Need grows for rural rads who can perform 12 low-risk, low-complexity interventional procedures

Most if not all diagnostic radiologists should be capable of performing numerous image-guided procedures, according to a task force jointly convened by the ACR and the SIR. 

These “level 1” clinical duties, 12 in number, include such potentially urgent interventions as thoracentesis, joint aspiration via arthrography and lumbar puncture for cerebrospinal fluid drainage.

The team also lists sample “level 2” procedures, with which only some diagnostic rads should be familiar (e.g., nontunneled central line placement, exchange and replacement), and “level 3” interventions that are the sole bailiwick of IR specialists.

The task force makes the recommendations in a consensus document that’s aimed not at delineating radiology competencies among practitioners but, rather, at broadening access to image-guided procedures for patient populations living in rural care settings or served by small IR practices.

Critical to achieving this aim, as task force members flesh out in a report published online in JACR Oct. 7, is recruiting, training and retaining interventional radiologists to work in small and rural practices [1].

No less important is ensuring basic IR education for all radiologist trainees.

“Limited data suggest that diagnostic radiology residency programs may not provide adequate training for the performance of level 1 procedures,” the authors comment.

The paper’s lead and corresponding author is Laura Findeiss, MD, of Emory Healthcare. Senior author is Tim Swan, MD, of Marshfield Clinic Health System and ACR’s board of chancellors.

They and co-authors aim their recommendations primarily at practice heads or individual interventional radiologists looking to launch or expand IR service lines in rural communities.

However, as a central theme is the looming radiologist shortage, there’s much in the document of interest to radiology as a whole.  


12 Low-Complexity Procedures That Are Widely Undoable for the Typical Graduating Diagnostic Rad

Along with categorizing procedures in to the three levels of complexity, the task force searched and reviewed the relevant literature, analyzed practice models and pinned down constituent parts of an economically healthy framework for delivering IR services.

They also drew from an annual ACR survey with questions aimed at assessing radiology residents’ comfort and competency with 12 relatively easy (i.e., level 1) image-guided procedures.

Aggregated results showed the resident cohort feeling “very comfortable” at the following rates for the 12 procedures (in descending rates of collective comfort):


46%—Solid organ biopsy

43%— Peripherally inserted central catheter

43%—Abscess drainage

39%—Breast biopsy

39%—Exchange of suprabubic/gastronomy catheter

36%—Arthrogram/Joint aspiration

36%—Thyroid fine-needle aspiration

36%—Lumbar puncture (e.g., CSF drainage, myelography)

29%—Lung biopsy

18%—Sacroiliac joint block

18%—Lumbar epidural steroid injection/facet block

“Presently, diagnostic radiology residents are required to perform only 25 image-guided biopsies or drainages during training,” the authors point out. “Consequently, the typical graduating diagnostic radiology resident may not be prepared to perform level 1 procedures.”


Wanted: Locally Sensitive Solutions

Discussing their findings on what comprises a solid economic framework on which to build or expand IR services in rural settings and from small practices, the authors note an “absolute requirement” for ROI that’s realizable by both the delivering practice and the client hospital or health system.

“Existing payment models generate significant hospital technical revenue from IR services,” the authors write, citing several studies. “The relatively low hospital costs for IR services and the decreased inpatient length of stay improve hospital margins.”

Warning that hospitals and groups may be misaligned on, or unrealistic about, financial expectations from new or expanded IR—confounding factors include lower work RVUs per time units in IR vs. diagnostic radiology—the authors recommend constructing a financial model showing a transparent value proposition for all stakeholders.

This model should be “sensitive to local considerations” and mindful of potential variations in revenue and expenses, including payer contracts and case mixes, they point out.


There are multiple successful models for providing IR services in small/rural communities that can be used as templates for practices or interventional radiologists who wish to establish sustainable IR services. Wide variation in practice models and hospital environments mandate development of locally sensitive solutions for the implementation and sustainability of a successful IR practice. … Appropriate financial models must be developed to recruit and retain interventional radiologists into smaller, more rural community hospital-based radiology practices.”

Full paper here (behind paywall).

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