Because ultrasound can demonstrate both normal thyroid anatomy and pathologic conditions with great clarity, the technique has become increasingly important in the diagnostic evaluation of many thyroid conditions. Sonographically guided percutaneous needle biopsy of thyroid masses has become an important technique in the management of many thyroid masses, and continuous real-time visualization of the needle is crucial for biopsy of small lesions.

However, the practice of radiology by nonradiology physicians raises serious questions concerning utilization, costs, and quality. Hillman et al showed that nonradiologist physicians who performed their own sonographic and radiographic studies performed 2 to 8 times as many imaging examinations as physicians who referred their patients to radiologists (1). Studies have also shown that actual reimbursements paid to nonradiologists tend to be higher than those paid to radiologists (2, 3).

The quality of the ultrasound examinations performed by radiologists compared with those performed by nonradiologists is an extremely important consideration, and this is dependent, at least partially, on the training and experience of the personnel performing the examination. Most imaging outside of hospitals is now done by self-referring nonradiologists who have never been formally trained in radiology. Many of these examinations are of inferior technical quality, and clinically significant misinterpretations occur in a significant number of cases. It has been proposed that payments for imaging examinations performed in private offices by nonradiologist physicians should be restricted or eliminated unless the physicians have been fully and formally trained to perform those examinations (3). A large preferred provider organization in Michigan requires nonradiologists performing ultrasound examinations to have accreditation by a national accrediting body such as the American College of Radiology or the American Institute for Ultrasound in Medicine. In the interest of quality patient care, all physicians performing imaging examinations and image-guided interventions should be required to meet standards mandated by formal accreditation programs. The federal Mammography Quality Standards Act of 1992 is an example of what can be accomplished by national requirements (4).

A study on clinical decision making comparing surgical office-based thyroid ultrasound with radiology office-based thyroid ultrasound would be informative and useful. Finally, greater involvement by radiologists and other physicians in outcomes studies and other types of health services research is needed, and these are clearly new frontiers and challenges for all physicians (1).

--William J. Bufkin, MD
Department of Radiology,
Baylor University Medical Center

1. Hillman BJ, Joseph CA, Mabry MR, Sunshine JH, Kennedy SD, Noether M. Frequency and costs of diagnostic imaging in office practice--a comparison of self-referring and radiologist-referring physicians. N Engl J Med 1990;323:1604-1608.
2. Hillman BJ, Olson GT, Griffith PE, Sunshine JH, Joseph CA, Kennedy SD, Nelson WR, Bernhardt LB. Physicians' utilization and charges for outpatient diagnostic imaging in a Medicare population. JAMA 1992;268:2050-2054.
3. Levin DC. The practice of radiology by nonradiologists: cost, quality, and utilization issues. AJR 1994;162:513-518.
4. Radiology by radiologists: advocating quality patient care. ACR Bulletin [on-line version] June 1999. Available at http://www.acr.org.

ecent Medicare reductions in the reimbursement of practice expenses have had an adverse impact on the ability of practicing physicians and surgeons to make capital investments in new technology. In “The effect of surgical office-based thyroid ultrasound on clinical decision making,” Dr. Gogel and colleagues present an interesting and timely study. Thyroid ultrasonography was used in a surgical office setting to assess an unselected array of thyroid pathology in 49 patients. The authors state that ultrasound impacted the clinical management in 80% of these patients. They confirm an old notion that ultrasound demonstrates greater sensitivity than physical examinations and nuclear medicine scans. These findings have clinical and economic implications.

General surgeons perform ultrasound examinations of the thyroid gland, breast, gastrointestinal tract, peritoneal cavity (laparoscopy), and vascular system. The essential components of these examinations have been reported, and outlines for educating surgical residents have been created (1).

That nonradiologists can and do perform ultrasounds has been long known. Spettell and others found, by reviewing 1993 Medicare payment data, that nonradiologists perform two thirds of nonhospital (office location) abdominal and pelvic ultrasounds (2). This finding is based on federal payors data, but it confirms our own experiences in Dallas.

Gogel and colleagues showed that nonradiologists can acquire adequate skills to use ultrasound in an office setting to accurately impact clinical decisions and to possibly help control costs. It is my opinion that CPT (Current Procedural Terminology) coding, Health Care Financing Administration payment policy, and reimbursement schemes frequently delay or impede the logical use of mid-level diagnostic technologies (such as office-based ultrasound) in the outpatient arena. Studies such as this one provide solid evidence that will support organized medicine's opposition to the reductions in practice expense reimbursement for specialty practices.

--John T. Preskitt, MD, FACS
Department of Surgery,
Baylor University Medical Center

1. Rozycki GS. Surgeon-performed ultrasound: its use in clinical practice. Ann Surg 1998;228:16-28.
2. Spettell CM, Levin DC, Rao VM, Sunshine JH, Bansal S. Practice patterns of radiologists and nonradiologists: nationwide Medicare data on the performance of chest and skeletal radiography and abdominal and pelvic sonography. AJR Am J Roentgenol 1998;171:3-5.

Reply

ardiologists, gastroenterologists, surgeons, obstetricians, and all physicians who perform radiologic imaging and analysis in their office should adhere to the quality guidelines that have been developed. All clinicians who utilize radiologic imaging must ensure that they are qualified and that the radiologic facilities and equipment they use are appropriate for the medical application.

Dr. Gogel and authors have strictly utilized the guidelines that have been developed by the American College of Surgeons (1). These guidelines are as follows:

1. The surgeon must meet the requirements for education and/or experience.
2. Each facility should have documented policies and procedures for monitoring and evaluating the effective management and proper performance of imaging equipment. Quality control programs should be designed to maximize the quality of the diagnostic information. Equipment performance should be monitored regularly in conformity with standards for ultrasound imaging and phantom testing for resolution. Such monitoring may be accomplished as part of a routine preventive maintenance program.
3. The surgeon should maintain qualifications through continued experience and formal continuing medical education in the technique and its applications.
4. The surgeons' outcomes using ultrasound should be assessed through a program of continued quality improvement. Quality improvement procedures should be systematically monitored for appropriateness of examination, for technical accuracy, and for the accuracy of interpretation. The total number of examinations and procedures should be documented quarterly. Incidences of complications and adverse events incurred during ultrasound-guided interventional procedures should be recorded and regularly reviewed to identify opportunities to improve patient care.

Radiologists and nonradiologists must avoid overutilization of radiologic procedures, operative procedures, or laboratory tests in which there may be secondary gain. The authors of this article consider billing only in cases where care is directly influenced by the result of the radiologic test.

--Joseph A. Kuhn, MD
Department of Surgery,
Baylor University Medical Center

1. Committee on Emerging Surgical Technology and Education, American College of Surgeons. Statement on ultrasound examinations by surgeons. Bull Am Coll Surg 1998;83:37–40. Also available at http://www.facs.org/fellows_info/statements/st-31.html.