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  • Subspecialty Second Opinions Often Critical to Patient Care

    A growing body of research shows that subspecialty second opinions can be critical to patient care. By Mike Bassett

    June 1, 2017

    In light of a growing body of research showing that subspecialty second opinions can be critical to patient care, academic radiology departments may want to consider offering formal second opinions as part of their services, experts say.

    Some have already gone that route. The Russell H. Morgan Department of Radiology and Radiological Science at Johns Hopkins University Medical Institution, Baltimore, has been offering second opinions as a service for more than 10 years, said David Yousem, MD, MBA, professor of radiology and director of neuroradiology at Johns Hopkins.

    “We’ve found second opinions to be important for patient care,” Dr. Yousem said. “Depending on what field you’re talking about — whether musculoskeletal, head and neck or neuroradiology — the revision rate is substantive and can range anywhere from 8 percent to 30 percent,” Dr. Yousem said.

    Similar findings were demonstrated by Fergus Coakley, MD, professor and chairman of diagnostic radiology at the Oregon Health and Science University in Portland, who analyzed data on the value of subspecialist reads published in journals including Radiology and the Journal of Otolaryngology — Head & Neck Surgery.

    In results presented at RSNA 2016, Dr. Coakley and colleagues determined that subspecialist opinions often alter the initial reading of radiologic studies in cancer patients.

    “The bottom line is, if you get a subspecialist opinion, 10 to 20 percent of the time it will result in actionable change,” Dr. Coakley said. “And usually — roughly 80 to 90 percent of the time — that change is for the better.”

    In one example cited by Dr. Coakley, a patient diagnosed with pancreatic cancer underwent four rounds of chemotherapy before a subspecialist reinterpreted the images. “There was no cancer; there had never been a cancer,” Dr. Coakley said.

    An analysis of second opinion subspecialty reads published in the American Journal of Roentgenology in 2016 also demonstrated the effectiveness of subspecialty reads.

    Researchers analyzed second-opinion subspecialty consults in 3,165 CT and MRI musculoskeletal examinations referred to an academic medical institution during a 24-month period. Of the 2,326 examinations that had an outside report available for comparison, researchers found 610 (26.2 percent) instances of clinically important differences.

    Furthermore, the subspecialty report was more accurate than the outside report in 82 percent of examinations when a pathologic confirmation was made, said study author John A. Carrino, MD, MPH, of the Department of Radiology and Imaging at the Weill Cornell Medical College of Cornell University, New York City.

    “There were substantial discrepancies,” Dr. Carrino said. “And having that subspecialty read was quite valuable. It validates the idea that having a subspecialist interpretation is warranted, especially in cases of neoplasm.”

    In a 2010 retrospective study in Radiology, Elcin Zan, MD, Dr. Yousem and colleagues also demonstrated the value of second-opinion subspecialty consults.

    In the research examining 7,465 outside neuroradiology studies, the authors reviewed 4,534 examinations that had an outside report for comparison. The authors found 347 (7.7 percent) instances in which clinically important differences were determined. When a final diagnosis was determined from pathology reports, clinical assessments, and/or imaging follow-up, the second-opinion consult was found to be correct in 84 percent of studies with clinically important differences.

    Reimbursement for Second Opinions

    Although the studies showing the effectiveness of second-opinion consults make the case that subspecialists reading these cases should be reimbursed for their services, getting insurance companies on board has been a challenge.

    “In general insurers aren’t crazy about paying for multiple interpretations of the same study,” Dr. Yousem said, “particularly if those second opinions turn into third or fourth opinions.”

    But, he pointed out that most institutions do not allow surgeries to proceed without a review of pathology slides. “And insurers have paid for second-opinion pathology slide review without objection,” he said.

    “Our policy is that the patient comes first; so whether we are reimbursed, we are going to provide this service to our patients and referring clinicians,” he said.

    Documenting “Curbside Consults”

    While academic centers are beginning to adopt formal second-opinion consultations, radiology departments have long provided what Dr. Carrino calls “curbside consults,” in which radiologists provide informal second opinions around the reading room.

    “Now there is more pressure to document these kinds of informal consults because you basically have the same medicolegal risks you have for regular reads,” Dr. Carrino said. “So if you are going to do a curbside consult, you might as well file an official report, get it documented, contribute it to clinical management and be compensated.”

    And instead of viewing advanced imaging as a commodity, Dr. Carrino adds that it may be equally important to triage the exam to the correct facility where subspecialty radiologists practice. He cites 2017 research in the journal Spine showing that where a patient obtains an MRI examination and which radiologist interprets the examination may have a direct impact on radiological diagnosis, subsequent choice of treatment and clinical outcome.