Journal of the American College of Radiology : JACR最新文献

Objective: Women remain a minority of trainees in interventional radiology (IR) since the residency's inception in 2014. Similar phenomena have been observed in other surgical specialties. Our study aims to quantify changes in female trainee representation in integrated IR over a five-year period from the 2018-19 to 2022-23 academic years and to compare with trends in other specialties.

Methods: We conducted a retrospective review of survey data collected from the National Graduate Medical Education database. The eight selected specialties, including IR, were chosen due to qualitative similarities with IR training or due to less than 30% female trainee representation in 2018-19. In this data, gender was categorized as male or female. Percentage of female trainees in each specialty was collected in the study period. Analysis was conducted using ANOVA, linear regression, and Tukey HSD (P < 0.05).

Results: In the five-year study period, female representation in integrated IR residency grew by 16.6% at a mean relative growth rate of 4.0% annually. By 2022-23, integrated vascular surgery residency had the highest female trainee representation (38.4%) whereas integrated IR had the second lowest (22.4%), ahead of orthopedic surgery (20.4%).

Discussion: Despite observed growth, female trainee representation in integrated IR lags behind other procedural and radiology specialties. Our analysis emphasizes the need for continued recruitment of female applicants to bolster gender parity. Supporting known ongoing initiatives like female mentorship programs and developing new strategies to support female interest in IR should be a priority for the field.

Objective: To evaluate the relevance of established surgical risk calculators (SRCs) for predicting complications in patients undergoing percutaneous lung cryoablation (PLC).

Methods: The institution's database was queried for PLC procedures from March 2015 to May 2024, excluding those patients with concomitant local therapies or five or more lesions treated in a single setting. Demographics, frailty metrics as defined by the surgical literature, and procedural variables were collected. To evaluate the suitability of surgical risk estimate calculators, the requisite demographic data were input into the American College of Surgery SRC; estimates for length of stay (LOS), serious complications, 30-day readmission, and mortality were calculated to determine the comparative risk profile were the patients to have undergone surgical wedge resection instead of PLC. Additionally, to evaluate the suitability of imaging predictors of complications, the volume of emphysematous lung was calculated using a machine learning algorithm and incorporated into a generalized estimating equation logistic regression analysis of other demographic and technical variables.

Results: The study included 217 patients who underwent 314 procedures. Chest tubes were placed in 49% of procedures. The median LOS was 1 day (IQR: 1-1,range: 0-13). The median percentage of emphysema within the lungs was 5.9% (IQR: 2.4-12.1%, range: 0.01%-50.3%). The median predicted surgical rates for serious complications (13.5%), 30-day readmission (12%), and 30-day mortality (5.9%) were all greater than actual rates following PLC (1.6%, 4.8%, and 0.3%, respectively). The estimated surgical LOS differed significantly from the actual PLC LOS (5 vs. 1 days, p<.001). In univariable analysis, the number of probes the number of tumors ablated (OR 1.90, 95% CI [1.18, 3.05], p = 0.008), and the number of probes used (OR 1.44, 95% CI [1.06, 1.96], p = 0.021) were significantly associated with increased LOS, demographic and emphysema details were not.

Conclusion: Complications following PLC are significantly less frequent than the estimated complication risks for wedge resection in the same patient population. Risk estimate calculators tailored to PLC would help screen for high complication risks related to this procedure.

Objective: The Neiman Imaging Comorbidity Index (NICI) was developed and validated in a claims dataset encompassing >10 million privately insured beneficiaries, in which it outperformed the commonly used Charlson Comorbidity Index (CCI) in predicting advanced imaging use. This external validation assessed the broader generalizability of NICI for predicting receipt of advanced imaging in nationally representative populations, including patients insured by Medicare, Medicaid, and private payers.

Methods: All 2018 to 2019 patient-level claims from the CMS Medicare 5% Research Identifiable File, CMS Medicaid 100% Research Identifiable File, and private insurance (commercial and Medicare Advantage) claims from Inovalon Insights, LLC, were included. Using 2018 comorbidity data, beneficiaries were assigned CCI and NICI. Area under the receiver operator characteristic curves (AUCs) measured index performance predicting advanced imaging in 2019. AUCs for NICI and CCI were compared overall, across age groups, and after adjusting for age and sex.

Results: A total of 108,846,549 beneficiaries were included across Medicare (n = 2,536,403), Medicaid (n = 49,685,052), and private insurance (n = 56,625,094) datasets. NICI outperformed CCI in Medicare (AUC: 0.7709, 95 confidence interval [CI]: 0.7702-0.7716 versus AUC: 0.7503, 95% CI: 0.7496-0.7510; P < .001), Medicaid (AUC: 0.6876, 95% CI: 0.6874-0.6878 versus AUC: 0.6798 95% CI: 0.6796-0.6800]; P < .001), and private insurance data (AUC: 0.6658, 95% CI: 0.6656-0.6660 versus AUC: 0.6479, 95% CI: 0.6477-0.6481; P < .001). NICI outperformed CCI in adjusted models and in nearly all age strata across the three cohorts.

Discussion: The NICI outperformed CCI in predicting advanced imaging in populations insured by numerous different payers. Validation data support NICI as the preferred index to adjust for patient comorbidities when studying advanced imaging as an outcome, but further investigations are warranted.

Objective: To determine the changes in procedural utilization for symptomatic uterine fibroids and adenomyosis over the past decade.

Methods: An IRB-exempt retrospective study of the National Inpatient Sample database from 2011-2020 was performed utilizing ICD-9 and 10 diagnosis and procedural codes for uterine fibroids, adenomyosis, hysterectomy, myomectomy, UAE, and endometrial ablation. Patients with endometriosis, uterine cancer, placenta accreta spectrum, pelvic inflammatory disease, and uterine prolapse were excluded. Data was analyzed through statistical process control (SPC) and chi square testing.

Results: A total of 247,476 inpatient procedures were identified in women with fibroids and/or adenomyosis. Of those patients with only uterine fibroids (n=212,532), 77.9% underwent hysterectomy, 18.9% underwent myomectomy, and 2.8% underwent UAE. The utilization of UAE remained stable over the decade, while an increased prevalence of myomectomy was offset by a decrease in hysterectomy (2011: hysterectomy- 81.4%, myomectomy- 15.4%, UAE- 2.9%; versus 2020: 73.7%, 24.0%, and 2.0%, respectively). Regarding adenomyosis only (n= 16,073), more women underwent hysterectomy (98.1%) when compared to or UAE (1.1%), with minimal change in these procedures across the decade. For combined fibroids and adenomyosis (n=18,871), hysterectomy was the most utilized procedure, with its utilization declining from 92.0% to 85.2% during the time period.

Discussion: The utilization of hysterectomy remains the dominant inpatient procedural intervention for the treatment of uterine fibroids and adenomyosis, however the proportion of myomectomy in the setting of fibroids is increasing. Utilization of UAE has not changed over the past decade and remains relatively underutilized despite initiatives to increase utilization.

Objective: To determine whether point-of-order clinical decision support (CDS) based on the Wells Criteria improves CT pulmonary angiogram (CTPA) yield and utilization in hospitalized patients in an enterprise-wide health system and identify yield-related factors.

Methods: This retrospective IRB-approved cross-sectional study in an urban, multi-institution health system included hospitalized patients undergoing CTPA 12 months before and after CDS implementation (entire cohort). Chi-square test was used to compare PE yield in patients in whom providers overrode vs. followed CDS alerts after CDS implementation. It was also used to compare utilization and yield pre- vs. post-intervention. Univariate and multivariable regression analyses were performed on patient factors and post-CDS Wells scores to evaluate yield-related factors.

Results: For 2,429 inpatient CTPAs post-intervention, CTPA yield was significantly higher when CDS recommendations were followed (18.3% [250/1365]) compared to those overridden (14.2% [151/1064] (p<0.01). For 5,372 CTPAs in the entire cohort, there was no difference in PE yield before (448/2,943; 15.2%) vs. after (401/2,429; 16.5%) CDS implementation (p=0.20). However, in 340,146 admissions over the study period, a 7.4% relative decrease in CTPA utilization (17.5 to 16.2 CTPA examinations/1000 admissions before and after CDS, respectively; p=0.003) was observed.

Discussion: When CDS recommendations were followed, the yield of CTPA was significantly higher than when clinicians overrode CDS alerts. In addition, point-of-order CDS to reduce unnecessary CTPA in hospitalized patients resulted in a significant decrease in CTPA utilization post-CDS implementation with a modest though nonsignificant increase in CTPA yield.