March 23, 2009

Ultrasound Exams — Bright Future, but Will It Be in Radiology?
By Beth W. Orenstein
Radiology Today
Vol. 10 No. 6 P. 12

The ultrasound market is expected to grow despite the economic downturn that is being felt worldwide. InMedica, a research firm that supplies market research to the medical device industry, recently predicted that vendors of ultrasound technology will continue to experience “robust” growth and that sales will reach nearly $6 billion by 2012.

The financial challenges facing the healthcare market may help propel ultrasound growth rather than hinder it, says Diane Wilkinson, a market research analyst at InMedica’s headquarters in Wellingborough, United Kingdom. Compared with other diagnostic imaging modalities, ultrasound equipment is low cost, with the cost of some smaller devices ranging from $15,000 to $200,000, depending on the features. And it costs far less to perform an ultrasound study than a CT or MRI exam. At a time when credit is tight and hospitals and healthcare facilities are scrutinizing—if not delaying or shelving—every purchase, they still are expected to buy ultrasound equipment because of its lower cost and increasing utility, Wilkinson says.

Another trend that will fuel the demand for ultrasound is that the equipment continues to shrink. Hand-carried systems are available that weigh just a few pounds and are the size of books. Even the more common hand-carried units weighing 10 to 15 pounds can be used in many environments. As a result, demand for compact ultrasound equipment is increasing, not only from traditional sources outside of radiology, such as in obstetrics/gynecology and cardiology, but also from point-of-care applications, such as the emergency department, the critical care unit, anesthesiology, surgery, remote locations, and even on the battlefield.

This growth of ultrasound presents somewhat of a dilemma for radiologists, who, while they never had complete control of sonography, tend to see their role in it continuing to erode. Radiologists, who undergo three to six months of ultrasound training and must pass written and oral examinations, worry about the competency of others performing sonograms. The other specialists, including emergency physicians who are scanning with more frequency, counter that even though their training in ultrasound is not as rigorous, they certainly are competent to perform point-of-care sonograms. They say their societies have recognized the need and have developed guidelines for their training and performance of ultrasound studies.

Proper Training
Harvey L. Nisenbaum, MD, FACR, FAIUM, FSRU, is chairman of the department of medical imaging at Penn Presbyterian Medical Center in Philadelphia and president-elect of the American Institute of Ultrasound in Medicine (AIUM), a multidisciplinary organization representing those who use ultrasound in medicine and research. Nisenbaum says that as ultrasound usage grows, the AIUM is focused on making sure that quality exams are performed by qualified individuals.

Ultrasound is a challenge, he says, because unlike other diagnostic imaging modalities, it is highly operator dependent. “The quality of the images is very dependent on the skills of the person creating them,” Nisenbaum says. Sonography is becoming more automated with the advent of 3D and 4D ultrasound, but the technology is still evolving. Until sonography becomes less of an art form and the interpreter can manipulate volumes of data after their acquisition, the exam practitioner’s skill is a key factor in making sure nothing is overlooked or misread, Nisenbaum says.

The demographics of the country make sonography even more challenging, he adds. Not only is the population aging, but it also is becoming more obese. Ultrasound exams of larger people are more difficult to perform. Also, people who are seen in hospitals these days are more sick than they had been in the past. These factors create greater challenges for the sonographer and the physician interpreting the exam, Nisenbaum says.

Carol M. Rumack, MD, FACR, a professor of radiology and pediatrics at the University of Colorado Health Sciences Center in Denver and a past chair of the ACR Ultrasound Commission, shares Nisenbaum’s worries about the quality of the ultrasounds by those who aren’t radiologists. “Our concern is that if they’re going to do it, that they will learn how to do it, not just pick it up. It’s like never having been trained on a stethoscope and thinking that you can identify heart murmurs when you need training on it to be able to do that,” she says.

Compact Equipment
Rumack is also concerned about the quality of compact ultrasound equipment, although she acknowledges it has improved since SonoSite Inc pioneered the technology in 1999. “The compact units were really not very good when they first came out,” Rumack says. “Ultrasound radiologists were very much against them for that reason, but they have gotten better.”

Rumack says radiologists tend to use larger equipment with higher frequency transducers because the resolution is higher and depth of field is greater. Because the exams are done in the radiologists’ suites or departments, they don’t have to worry about the equipment’s portability, and the fact that the machines are lightweight isn’t an advantage to them. Rumack doesn’t believe radiologists will adopt miniaturized ultrasound equipment in most cases even if it is less expensive, because “it doesn’t do what we want it to do.” On the other hand, she says, “The present economic situation may just drive radiologists to consider compact ultrasound equipment.”

Some contend the real issue of who performs ultrasound is financial. The physician interpreting the scan is the one who is reimbursed, and some believe radiologists are concerned about nonradiologists who are using ultrasound because they are worried about their jobs. However, Nisenbaum says it is not a turf battle. “There is enough business for everybody. The real issue is that the individuals performing the studies are appropriately trained and that quality studies be performed,” he says.

Controlling Ultrasound
Levon N. Nazarian, MD, a professor of radiology at Thomas Jefferson University in Philadelphia and a specialist in musculoskeletal ultrasound, says that if radiologists are concerned about losing ultrasound to other specialties, they have no one to blame but themselves. Nazarian says many other specialists have learned ultrasound because radiologists would rather spend their time reading modalities such as CT and MR that produce higher reimbursement rates for exams. Physicians in the emergency department, sports medicine, and other settings have learned to do ultrasound, a real-time diagnostic exam, out of necessity, he says. In the emergency department and critical care, the physicians need answers and often a radiologist is not on site to perform the ultrasound. That is why, Nazarian believes, “there is no reason why a nonradiologist with proper training and with the proper equipment should not be able to practice ultrasound, especially if a radiologist is not available at their site of practice to provide their service in a timely fashion.”

Some of those outside of radiology believe that not only are they appropriately trained to perform ultrasound but also that they should be using it for their patients’ benefit.
Paul R. Sierzenski, MD, RDMS, the director of emergency, trauma, and critical ultrasound and the emergency ultrasound fellowship at Christiana Care Health System in Newark, Del., as well as past chair of the American College of Emergency Physicians Ultrasound Section, points out that the ultrasound exams being performed outside of radiology are goal directed and clinically focused. They are typically done at the bedside to aid in a real-time diagnosis or guide an emergency procedure such as central line placement.

Sierzenski doesn’t see how anyone can question the competency of physicians performing point-of-care ultrasound for such purposes outside of radiology. Every hospital in the United States is required to have a credentialing committee to approve who can perform every procedure, whether it is a gallbladder operation or a gallbladder ultrasound, he says. “Everyone—whether radiologist, emergency physician, or critical care physician—goes through that process before performing any procedure,” he says.

Also, the American Medical Association (AMA) House of Delegates Resolution 802 from 1999 affirms that ultrasound is within the scope of practice of all appropriately trained physicians, Sierzenski says. Not only does the AMA support the use of ultrasound by different specialists, but several medical societies have developed their own training and competency guidelines for their members’ use of ultrasound. “In emergency medicine,” he says, “we have the longest history and library of documentation on that. We have had American College of Emergency Physicians guidelines since 2001, and our most recent rendition came out in 2008.” The Society for Academic Emergency Medicine also supports ultrasound as a best practice for emergency medicine.