PurposeIR consultation and follow-up improves IVC filter retrieval rates. However, limited resources may pit these practices against RVU-generating procedures. We propose that these practices also generate RVUs, through improved retrieval rates. The current CMS physician fee schedule restructures RVUs for insertion and retrieval of IVC filters, further incentivizing practices that improve retrieval rates.Materials and MethodsWe identified patients who had retrievable IVC filters placed between January 2000 and January 2010. In 2009, an IVC filter clinic was implemented in which an IR and nurse methodically followed patients after filter placement. PW-RVUs assigned to insertion and retrieval of IVC filters were obtained from the CMS physician fee schedule. Average PW-RVUs generated per patient was calculated by:(Σ(RVUins)+Σ(RVUret))/n, where n represents patients.ResultsPre-clinic, 369 patients had retrievable IVC filters placed with a retrieval rate of 29%. Post-clinic, 100 patients had retrievable IVC filters placed with a retrieval rate of 60%. In 2012, PW-RVUs decreased 42% for retrieval and 70% for insertion(Figure 1). Average PW-RVUs generated per patient pre-clinic was 19.32. Post-clinic, this increased 21% to 23.30. Under the 2012 physician fee schedule, average PW-RVUs per patient pre-clinic would have been 6.84. Post-clinic, average PW-RVUs would have increased 33% to 9.12.ConclusionManagement of patients with retrievable IVC filters, through an improvement in retrieval rates, results in greater average PW-RVUs generated per patient. The updated CMS physician fee schedule reverses the relative reimbursement of insertion and retrieval, thus further incentivizing practices that improve retrieval rate, though reducing reimbursement overall.Tabled 1Abstract No. 8 CMS physician work-RVUs for IVC filter insertion and retrievalInsertionRetrievalPre-2012Post-2012Pre-2012Post-2012CPTRVUCPTRVUCPTRVUCPTRVU3762011.49371914.71372035.02371937.35360102.4336010-512.4375825-261.1475825-261.1475940-260.5475961-264.24Total15.64.7112.837.35 Open table in a new tab PurposeIR consultation and follow-up improves IVC filter retrieval rates. However, limited resources may pit these practices against RVU-generating procedures. We propose that these practices also generate RVUs, through improved retrieval rates. The current CMS physician fee schedule restructures RVUs for insertion and retrieval of IVC filters, further incentivizing practices that improve retrieval rates. IR consultation and follow-up improves IVC filter retrieval rates. However, limited resources may pit these practices against RVU-generating procedures. We propose that these practices also generate RVUs, through improved retrieval rates. The current CMS physician fee schedule restructures RVUs for insertion and retrieval of IVC filters, further incentivizing practices that improve retrieval rates. Materials and MethodsWe identified patients who had retrievable IVC filters placed between January 2000 and January 2010. In 2009, an IVC filter clinic was implemented in which an IR and nurse methodically followed patients after filter placement. PW-RVUs assigned to insertion and retrieval of IVC filters were obtained from the CMS physician fee schedule. Average PW-RVUs generated per patient was calculated by:(Σ(RVUins)+Σ(RVUret))/n, where n represents patients. We identified patients who had retrievable IVC filters placed between January 2000 and January 2010. In 2009, an IVC filter clinic was implemented in which an IR and nurse methodically followed patients after filter placement. PW-RVUs assigned to insertion and retrieval of IVC filters were obtained from the CMS physician fee schedule. Average PW-RVUs generated per patient was calculated by:(Σ(RVUins)+Σ(RVUret))/n, where n represents patients. ResultsPre-clinic, 369 patients had retrievable IVC filters placed with a retrieval rate of 29%. Post-clinic, 100 patients had retrievable IVC filters placed with a retrieval rate of 60%. In 2012, PW-RVUs decreased 42% for retrieval and 70% for insertion(Figure 1). Average PW-RVUs generated per patient pre-clinic was 19.32. Post-clinic, this increased 21% to 23.30. Under the 2012 physician fee schedule, average PW-RVUs per patient pre-clinic would have been 6.84. Post-clinic, average PW-RVUs would have increased 33% to 9.12. Pre-clinic, 369 patients had retrievable IVC filters placed with a retrieval rate of 29%. Post-clinic, 100 patients had retrievable IVC filters placed with a retrieval rate of 60%. In 2012, PW-RVUs decreased 42% for retrieval and 70% for insertion(Figure 1). Average PW-RVUs generated per patient pre-clinic was 19.32. Post-clinic, this increased 21% to 23.30. Under the 2012 physician fee schedule, average PW-RVUs per patient pre-clinic would have been 6.84. Post-clinic, average PW-RVUs would have increased 33% to 9.12. ConclusionManagement of patients with retrievable IVC filters, through an improvement in retrieval rates, results in greater average PW-RVUs generated per patient. The updated CMS physician fee schedule reverses the relative reimbursement of insertion and retrieval, thus further incentivizing practices that improve retrieval rate, though reducing reimbursement overall.Tabled 1Abstract No. 8 CMS physician work-RVUs for IVC filter insertion and retrievalInsertionRetrievalPre-2012Post-2012Pre-2012Post-2012CPTRVUCPTRVUCPTRVUCPTRVU3762011.49371914.71372035.02371937.35360102.4336010-512.4375825-261.1475825-261.1475940-260.5475961-264.24Total15.64.7112.837.35 Open table in a new tab Management of patients with retrievable IVC filters, through an improvement in retrieval rates, results in greater average PW-RVUs generated per patient. The updated CMS physician fee schedule reverses the relative reimbursement of insertion and retrieval, thus further incentivizing practices that improve retrieval rate, though reducing reimbursement overall.

Purpose: The use of inferior vena cava filters (IVCFs) is under increasing scrutiny because of device safety and economic considerations. The aim of this study was to test the hypothesis that interventional radiologist (IR) consultation results in better utilization of optional and permanent filters.Methods: Over 6 months, an IVCF decision-making database at a single institution was prospectively studied. After IR consultation, each case was classified as concordant (agreement between the referring physician and the IR over filter choice) or discordant (disagreement over filter choice). The consulting IR estimated the likelihood of retrieval attempt for all optional filters at the time of placement (0%-100%). Chi-square and t tests were used for statistical analyses. The null hypotheses were rejected at P < .05.Results: Sixty-six IVCFs (23 permanent, 43 optional) were placed in 66 patients. Sixteen of 66 decisions were discordant. In 7 of the 16 discordant cases, patients received optional filters; of these, 6 (86%) were declared permanent by the referring physician. For this group, the IR's prospective estimate of subsequent retrieval was 6.4% (0%-15%; P < .001). Fifty of 66 decisions were concordant. Of these, 36 patients received optional filters. Thirty-one of 36 concordant optional filters (86%) were successfully retrieved (P < .001). For this group, the IR's prospective estimate of subsequent retrieval was 88.3% (80%-100%; P < .001). Of the 5 concordant devices not retrieved, 2 patients died, and 3 devices were declared permanent. There were no IVCF placement or retrieval failures. No patients were lost to follow-up.Conclusions: Interventional radiologists can prospectively predict the likelihood of optional filter retrieval. Significantly higher retrieval rates are achieved as a result of IR consultation. Interventional radiologist consultation positively affects IVCF device choice, patient safety, and effective utilization.

Objective:To assess the incidence of clinical and imaging radiation pneumonitis (RP) in a cohort of patients treated with >30 Gy cumulative lung dose (CLD) using Y90 microspheres. Materials and Methods:Four hundred three patients were treated with Y90 microspheres during a 4-year period. Of these, 58 patients received >30 Gy CLD. Patients were followed for toxicities suggestive of imaging or clinical RP. Toxicities were graded using the Radiation Therapy Oncology Group/European Organisation for Research and Treatment of Cancer Late Radiation Morbidity Scoring Schema. Patients were also followed for survival from time of first treatment. Results:There were 44 men and 14 women. Forty-three patients had hepatocellular carcinoma (HCC), whereas 15 had liver metastases. Mean and median follow-up were 7.3 and 6.0 months, respectively. Mean lung shunt fraction was slightly greater in the patients with HCC versus metastases (20% vs. 16.7%, P = 0.2308). The lifetime CLD for metastases and HCC groups were not statistically different (54.04 Gy vs. 48.44 Gy, P = 0.4303). Forty-three of 53 patients demonstrated no lung imaging findings suggestive of pneumonitis. Imaging findings in 10 patients included pleural effusions, atelectasis, and ground glass attenuation. There were no cases of clinical or imaging RP. Survival varied depending on stage as well as single and CLD. None of the patient deaths were attributed to respiratory compromise. Conclusion:RP was not predicted using the currently used Y90 dosimetry models that assume uniform distribution in the lungs. Further investigation and dose escalation studies are required to more precisely define the radiation tolerance of lung parenchyma using this mode of therapy.

90Yttrium (90Y) microspheres are 20- to 40-μ particles that emit beta radiation. Because the microspheres are delivered via the hepatic arterial route, the process can be considered “internal” rather than external radiation. The treatment algorithm is analogous to that followed with transarterial chemoembolization (TACE). Clinical history, physical examination, laboratory values and performance status are obtained. Patients are initially evaluated and staged using cross-sectional imaging techniques (computerized tomography [CT], magnetic resonance imaging [MRI], positron emission tomography [PET]). Once a patient is considered a possible candidate for therapy, evaluation using mesenteric angiography followed by treatment on a lobar basis is undertaken. Patients are followed clinically to assess toxicities and response prior to proceeding with treatment to the other lobe. A comprehensive review of the technical and methodological considerations in 90Y has been previously published (1–3).