Transcript HEALTH CARE ECONOMICS

Ultrasound 1984-2010
Stethoscope of the 21st Century
• Camellia Foundation Eugene “Skip”Felmar
Visiting Professor
• Wm. MacMillan Rodney MD, FACEP
– Board of Surgical Family Medicine Obstetrics
– Professor and Chair, Medicos para la Familia
Memphis, Nashville, Rural, International
– Editor: American Journal of Clinical Medicine
– Senior Member, American Institute for Ultrasound in
Medicine
“Yo soy el camino, la verdad y la
vida y nadie viene al Padre si no
es por mi”
Juan 14:6
Con la Fe, no es necesario una explicacion
Sin la Fe, no hay explicacion suficiente.
Without OB, is Office Ultrasound
Feasible in Primary Care?
• A research question from--David McCray MD.
Does ultrasound belong in the Family Medicine
market basket of services? --Dr. Young
• If the equipment costs $35,000, will
reimbursement cover equipment cost, overhead,
and a reasonable payment to the physician?
• Can family physicians demonstrate and maintain
high quality[the standard of care]?
• Will it lose money, break even, or make money
Is there a Predictable Clinical
Volume and Revenue?
• What is the expected frequency of need in a
family medicine office where a full range of
services is encouraged?—Medicos Model
• There are overlapping universes of “OB care”
versus women’s health care in the family
medicine office[generic primary care]
• Pure counts of Gyn ultrasound codes, will
undercount. Accounting bias.
• Start with published studies including all types of
ultrasound. Then, design a better study.
Which Procedures Add Value?
University Tennessee 1997
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Revenue Projections by Specific Service Groups in the Office 1997; visits 30,422;deliveries 252;
Limited Generalist Project: Part III---Rodney WM, Hahn RG. The impact of the limited generalist
(no procedures, no hospital) on the viability of Family Medicine Training. J Am Board Fam Pract,
May-June 2002;15:191-200
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X-rays
ECG
Skin Surgery
EGD
Colon
Flex Sigs
Colposcopy
1323
408
265
104
129
73
161
82
51
243
838
947
200
296
28
23
97
281
315
85
122
27.9
9.4
25.7
29.2
40.6
6.2
19.6
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Ultrasound
525
320
130
68.3
256
134.4
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NST/AFI
95
376
144
13.7
300
28.6
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Subtotals
$249.6k
$535.7*k
This gave rise to the notion of a Defining Dozen service groups in Family
Medicine.-minor ER See Nothnagle et al, Fam Med 2008.
Volume
One Yr.
Charge
$
TennCare
Allowed
Net
$k/Yr
If 80%
Allowed
66
40
194
671
757
160
197
Net
$/Yr
87.3
16.6
51.5
69.7
97.7
11.7
38.1
Dra Conchita Martinez
and the ultrasound
curriculum—ABFM OB
Identify the baby’s head
Identify location of amniotic
fluid
Identify myometrium if
present
Identify placenta if present
Identify and specify
characteristics of any
extremities if present.
Predict most likely football
allegiance
Bibliography
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1. Morgan WC, Rodney WM, Hahn RG, Garr DA, O'Brien J. Echografie bij Verloskunden en
gynaecologie in de praktijruiute: Een ondersteuning voor Luisartsenverloskunde (Office-based
ultrasound as a support for family centered obstetrics), Huissarts Nu (HANU) 1987; 16:277-280.
2. Morgan WC, Rodney WM, Garr DA, Hahn RG. Ultrasound for the primary care physician:
Applications in family-centered obstetrics. Postgrad Med 1988; 83(2):103-107
3. Hahn R, Ornstein S, Davies TC, Rodney WM, et al. Obstetric ultrasound training for family
physicians: results from a multi-site study. J Fam Pract 1988; 26:553-558.
4. Hahn RG, Davies TC, Rodney WM. Diagnostic ultrasound in general practice. Fam Pract--An
International Journal 1988; 5(2):129-135.
5. Rodney WM, Prislin MD, Hahn RG. Family practice obstetrical ultrasound in an urban
community health center: Birth outcomes and examination accuracy of the initial 227 cases. J
Fam Pract 1990; 30:163-168.
6. Rodney WM, Hahn RG, Hartman KJ, Deutchman ME. Obstetric ultrasound by family
physicians. J Fam Pract 1992; 34:186-200.
7. Deutchman ME, Hahn RG, Rodney WM. Maternal gallbladder assessment during obstetric
ultrasound: results and technique. J Fam Pract 1994; 39:33-37.
8. Euans DW, Hahn RG, Rodney WM. A comparison of manual and ultrasound measurements of
fundal height. J Fam Pract 1995; 40:233-236.
9. Rodney WM. Historical observations from the RRC 1994-2000: Maternity care[OB] training in
FP. J Am Board Fam Pract 2002;15:255-56.
10. Dresang LT. Rodney WM, Dees J. Teaching OB ultrasound to family practice residents. Fam
Med 2004; 36: 98-107.
11.Dresang LT, Rodney WM, Leeman L, Dees J, Koch, P, Palencio M. ALSO in Ecuador:
Teaching the Teachers. J Am Board Fam Practice. 2004;17(4): 276-282.
http://www.jabfp.org/cgi/content/full/17/4/276
12. Dresang LT, Rodney WM, Rodney KMM. Prenatal Ultrasound: A tale of two cities. J Nat Med
Association Feb 2006; 98: 167-171.
Proposal for Curriculum in the
Residency and for the Community
• The value and effectiveness of imaging by nonradiologists is
well established in the scientific literature.
• Today we are sharing the results and outcomes of ultrasound
studies started in 1984.
• Ultrasound serves a hybrid physician combining Public
Health, Family Medicine, obstetrics, office surgery, and
emergency medicine.
• A longitudinal curriculum based on an adult learning model
should include lectures, performance based learning, and
monitored outcomes.[QA/QI]
• Generic primary care jobs usually do not accommodate
procedural skills such as ultrasound.
Frequent Diagnoses in Patients Presenting
with Abdominal Pain:
Ann Emerg Med 1984;13: 314[pre TransVaginal]
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Ovarian Cyst
Gallbladder disease
Ectopic Pregnancy--Pregnancy of Unknown Location 2011
Pelvic Mass or Abcess
Pelvic Inflammatory Disease
Mittleschmerz
Intrauterine Pregnancy
Acute Appendicitis
Others, nondiagnostic and/or chronic
Vaginal Bleeding—Diagnostic
Events in Acute Care
• Spontaneous Miscarriages, Threatened Ab
• Normal Pregnancy
• Normal Pregnancy with 3rd Trimester
Bleeding
• Dysfunctional Uterine Bleeding
• Ectopic Pregnancy
• Placenta Previa
• Molar Pregnancy
What is non OB Ultrasound?
What Does it Pay?
• Gyn ultrasound CPT4 codes are known, but there
are extenuating circumstances.
• Does Family Medicine without OB[deliveries]
include the initial diagnosis of pregancy?
• Does Primary Care include the evaluation of
amenorrhea, pelvic pain, vaginal bleeding,
dyspareunia, and others?
• Should our study include ultrasounds incidentally
diagnosing pregnancy prior to OB referral?
• Could we do this study at John Peter Smith?
2009 Medicare Physician Fee
Schedule
Not Prenatal Care
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76705 Abdominal limited, real time with image documentation-$103.15
76700 Abdominal complete with image documentation
$100.77*
76880 Extremity, non-vascular, real time with images-$124.22
76942 Ultrasound guidance for needle placement[e.g., biopsy, aspiration, injection,
localization device--This would include IUD placement]
$ 183.94
G0389 Aortic Aneurysm screening
$110.09
76830 Gyn transvaginal; Gyn complete transabdominal768576
$ 81/77*
Common Urgent Care Services
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76815 Pregnant uterus limited-- [ this would be " fetal heart beat, placental location,
fetal position, and/or quantitative amniotic fluid volume].
$90.53
76817 Pregnant transvaginal-$99.57
Common Family Medicine with Obstetrics Services
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76805 Pregnant uterus complete--This is the standard 20 week exam but applies to many
other situations.[late prenatal care is entry after 13 weeks V20.7]
$196.04*
76818 Biophysical profiling with non-stress testing-$120.46
Defining An Opportunity for Clinical
Excellence—Ultrasound
A Two Hour Seminar from the Transfer of Technology Series www.psot.com
• Pre Event; Staging of Equipment, Projectors, Monitors, Patient
Recruitment, Handouts, Assistant, pointer, printers, pelvic models
• Slides 1-15 : Introduction-handout-Related to Research Questions
from Drs. McCray and Young
Demo-Complete OB exam —How much time does it take?
• Slides 16-30 Case Examples; Performance Based Learning
Demo-Transvaginal with audience volunteer
• Slides 32-36 Ultrasound Frequencies-- 1997,2004-2006, 2009;
• Slides 37-48 Ecuador Mission —Family Medicine+ER+OB. US in
Trauma. The most logical hybrid for developing countries.
Demo-The abdominal exam using a volunteer from the
audience. With pulse count demo. Dual screen video camera ?
• Slides 49-61 Faculty Development and proposed curriculum. An
opportunity for collaboration
Welcome to Medicos
• Medicos was opened in 1999 as a health care model
for uninsured Spanish speaking patients in Memphis.
Due to the need, Nashville opened in 2004. It is a
teaching practice for mission medicine.
• Family Medicine+ER+OB+Technology Transfer.
• Medicos is open 7 days a week and patients do not
need an appointment. Medicos has seen over 340,000
patients and delivered over 4000 babies.
• Medicos does not receive government funds, or
charity support. Medicos pays taxes.
• Through Grace, Medicos provides twice the service at
less than half the cost.
• Ultrasound has been a key curriculum innovation.
Published Studies 2006-2009
Providing Related Data
• See Handout and www.psot.com reprints
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Dresang LT, Rodney WM, Rodney KMM. Prenatal ultrasound: A tale of two cities. J
Nat Med Assoc. Feb 2006;98:167-171.
Rodney WM, Hardison D, McKenzie LD, Rodney-Arnold KMM. The Impact of
Deliveries on the Office of Family Physicians. J Nat Med Assoc. October 2006; 98:
1685-1690.
Nothnagle M, Sicilia JM, Forman S, Fish J, Ellert W, Gebhard R, Kelly BF, Pfenninger
J, Tuggy M, Rodney WM, et al. Required Procedural Training in Family Medicine
Residency: A Consensus Statement. Fam Med 2008; 40: 248-252.
http://stfm.org/fmhub/fm2008/toc.cfm?xmlFileName=fammedvol40issue4.xml
Rodney WM, Martinez CM, Chiu KW, Garcia RL, Carson G. Prenatal patients not
delivered: Unplanned events, uncounted services , and risks.[Delivery volumes at one
office in Memphis] selected for presentation at AAFP in San Diego September 2008.
Published Am J Clin Medicine Spring 2009; 6[2]: 31-36.
Ultrasound More Frequent than
CXR and ECG 2001-2003
• Dresang LT, Rodney WM, Rodney KMM.
Prenatal ultrasound: A tale of two cities. J
Nat Med Assoc. Feb 2006;98:167-171.
• A multi site study. US=>2x deliveries. US> ECG,
XR, any other procedure
• Addressed the criticism that ultrasound was not as
essential than other common skills.
• This study suggested that physicians were not
reporting all procedural activities[Underreporting][Accounting Bias]
Open Access Ultrasound Y2K—Will it
Improve Accessibility, Quality and Revenue?
• Point of Service Theory stated that immediately
available ultrasound would lower barriers to
access, would lead to more rapid diagnosis and
lower risk.
• In the office, on-demand ultrasound would lead to
fewer no-shows and increased patient satisfaction.
• Physicians doing the bedside ultrasound exam
would improve management of psychosocial
issues. This decreases fragmentation of care, and
improves quality.
Objections to Immediately Available
Ultrasound in the FP Office
• It deflects us from our primary mission in
providing chronic care and patient education.
• We will not be reimbursed for it.
• Medicolegal risk will increase. We might miss
something like Tetralogy of Fallot.
• It will throw us off our schedule of appointments,
because it will take too long. We will need extra
nursing staff. We will lose money. Opp Cost
• WMR--Let’s do a timed demonstration of
ultrasound on an unknown patient.
4 Common Questions—FP, el
Magnifico Predicts the Future
• My baby isn’t moving. Viability Time __
• The baby feels different from my other
seven babies. “It’s like sideways or
somethin”.
Presentation Time__
• I forgot to come in for prenatal care, but I
stopped my diabetes pills ‘cuz they might
hurt my baby.
Fetal Size/EGA Time__
• I felt a gush of water down there last night,
but the ER doc told me to see my PCP
today.
Amniotic Fluid Time__
Ultrasound-A Disruptive
Technology Improves Quality
• This 47 yo female with
dyspepsia failed med tx and
her EGD was “gastritis”
• Case based learning with
diagnostic ultrasound. A
picture is worth a thousand
words. Exam time 3 minutes
• Bedside ultrasound is vital
for ER, Cardiology, OB,
Gyn, Gen Surg,
FamilyOB+ER Medicine.
• Near Elimination of
culdocentesis, DPL, HIDA
scan, others
For physicians, how did ultrasound to
improve quality 1984-2014?
• Ultrasound made the following suboptimal
or obsolete.
– Culdocentesis, blind paracentesis, blind amniocentesis,
blind bladder taps
– HIDA scan, pelvimetry, Leopold’s Manuevers, others
– Ultrasound services remote from women’s health care
– Pelvic exam under anesthesia
• Ultrasound dramatically improves
sensitivity and specificity of these events.
– The bimanual pelvic examination[ should be obsolete]
– The digital rectal examination[90 % obsolete]
– The stethoscopic examination
2004-2006 in Private Practice:
Am J Clin Med; 2009 A 3 Year Study
ULTRASOUND Frequencies and $
• During the study, there were 965 deliveries, 95 981 office visits,
– 2 531 billed ultrasounds, and 360 women who did not deliver. This is a private
medical practice which does not receive government grants or charity. It pays taxes
– Ethnic groups included African Americans 129[35.8%], Latinos
165[45.8%],Caucasians 61[17.0%], and other[1.6%].
– Over 97% of patients were either uninsured [39.4%] or Medicaid[ 57.8%].
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There were 2531 billed diagnostic ultrasound procedures in Memphis
2004-2006. Of these, 1554 were obstetrical and 356 were transvaginal of
which 222 were OB related.
Among the undelivered, 295 Ultrasounds collected an average of $105.86.
Total collected for this group =$31,229. [Usually uncounted]
Undelivered services collected slightly more than the average US--$95
Open access scheduling increased the acuity of care. MEDICOS’ comfort
with pelvic and abdominal ultrasounds grew as the study progressed. The
percentage of non-OB ultrasounds was significant.
Collections 2004-2006 for
Ultrasound in a Private Practice
• Revenue per ultrasound from the 2004-2006 CPT4
frequency report . During this time, physicians were using an ultrasound
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machine purchased for less than $30,000 new.
2004
2005
2006
US OB 676 [$60 800]
547 [$60 786]
331 [$38 674]
US TV 128 [ $ 9 355]
112 [ $8 933]
116 [$10 697]
US ABD 171 [$11 727]
142 [ $ 9 767]
154 [$11 375]
US GYN 14 [$ 944]
38 [ 2 070]
72 [$ 4 003]
Total
1554 [$160 260]
356 [$ 28 985]
467[$ 32 869]
134 [$ 7 117]
Total s for each calendar year.
1019 [$ 82 826] 839[$ 81 556]
673 [$ 64 749]
How many MD hours to do 2531 ultrasounds? $95 each.
Conclusions were drawn and an interventions were proposed.
Study 2007-2009; Defining the
Issues and Terminology
• The fellowship curriculum for Family Medicine
Obstetrics was expanded to include Gyn issues.
– Pelvic pain[625.9], infertility, fibroids, trauma, menstrual
irregularities[626.4], vag bleed[623.8]
– PCOS, ovarian cysts[620.0], PID, free fluid in the peritoneum
– Ultrasound assisted IUD location, endometrial biopsy, D&C
– Others
• Physicians were given a 1-2 hour course in coding
and billing. Monthly feedback sessions .
• A new ultrasound machine was purchased for $
35,000. Projected Life = 10 years. No 3D/4D but
added color doppler and pulsed wave doppler.
Non OB Clinical
Cases from 2009
• Family Planning-- I can’t feel my IUD string.
• Abdominal Pain-- My incision is bleeding, and I
have lot of pain after my MVA
• Pelvic Pain, fragmented care--Need my lortabs for
pain. I have an ovarian cyst, and that what the ER
doc always gives me.
• Hemoperitoneum/Ascites/ post ESSURE
• Detection of Unsuspected Multiple Gestation
• The Tranvaginal challenge test—A volunteer is
requested
I Had an MVA, and it may have
dislodged
my
IUD.
IUD checks >100/year
I can’t be pregnant, Can I”
Let’s take another view.
Exam time 8 minutes
Any Suggestions for future
management based on these images?
Fecal Debris occurs
spontaneously.
This IUD is imbedded in the
myometrium. And….
s/p MVA today. Cesarean 7 d
ago. Hematoma Mapping
Is this blood above the fascia or
below it?
Mapping directs
management. Time 5 minutes
Changes surgical technique
31 aa LMP irreg; hx ovarian cystectopic, unprotected sex x 2 yrs
Transabdominal View
Transvaginal View
31 aa LMP irreg; hx ovarian cyst,
ectopic, unprotected sex x 2 yrs
Does this information add to the
management ? Time 12 minutes
• Is it common to have two
ovarian cysts of this size side by
side?
• This view shows free fluid with
a probable loop of bowel
floating in the fluid.
• This amount of free fluid
creates pain greater than a
simple ovarian cyst.
• Your office has no pregnancy
services and the HCG quant
will take 2 hours-days. What
next?
Gyn US Study-Design Issues
• For women’s health care, there is no clean
distinction between Family Medicine Obstetrics
and general primary care where women are seen.
• Women who suspect pregnancy visit physicians
who do not deliver babies.
• For purposes of study design, women delivering
with the family physician could be excluded.
• Salaried physicians under report and under charge
for ultrasound services. Accounting Bias
• A curriculum in Transvaginal Ultrasound can be
designed, taught and tested. Demonstration Here
Medicos Family Medicine has a
Mission which is a Confounder
• Seeks to provide continuing comprehensive high
quality health care unrestricted by age, gender,
organ system, and location of service.
• Twice the service at half the cost.
• Ten percent of the information makes ninety
percent of the difference
• The physician shall have authority to provide
some charity care.
• Due to confounders, a Multi site Study for the
impact of procedures is better.
Under Reporting Bias Creates Risk
Through Failure to Document
• Accounting and Reporting bias--Salaried physicians under
report and do not charge for some ultrasound services.
• Manage accounting bias with new technology improving
information management through automatic
documentation and easier image storage.
• A dual probe, higher resolution ultrasound was combined
with a Windows XP computer and internal 80 GB hard
drive. Equipped with color and pulse wave doppler. No 3D
• Physicians log on to the machine and each event is
“remembered”.
• Cost was $35,000 with projected life 7-10 years.
Unpublished 2009 Data on the
Magnitude of Under-Reporting
• 2009 Data
– Number of Medicos office visits = 44,408
– Number of Medicos deliveries =
484
• Frequency of selected procedures
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ECG Reports
429
CXR Reports
517
Non CXR[bones]
241
All Ultrasound Reports.801+473=1274
Recorded Ultrasound Events: 2009
• 44,408 visits suggests the equivalency of 7
physicians seeing 6,300 visits a year each.
• Computer log
with ID
No ID
• OB exams
2513
583
• Gyn exams
493
69
• Abdominal exams
117
19
• Computer log without ID[undocumented]. These no-ID
exams suggest psychosocial-uncharged use.
• Do the arithmetic at $100/exam and less than 15 minutes
per exam. These data imply there is an upside.
Ultrasound Events 2009—
Medicos and the Mission
• 2009 actual billing data: 44, 408 office
visits; 484 Medicos deliveries
• Family Practice Charity Gene Exists
• Almost no billing for false labor admits and
probable 30-40% free ultrasound
• 1746 billed ultrasounds–
total collections-$167,844
• Average $ per ultrasound approx $95/ exam
• There are implications for underserved
areas and developing countries.
Ecosonografia y Trauma en el
Embarazo-Quito 2010
• Un Taller mezclando conferencia, demostracion,
aprendezaje basada en hacer
• Actualizando el manejo de trastornos y
enfermadades comunes en la comunidad
• Ultrasonido es una necesidad para cada medico
involucrado en la salud de las mujeres. Se
incluyen cuidado prenatal y los problemas de
gynecologia.
• En el manejo de trauma, radiografia y ultrasonido
son los herramientos mas importantes.
Pelvic Pain
Am I Bleeding Inside?
Anterior Uterus Normal?
What Does a hematoma look like?
Develops a sense of judgement
about old versus new blood
In this view the clot has
organized
We are measuring size to
follow progress.
10% of the Information Makes
90% of Difference
• Is my baby alive? Would
you like a photo?
• Is the heart rate normal?
• Systolic-diastolic ratios
possible, but we don’t
use them yet.
• Color flow useful for
learning.
Baby’s not Moving
• Simplicity of Power
wave Doppler function
• Produces wooshwoosh like hand held
Doppler
• Time needed = 1 min
• Creates permanent
record of viability at
time of exam
Which heart rate do you want for
your baby?
Had an OB, but referred from ER
for Abdomnal Pain at 28 wks.
Send her home? Cesarean
wgt 568 Grams.
Two Years later. Now
pregnant again
Suggested Parameters for JPS
Study—wmr Jan 20, 2010
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Track all ultrasound referrals from Family Medicine Center 2009.
Identify ICD9 codes and count frequencies
Tabulate likely charges
Tabulate likely collections from medicaid, uninsured, and others.
Design curriculum for family medicine faculty “champions”, create
longitudinal gyn/OB curriculum using case report format.
Phase one Spring 2010--Tabulate faculty exam time, complete report,
don’t charge, refer, and compare diagnosis to radiology.
Publish Case reports , curriculum design, learning curve data, and
financial feasibility data.
Phase two 2011—Tabulate resident learning curves after cognitive
preloading with ABFMOB test questions.
Design grant application for family medicine fellowship in ultrasound
studies. Collaborate with emergency medicine.
Consider international outreach. Mission Medicine
Board of Surgical Family
Medicine Obstetrics
16 yo LMP 7 wks ago; hcg
pos; pelvic pain; TV US
Identify
• Is the Uterus sagital or
transverse?
• Identify the
– Hypoechoic Structure in
upper left hand corner.
– Posterior surface of uterus
– Pouch of Douglas
• State the most likely
explanation for hypoechoic
area posterior to uterus
Board of Surgical Family
Medicine Obstetrics
• 16 yo LMP 7 wks ago.
HCG pos; quant #1
drawn. Pelvic pain
without bleeding
• This image displays a
clear space in the
uterus and a larger
circular clear space
above it and to the left.
Board of Surgical Family
Medicine Obstetrics
• 16 yo pelvic pain with
HCG positive
• 3/4 slide sequence
• Identify the area most
likely to be uterus
• Is the circular
structure simple or
complex?
• What is the most
likely diagnosis?
Board of Surgical Family
Medicine Obstetrics
• 16 yo LMP 7 wks ago.
HCG pos; pelvic pain
• Identify
– Uterus
– Posterior cul de sac
• Is Douglas’ pouch
normal?
• Do these findings
suggest a most likely
diagnosis? Plan?
Ectopic Probabilities: Ultrasound
Nygard, Filly R, etal. J Ultrasound Med 1995
Finding:
Risk of ectopic (%)
No mass or free fluid
20
Any free fluid
71
Echogenic mass adnexa
85
Mod to large amt fluid
95
Echogenic mass w/fluid
100
S/p MVA; at Term; Vag
Bleeding
• 31 yo G3P2 EGA 38
weeks; PMH neg
• Fetal monitor strip
• This is a sagital view
of the inferior uterus
with the baby to the
left. Breech
• Where is the cervical
os likely to be?
American Board of Family
Medicine Obstetrics Curriculum
• Given the image, what
would be the most
likely cause of the
bleeding?
• The doctor should
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a. obtain Hct?
b. Prepare for Cesarean
Induce labor
See patient tomorrow
79267 Placenta Previa
• Labelng is
recommended
• Video clips are
possible
• Using the challenger
programmed learning
discs is recommended.
• Mark Deutchman MD
merits recognition for
his work in this area.
62693 19 yo Pelvic Pain; HCG
neg; Use of color flow
• Identify
– Endometrial stripe
– Posterior surface of the
uterus
– A hypoechoic area
– A lemon shaped area
posterior to the uterus
which has a texture
different than the uterus.
• From this image, is an
intrauterine pregnancy
likely?
Using calipers and labels
• Annotation features
can and should be
used for later review
of each image.
• Is the architecture of
this ovary normal?
• Is there any condition
more likely to create
free fluid and a mushy
ovary? HCG neg
Ovarian size and consistency
• How is ovarian
volume measured?
• What is the upper limit
of normal ovarian
volume?
• What conditiions are
associated with an
enlarged ovary?
Color Doppler identifies vessels
and other structures with fluid
• Measurement commands
are blocked until the
image is frozen
• Color doppler commands
are blocked if the image is
frozen.
• A visible fallopian tube is
unusual. But can be
mistaken for a blood
vessel.
“Hippocrates” by
H. MacMillan Rodney, M.D.
1920-1972
Study the past,
Diagnose the present,
Foretell the future,
Practice these acts,
As to disease, first of all,
do no harm.
Hippocrates 460-377 B.C.
Proposal for Curriculum in the
Residency and for the Community
• The value and effectiveness of imaging by nonradiologists is
well established in the scientific literature.
• Today we are sharing the results and outcomes of ultrasound
studies started in 1984.
• Ultrasound serves a hybrid physician combining Public
Health, Family Medicine, obstetrics, office surgery, and
emergency medicine.
• A longitudinal curriculum based on an adult learning model
should include lectures, performance based learning, and
monitored outcomes.[QA/QI]
• Generic primary care jobs usually do not accommodate
procedural skills such as ultrasound.
Ultrasound Seminar: John Peter
Smith January 20,2010
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Outline
Handout
Key References
New Information and Unpublished Data
Proposal for an Ultrasound Fellowship
Proposal for Collaborative Research
Could link to American Board of Family
Medicine Obstetrics
Without OB, is Office Ultrasound
Feasible in Family Medicine?
• A research question from--David McCray MD.
Does ultrasound belong in the Family Medicine
market basket of services? --Dr. Young
• If the equipment costs $35,000, will
reimbursement cover equipment cost, overhead,
and a reasonable payment to the physician?
• Can family physicians demonstrate and maintain
high quality[the standard of care]?
• Will it lose money, break even, or make money
Gyn US Hypotheses Proposed
• Pregnant women visit physicians who do not
deliver babies.
• For women’s health care, the boundary between
Family Medicine Obstetrics and Family Medicine
without obstetrics is not clear.
• Women receiving prenatal care would be excluded
from the NonOB ultrasound study. Others count.
• Accounting bias has been recognized as a
confounding influence. Reporting and charging
would need to be tightly controlled.
• How do we design a better study?
60 Minutes x2: Family Medicine’s
Opportunity for Clinical Excellence-Ultrasound
• Pre Event; Staging of Equipment, Projectors, Monitors, Patient
Recruitment, Handouts, Assistant, pointer, printers, pelvic models
• Slides 1-14 : Introduction-handout-The proposed Research Question
from David McCray MD
Demo-Complete OB exam —How much time does it take?
• Slides 15-29 Case simulations
Demo-Transvaginal with audience volunteer
• Slides 30-35 Ultrasound Frequencies-- 1997,2004-2006, 2009;
• Slides 35-43 Case simulations for the Ecuador Mission —Family
Medicine+ER+OB. The most logical hybrid for developing countries.
Demo-The abdominal exam using a volunteer from the
audience. With pulse count demo.
• A call for collaboration from the Board of Surgical Family Medicine
Obstetrics , the Camellia Foundation, and Medicos para la Familia
Suggested Parameters for JPS
Study—wmr Jan 20, 2010; 9-4-11
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Track all ultrasound referrals from Family Medicine Center 2009.
Identify ICD9 codes and count frequencies
Tabulate likely charges
Tabulate likely collections from medicaid, uninsured, and others.
Design curriculum for family medicine faculty “champions”, create
longitudinal gyn/OB curriculum using case report format.
Phase one Spring 2010--Tabulate faculty exam time, complete report,
don’t charge, refer, and compare diagnosis to radiology.
Publish Case reports , curriculum design, learning curve data, and
financial feasibility data.
Phase two 2011—Tabulate resident learning curves after cognitive
preloading with ABFMOB test questions.
Design grant application for family medicine fellowship in ultrasound
studies. Collaborate with emergency medicine.
Consider international outreach. Mission Medicine