Keywords
interventional radiology - private practice - practice pattern
Interventional radiology (IR) has evolved beyond angiography and “special procedures.”[1] As a specialty, IR prides itself in part on the ability to solve problem, adapt,
and innovate new therapies using imaging guidance. However, the scope and breadth
of procedures performed varies widely across institutions, geographic regions, and
individual practice patterns.[2] The reasons for these variations are multifactorial and are the combined result
of external forces and internal practice decisions.
External forces include hospital service agreements, credentialing, service overlap
with competing specialties, and facility or equipment availability. Internal factors
include competency and training of procedural physicians as well as willingness or
interest in providing or expanding services. All of these factors have played a role
in the evolution of our practice model.
The purpose of this retrospective analysis is to examine the evolution of our practice
utilizing procedure volume data from a variety of service lines to gain a better understanding
of those forces and decisions which have influenced our scope of practice over the
last decade and a half.
Materials and Methods
Electronic procedural records were available from our primary hospital PACS beginning
in 2002. In addition, procedural billing records were available from the partnership's
accounting service beginning in 2013. Data from both of these sources were queried
and used for analysis of all IR procedures performed from January 2002 through July
2018. The resultant dataset summarized the IR procedure volumes by month and year.
These data were then further subanalyzed using spreadsheet software (Microsoft Excel,
Redmond, WA) to yield procedure volume trends over time.
A subset of procedures was then chosen to exemplify the evolution of service lines
over the study period. Service lines, as defined by their individual procedures, can
be seen in [Table 1].
Table 1
Service lines and the procedures associated with them
|
Spinal intervention
|
Interventional oncology
|
Neurointervention
|
Peripheral arterial disease
|
Minor procedures
|
|
Vertebroplasty
Kyphoplasty
Sacroplasty
|
SIRT
Ablation
TACE
DEB-TACE
|
Cerebral angiography
Spinal angiography
Aneurysm coiling
Carotid stenting
Cerebral stenting
Wada testing
Thrombectomy
|
Angiography
Angioplasty
Atherectomy
Stent placement
|
Paracentesis
Thoracentesis
Lumbar puncture
PICC
|
Abbreviations: DEB-TACE, drug-eluting bead transarterial chemoembolization; PICC,
peripherally inserted central catheter; SIRT, selective internal radiation therapy;
TACE, transarterial chemoembolization.
Normalization of procedure naming had to be performed, as the “Orderable” terms changed
several times over the study period. For instance, paracentesis consisted of two orderables:
“Interventional Radiology Paracentesis with Image Guidance” and “IR PARACENTESIS WITH
IMAGE GUIDANCE.” Many of the name changes were due to a switch in radiology information
system (RIS) as the hospital system adopted a new electronic health record. In addition,
a single procedure may result in creation of multiple procedure orderables. For example,
treatment of a peripheral arterial stenosis could involve orderables of angiography,
angioplasty, and stent placement. These were consolidated when possible. Finally,
more specific procedure names have been added to the RIS over time, such as “IR EMBOLIZATION
TUMOR” to describe oncologic transarterial embolization. The use of billing data introduced
additional complexity in analysis, as the billing codes do not always correspond to
a procedure orderable in a 1:1 relationship. Use of billing data was confined to analysis
of neurointerventional (NIR) procedures and a corrected ratio of orderables to billing
codes was used to estimate total procedures. In total, the derived data represent
a high-level evaluation of the procedural trends over the study period.
Discussion
One of the unique aspects of IR is the depth and breadth of minimally invasive image-guided
procedures. Forces driving the scope of practice of an individual interventional radiologist
include those internal to the practice and individual practitioner as well as external
forces related to contractual agreements and the environment within partner health
systems. All of these forces have played a role in defining our current state of service
lines.
Interventional oncology has expanded in our practice in parallel with the growth of
oncologic intervention across the country. The primary drivers of our success in growing
our referral base is through participation in multidisciplinary tumor conferences
and developing the personal and collegial relationships with our surgical and medical
oncologists. Having IRs dedicated to interventional oncology who are responsive to
the needs of the surgical and medical oncologists regarding medical decision making
has helped establish our service line as the fourth pillar of oncologic care. Similarly,
our willingness to participate in clinical trials has helped solidify our position
among our oncology colleagues.
Interventional spine procedures were started in 2002 and peaked in volume in 2007.
There was a decline in volume commensurate with the publication of two sham studies
in the New England Journal of Medicine showing no benefit of vertebroplasty versus placebo.[3]
[4] The volume has since plateaued between 150 and 200 procedures a year. We have evolved
our vertebroplasty practice to follow newer data supporting the use of early intervention
for acute vertebral fractures. The ability to intervene early has been buoyed by the
efficiency of our outpatient clinic in moving from referral to consultation and treatment,
limiting delays to achieve optimal results for our patients. Using an outpatient clinic
model similar to the one described by Siskin, we have secured our role as spine interventionists
in the region with a referral pattern built directly to primary care providers.[5]
Peripheral arterial intervention has suffered a long slow decline. This began with
the loss of exclusivity for endovascular intervention during contract negotiations
in the early/mid-2000s, allowing vascular surgeons and cardiologists the credentialing
needed to begin performing these procedures in the same hospital system. This loss
of exclusivity was another battle in the “Turf War” which has played out between IR
and nonradiologists throughout the country.[6] The peripheral arterial services declined even further after an internal decision
made by the partners to cede arterial thrombolysis cases to vascular surgery.
NIR procedures were a cornerstone of our practice until 2015, when contract negotiations
with our primary hospital system resulted in loss of exclusivity for NIR. Specifically,
the hospital system pressured heavily for a monolithic approach to stroke care, opening
the door to both interventional neurologists and neurosurgeons participating in NIR
procedures. The decision to ultimately relinquish NIR was based primarily on the hospital's
decision to have a dedicated Neurosciences Service Line directed by a highly recruited
and high-profile neurologist and neurosurgeon, and our model with interventionalists
who also did neurointervention did not fit. Given the organization's commitment to
their new model and the leverage over us during contract negotiations, we decided
that it was better for the group as a whole to cede NIR to the hospital than to fight
and risk negative repercussions to our contract. Subsequently, the referral patterns
for NIR procedures changed and our primary NIR left the practice. The NIR service
is now performed exclusively by the hospital-employed physicians.
Throughout the past 15 years, there has been a steady increase in volume of smaller
procedures, which threatens to overwhelm procedural time for larger cases. Many of
these minor procedures used to be performed bedside “blind,” but have moved toward
image-guided intervention for both patient's and referring provider's satisfaction.
Examples of smaller cases include paracentesis, thoracentesis, and lumbar puncture.
This increase in volume continues the trend observed by Duszak et al on Medicare beneficiary
data that radiologists are now the primary providers for patients undergoing paracentesis.
In contrast, our thoracentesis volumes have risen in parallel rather than declined.
Overall, our experience supports their conclusions that the increase in minor procedures
is “likely attributable to both the incremental safety of imaging guidance and also
the unfavorable economics of these procedures.”[7] This increase in volume has been partially handled through utilization of advanced
practice professionals (APPs) to offload the burden on IR physicians. However, the
clinical rounding duties of the APPs and staffing constraints spread between multiple
sites means that the majority of cases still fall to the attending physician. Work
toward optimizing the utilization of nonphysicians for small procedures is difficult
with many scheduling constraints, but remains an ongoing process.
PICC insertion is one smaller procedure where the data show a steady decline over
the study period. This may be partially a result of national trends for reducing bloodstream
infections by reducing or avoiding these types of devices. More recently, the hospital
administration pushed for the formation of a vascular access service using midlevel
providers separate from the IR service to provide bedside PICC placement. With the
initiation of this “Vascular Access Team” in September 2017, the mean monthly PICC
placement procedures dropped from 183 in the 6 months preceding the change to 8 in
the 6 months after.
Despite these gains and losses in service lines over time, the overall trend is toward
continued growth of procedural volumes in our IR practice. As practice patterns change,
new procedures and service lines have filled the gaps left by procedures that have
either gone out of favor or where referral patterns have moved to other specialties.
Peripheral arterial intervention and NIR procedures represent two of our largest service
lines to suffer declines related to external pressures from both hospital administration
during contract negotiations and competition from other specialties.
Strategies for future success include hiring of new partners with skill sets acquired
in training that add to existing or form the basis for new service lines. A dedicated
IR clinic with efficient patient management to move patients through consultation,
workup, procedures, and postprocedure follow-up has also been indispensable to our
success. Fostering relationships with referring providers and participating in multidisciplinary
conferences are key to building the referral patterns to sustain growth. Anticipating
service areas with specialty overlap where an established IR presence could provide
a barrier to entry to competing specialties may prevent loss of a service line, but
ultimately external forces may have the final say. Finally, the recognition of IR
as a distinct medical subspecialty with new training pathways focused on the clinical
model of care delivery is continuing the separation of interventional and diagnostic
radiologists. This may lead to a shift in IR practice models which will alter the
dynamics of contract negotiations and may ultimately provide a fertile environment
to regain lost ground and grow even further.
Limitations of the study are primarily a result of limitations in the data. Billing
data are only available beginning in 2013. Procedural “orderable” data are only as
good as the specificity of the individual codes. For example, for TACE procedures
performed prior to 2014, the true volume data are unavailable because neither the
billing nor orderable datasets capture the true volume of procedures. Extensive chart
review could solve this limitation. Service line selection for analysis in this study
was driven in part by procedural and billing data that were complete and unambiguous
to minimize effects of the dataset limitations.
Conclusions
The breadth of interventional procedures performed within a particular practice is
determined by the local environment. This includes a variety of internal and external
forces such as referral base, administrative control, partner interest, and contract
negotiations. As a large combined interventional and diagnostic radiology practice,
advanced radiology services. As a large combined interventional and diagnostic radiology
practice, Advanced Radiology Services, PC has experienced all of the aforementioned
forces which have contributed to our successes and failures in service lines over
the past 15 years. Inevitably, as minimally invasive procedures gain favor, establishing
a direct referral pattern and providing beneficial and efficient outcomes are key
to growing and maintaining new service lines. Some external forces are beyond avoiding,
but impact to a practice can be mitigated in part by the willingness of IRs to innovate
and adopt new treatments to fill care gaps in the local environment.
