ritual that precedes our privileged access into an otherwise inaccessible place pulsating with life, hope and promise. The trilogy of preparing the patient, applying the gel, and selecting the transducer helps us transition as we open a window to the womb, sharing a highly anticipated and treasured moment with the family.

old windowWhile this privileged access may provide priceless reassurance, it is accompanied by a huge responsibility for the sonologist who is attempting to make sense of what is seen while trying to decide how to share the information with the family.

As diagnosticians, we are taught to be vigilant, careful and meticulous, making note of every single finding. We employ the most sophisticated machines and the importance of being non-paternalistic is deeply engrained in our brains. Yet at the same time, care and caring must come into play if we need to break news that may shatter dreams or induce significant parental anxiety.

Personally I find that the most challenging cases are those in which various isolated sonographic markers may be detected. The struggle between wanting to be scientific, factual and transparent and the fear of labeling an otherwise healthy being and worrying a hopeful parent becomes paramount. This is becoming more commonplace nowadays with the advancing technology as we delve into fetal evaluations with much more detail and at earlier points in gestation. We must not mistake normal developmental findings with pathology. We must be careful with enhanced image resolution and the employment of harmonics as these may increase tissue echogenicity and lead to over diagnosis of physiologic “cysts” in fluid producing structures.

With the continuing advancement of the technological capabilities of this most versatile of medical diagnostic modalities and its evolving portability, the number of probe-handlers globally is increasing exponentially across the disciplines. The problem is that education, training and experience are not uniform. The expertise to discuss the implications of various sonographic findings, particularly soft markers, and to recognize serious abnormalities, may be lacking. Despite the well-established positive impact of prenatal diagnosis, allowing us to prepare families and formulate the optimal plan of care, it may also be a double-edged sword, particularly in inexperienced hands.  As such, and in keeping with the mission of the AIUM and its communities of practice, the importance of proper training cannot be overstated. One must adhere to the basic sonographic teachings, employ the ALARA principle, and implement practice parameters when incorporating sonography into daily clinical practice. Referral to centers of excellence, whenever there may be doubt, is critical. Sound judgment remains the key to utilizing ultrasound first.

A new life is purity in the absolute form: a blank sheet of paper. Much caution must be exercised before any marks are made. Every word uttered has the potential of tainting the page, of taking away hope, of falsely “labeling” this promising life before it has even come into physical being. “First do no harm” should continue to echo in our brains and we must always proceed with caution, and tread with care.

What’s your opinion on the quality issue? Do you see a wide range of quality in ultrasound scanning?  Comment below or let us know on Twitter: @AIUM_Ultrasound.

Reem S. Abu-Rustum, MD, FACOG, FACS, FAIUM, is the Director of the Center For Advanced Fetal Care in Tripoli, Lebanon. She has served the AIUM in several capacities, including her current role on the AIUM Board of Governors.

  • Image adapted from A Practical Guide to 3D Ultrasound. RS Abu-Rustum. CRC Press 2015.

The Nerve of Ultrasound

I’m a fan of ultrasound. In the past, ultrasound has been seen as the less attractive cousin of the other imaging modalities, CT and MRI. Maybe that’s why I champion it so much, because I can’t help but root for the underdog! Either way, I am always eager to find ways to incorporate ultrasound in my practice as a musculoskeletal radiologist. It is fast, convenient Ultrasound and MRI of Nerveand inexpensive, and patients tend to find the experience less daunting than being in a metal tube.

Now, I think it is high time that ultrasound take a place on the front lines of nerve imaging. We’ve made several advances in the imaging of nerves under ultrasound; nerves have a characteristic appearance on ultrasound and it is often used for image guidance in nerve blocks. In my practice, we use ultrasound to diagnose and treat nerve pathology. However, a lot of nerve imaging is still primarily done via MRI. This is probably because much of the research in nerve imaging has been done in MRI. Additionally, many clinicians are not aware of the diagnostic capabilities of high resolution ultrasound in nerve imaging. I’m hoping to change that!

Funded by a generous grant from the AIUM’s Endowment for Education and Research, my colleagues and I are hoping to compare the utility of ultrasound in nerve imaging to MRI. What we hope to confirm is that ultrasound has similar diagnostic capabilities to MRI in the imaging of neuropathy. In addition, we plan to use ultrasound’s capability for dynamic imaging to produce new methods for evaluation of the brachial plexus and peripheral nerves. This grant will fund one of the largest volume studies of ultrasound in nerve imaging, which will in turn help to further expand the role of one of the most valuable imaging modalities we have. So, hopefully soon, this “underdog” will have its day.

In what other areas is ultrasound emerging from its “underdog” label? Where can we use Ultrasound First? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Ogonna Kenechi “Kenny” Nwawka, MD is the assistant attending radiologist in the Hospital for Special Surgery as well as assistant professor of radiology at the Weill Medical College of Cornell University.

Dr. Nwawka’s research project is being funded by a $50,000 grant from the Endowment for Education and Research. To help support these and other projects, consider donating.