key: cord-259331-hi6gyp52
authors: Malhotra, Ajay; Wu, Xiao; Fleishon, Howard B.; Duszak, Richard; Silva, Ezequiel; McGinty, Geraldine; Bender, Claire; Williams, Beth; Pashley, Neale; Stengel, Casey J.B.; Naidich, Jason J.; Hughes, Danny; Sanelli, Pina C.
title: COVID-19 Initial Impact on Radiology Practices: Survey from ACR/RBMA
date: 2020-08-04
journal: J Am Coll Radiol
DOI: 10.1016/j.jacr.2020.07.028
sha: 
doc_id: 259331
cord_uid: hi6gyp52

Abstract Objective The coronavirus disease 2019 (COVID-19) impacted radiology practices in many ways. We aimed to estimate declines in imaging volumes and financial impact across different practice settings during April 2020. Methods The survey constituting 48 questions was conducted through members of the ACR and the Radiology Business Management Association (RBMA) during May 2020. Survey questions focused on practice demographics, volumes, financials, personnel and staff adjustments, and anticipation of recovery. Results During April 2020, nearly all radiology practices reported substantial (56.4-63.7%) declines in imaging volumes with outpatient imaging volumes most severely affected. Mean gross charges declined 50.1-54.8% and collections declined 46.4-53.9%. Percentage of reductions did not correlate with practice size. Majority of respondents believed that volumes would recover but not entirely (62-88%) and anticipated a short-term recovery, with a surge likely in the short-term due to postponement of elective imaging (52-64%). 15.6% reported that radiologists in their practices tested positive for COVID. Over half (52.3%) reported availability of personal protective equipment had become an issue or was inadequate. A majority (62.3%) reported that their practices had existing remote reading or teleradiology capabilities in place prior to the pandemic, and 22.3% developed such capabilities in response to the pandemic. Conclusions Radiology practices across different settings experienced substantial declines in imaging volumes and collections during the initial wave of the COVID-19 pandemic in April 2020. Most are actively engaged in both short- and long-term operational adjustments.

uncertain whether this level of funding would be adequate or additional congressional action may be necessary to stabilize health care markets. [7] It is unclear how and to what extent the pandemic has affected different radiology practices, and how the administrators and practice leaders are responding to the disruptions caused by the pandemic.

We undertook this survey to assess the impact of the COVID-19 pandemic on radiology practices in different settings, and to assess their anticipation of recovery. The purpose of this study was to assess the changes in radiology practices during the initial wave of the COVID-19 J o u r n a l P r e -p r o o f pandemic as of April 30,2020, and provide information that could assist in both short-term and long-term recovery plans.

Institutional review board oversight was not required for this study since the study involved no private identifying information and did not constitute human subjects research. 

All survey results were compiled and graphed using Microsoft Excel. The numerical estimates from reduction in volume, reduction in receipts, and reduction of gross charges were plotted against the reported FTEs. Data points with FTEs above 100 (from 6 respondents) were removed from the plot only to improve visualization due the scaled effects. Responses from others/breast centers were not plotted due to the limited number of FTEs reported. A best-fit linear regression line with 95% confidence interval was added to each graph to show the overall trend. For family-wise correlation, a statistically significant alpha was defined as 0.00278 after Bonferroni correction.

There was a total of 248 responses, with 13 zip codes being identified with more than one response and assessed for similarities in the number of reported FTEs and other responses. Out of these respondents, 6 were considered duplicates and not eligible for inclusion. Among the remaining 242 responses, 26 were from imaging centers, 80 from hospital-based organizations, J o u r n a l P r e -p r o o f 64 from mixed practices, 1 from breast center, 3 from others and 68 were missing data. Details of the respondents' characteristics are available in the Online Supplement. Responses from respondents with unsure, limited or no input management decisions were excluded, leaving a total of 228 responses for analysis (a response rate of 28.9%).

Overall, a decline in imaging volumes in April 2020 was reported by 97.4% (222/228) of The overall decline in imaging volumes is depicted in Figure 1 in relation to the number of FTEs.

Details about the reported overall reduction in imaging volumes and stratified by patient service location (ED, outpatient and inpatient settings) in different practice settings are provided in Table 1 .

There was a drop of nearly 90% in elective procedures across practices, with a decrease 7.6% (13/170) responders indicated that PPE was only provided for high-risk procedures due to inadequacy, 0.6% (1/170) reported PPE was not available and 4% (7/170) responded "unsure."

A total of 100% (24/24) responders from imaging centers, 96% (72/75) from hospital- Injury Disaster Loan Emergency Advance, Accelerated payments, and HHS Stimulus Fund (#1 and #2). Among the 23 imaging centers that applied, only 9% (2/23) applied for 1 program, and 91% (21/23) applied for 2 or more programs. Among the 69 hospital-based organizations that applied, only 6% (4/69) applied for 1 program, and 94% (65/69) applied for 2 or more programs.

All 62 mixed practices indicated that they had applied for financial relief programs, with 5%

(3/62) applying for only 1, and 95% (59/62) applying for 2 or more programs. Ten of the 11 (91%) recorded responses from other/breast center indicated that they had applied, with 10%

(1/10) applying for 1 program, and 90% (9/10) for 2 or more programs. Table 2 summarizes the responses regarding the expected speed and extent of recovery in imaging volumes, possible short-term surge due to postponed elective imaging, and adverse impact on practices. In imaging centers, 62.5% believed that imaging volume would recover but J o u r n a l P r e -p r o o f not entirely. The corresponding proportion was 88% for hospital-based organizations and 74.2% for mixed practices. Respondents expecting a short-term surge due to postponed elective imaging was 58.3% for imaging centers, 56.0% for hospital-based organizations, 51.6% for mixed practices, and 63.7% for others/breast centers. The details on the extent of likelihood (somewhat likely vs very likely) and exact response counts are provided in the Online Supplement.

The survey results quantify the extent of impact of the COVID-19 pandemic on radiology practices across the spectrum of settings. There were initial anecdotal reports of substantial (50-70%) declines in nationwide imaging volumes. [8] Recently, COVID-19 associated declines in imaging volumes were described for a single large health system in New York, the area hit hardest by the initial wave of COVID-19 cases, as well as a large University Hospital in Northern California.[1; 2] The survey shows similar results with estimated percentage decline from baseline in imaging volumes being greatest for imaging centers (63.7%), with smaller declines from hospital-based, mixed and other practices (56-58%). The decrease in imaging volumes included a 40-45% drop in cases from the Emergency Department as well as for inpatients from hospital-based and mixed practices. As expected, the drop in imaging volumes in the outpatient setting was greater at 55-60%. There was no statistically significant correlation between the percentages of reduction in imaging volume and the size of practice (number of FTEs). These drop in volumes are a reflection of most practices avoiding all non-urgent imaging.

Substantial COVID-19 related imaging work volume declines have been recently reported, similar across community practices. [9] J o u r n a l P r e -p r o o f A majority of respondents (62 to 88%) felt that imaging volume would recover but not entirely, with the lowest proportion in imaging centers. More than half (52 to 64% respondents) felt there may be a surge in the short-term due to postponement of elective imaging, with the highest proportion in breast centers/others. Radiology practice volumes were reported to be increasing recently. [2] However, at the time of this manuscript preparation, there is a rapid increase in the number of reported cases, especially in some geographical areas.

[10] The areas affected most adversely by the initial wave in April are starting to show declining trends.

However, the overall impact of increasing number of positive cases and reported deaths on radiology practice remains unknown and would require further study. Approximately, 50-68% respondents felt that smaller practices may get more adversely affected, with the higher proportions reported by imaging centers and breast centers/others. This could make access to radiology services in rural areas even more challenging. [9] Hospital-based organizations and mixed practices reported radiologists providing interpretations from remote locations in approximately 75% cases. Only around 10% were reassigned to academic, research, or administrative time. Paid time off (PTO) was reported in 30-50% and working hours and compensation were reduced in approximately 60%, with furloughs reported by 23.5%. Roughly half the practices gave exemptions from physical working on-site in the hospital for individuals at high-risk, but approximately a fourth of respondents gave no exemptions. Significant changes to practice had to be made for invasive/ interventional procedures and nearly half the respondents reported that availability of PPEs had become an issue or was inadequate.

A majority of practices felt well-prepared for remote reading/teleradiology and felt that it would become standard operating procedure in the future. Roughly half of all respondents J o u r n a l P r e -p r o o f thought that onsite reading would be utilized only to maintain visibility and availability.

Increasing teleradiology services has significant implications for faster turnaround times and opportunities for greater access to sub-specialized radiologists. [11] Over 40% of respondents in our survey reported adverse impact on their radiology training programs.

The reduction in receipts and gross charges was nearly 50% across the spectrum of practice settings, and almost all practices have applied for financial relief through one or more programs. As a result, 87% reported reduction of salary and/or headcount with nearly half reducing/ postponing or eliminating incentive payments. Disproportionate declines have recently been reported in some subspecialty areas (e.g., breast imaging). [9] The short-and long-term impact on radiology practices remains to be seen.

A main limitation inherent in survey studies is that systematic bias could have been introduced by possible higher response rate from practices in geographic regions more severely affected by the pandemic. In order to minimize this response bias, we instructed practices to submit only a single response to our survey and removed multiple responses from the same practice in the statistical analysis. Another important limitation in this study is the percentage declines from baseline in imaging volumes, as well as receipts and gross charges, for the month of April 2020 are reported estimates, and not actual numbers that can be audited. However, these reported estimates in imaging volume decline are compared with the current literature to evaluate the difference with real-world data.

In conclusion, the survey shows the dramatic impact of the COVID-19 pandemic on radiology practices and the response measures taken during the crisis. The continued spread in parts of the U.S. and possibility of further increases in parts previously affected adversely make 

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Accessed 6/25/2020