Doc offices more than double use of nonphysicians for interpreting medical images
Doctors’ offices have doubled their deployment of nonphysician practitioners to tackle image interpretation, according to Neiman Health Policy Institute research published Wednesday.
Nonphysicians in primary care practices accounted for the largest share such of interpretations (40%) followed by those working in orthopedic groups (34%). Researchers unearthed measurable gains for NPPs across all modalities between 2013 and 2022. These included nuclear medicine (up 87%), X-ray (115%), ultrasound (124%), CT (124%) and MRI (135%), researchers detailed in the Journal of the American College of Radiology [1].
Imaging experts fear these numbers will only worsen. NPPs—nurse practitioners and physician assistants—younger than 55 were upward of 43% more likely to interpret medical images versus those 65 and up.
“With new NPPs entering the workforce at an increasing pace, this age discrepancy suggests that the growth of NPP imaging interpretation could further accelerate, drawing additional attention to considerable mismatches in education and training for imaging interpretation when compared with radiologists,” study co-author Richard Duszak, MD, professor and chair of the University of Mississippi Medical Center’s Department of Radiology, said in a statement.
Amid growing backlogs of imaging and radiologist staffing shortages, doc groups are increasingly considering tapping NPPs for help, previous research has shown. This shift has been a concern for societies such as the American College of Radiology and American Medical Association, which emphasize that NPs and PAs complete far less training than subspecialized physicians.
For this latest study, Neiman researchers used a nationally representative 5% sample of Medicare fee-for-service claims spanning a 10-year period. They identified all image interpretation claims submitted by nurse practitioners and physician assistants in office settings, pinpointing practice specialties and characteristics.
During that time span, the total number of NPPs providing any type of service to Medicare beneficiaries increased from 133,364 to 321,583, a 141% uptick. Office-based image interpretations handled by NPPs each year jumped from 20,974 per 1 million beneficiaries up to 35,134 in 2022 (up 68%). Across all modalities, nonphysicians’ share of all such interpretations more than doubled from 2.52% up to 5.47% by the end of the study period (a 117% increase).
Only a small fraction of all nonphysician practitioners—about 5.55% on average annually—handled office-based image interpretations. X-ray was the most popular modality, with NPPs accounting for about 5% of office-based reads in this segment, followed by ultrasound (0.6%), CT (0.07%), MR (0.07%), and nuclear medicine (0.02%). Nonphysicians working at primary care groups and orthopedic practices handled the largest share of NPP-interpreted X-rays at 40% and 37%, respectively. Meanwhile, PCP groups (45%) and practices without physicians (13%) delivered the most nonphysician ultrasound reads. Orthopedist and PCP offices also led for MRI (60%, 24%), while PCPs and cardiologists led in nuclear medicine (40%, 26%). An “unexpectedly high” share of sinus CT interpretations in ear, nose and throat specialist practices went to NPPs and same for spine and extremity-joint MRIs delivered in orthopedic offices.
“Given that such studies are frequently interpreted by subspecialist radiologists, this raises questions about the differential adequacy of NPP training in radiology and the associated quality of their interpretations,” Duszak said in the statement.
The study’s authors also highlighted widespread variation in nonphysician medical image interpretation tied to geography. For instance, NPPs handled over 16% of office X-rays in Alaska, Idaho and Montana but less than 1% in Hawaii. They also interpreted about 2% of CT images in Utah and South Dakota while several other states had zero such scans read by NPPs.
“While our study does not permit us to assert definitive reasons for dramatic state-level variation, we believe this could be related to regional radiologist and other physician manpower shortages as well as differences in state laws and regulations such as with NPP scope of practice,” lead author Eric Christensen, PhD, research director at the Neiman Health Policy Institute, said in the announcement.
Chatter on social media
Duszak shared the study on X.com Wednesday, with his post generating over 35,000 views as of late Wednesday and prompting radiologists and other physicians to weigh in. He also highlighted one of the study’s citations, buried in the text: A previous survey found that 98% of NPPs reported only two or fewer days of radiology training, which frequently occurred on YouTube.
“Take home message: ask about the credentials, training, certification, and experience of who interprets your imaging study!” Duszak wrote.
“I wonder, though, if this is a bit misleading,” responded Eric Novack, MD, a surgeon based in Phoenix. “In orthopedics, for example, the nonphysician providers end up doing a great deal of postoperative follow-ups. In many of these cases, there is X-ray imaging. Saying that they are capable of reviewing a postoperative X-ray and comparing it with what is expected and having the surgeon readily available if there is a concern is very different than having them doing MRI reads, for example.”
“Agree. There can be multiple appropriate reasons for this,” responded John Asghar, MD, an adult and pediatric spine surgeon based in Fort Lauderdale, Florida. “My PAs help ensure my new patients have all the appropriate imaging for their visits, especially for those without prior history of imaging. This makes the process for my patients to get an appropriate opinion and care much more efficient. Even though we review all of the imaging, the dictation/note is done under my PAs since that visit is documented as such.”
“I think we should always be making sure we have qualified people reading imaging studies. I am not sure the data you are reviewing (which is based on billing/charge submissions) accurately portrays what is happening in the office. More studies would be helpful,” wrote Peter G. Mangone, MD, chief of foot and ankle surgery in UPMC’s Department of Orthopedic Surgery.
“While the numbers may be correct, the conclusion you are drawing that somehow a NP or PA working directly under me in the orthopedic clinic is the only person reading the X-ray [is not]. They have direct oversight in most all cases (not all cases) by the supervising physician,” Mangone added in a second tweet.
“Standardization of non-MD training is tough to ascertain. What I think would be helpful is to understand from docs what [advanced practice providers] can/should be doing within your specialty with a specified level of experience/training,” wrote Atul Grover, MD, PhD, an internal medicine physician and executive director of the AAMC Research and Action Institute.
“All patients should ask who is actually reading their imaging study and demand an official report. It matters that a radiologist who spent 5-6 years post-medical reads it vs. others with far less training,” added Tarang Patel, MD, a radiologist and podcaster based in Scottsdale, Arizona.
“Patients should demand a reduction in premiums or co-pay if they are being treated by an NP or PA,” responded Rex Pillai, MD, a California adult and pediatric interventional radiologist.
“Sounds like it's mostly X-rays from machines that the PCP or ortho clinics own. Historically I doubt this work ever ended up in a radiologist's inbox anyway given how expensive it is to set up HL7 connections for low-volume and low-paying work,” added Ned Holman, MD, an Alaska-based radiologist.
You can read more about the results, including potential study limitations, at the link below.
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.