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Original Research |
1 Department of Diagnostic Radiology, Yale University School of Medicine, New
Haven, CT.
2 Present address: 43 Boone St., Staten Island, NY 10314.
3 Department of Radiology, Bridgeport Hospital, Bridgeport, CT.
4 Advanced Radiology Consultants, LLC, Trumbull, CT.
5 Statistical Consultant, Beverly, MA.
6 Yale College Department of Economics, Yale School of Management and Yale
School of Public Health, New Haven, CT.
Received July 27, 2005;
accepted after revision February 14, 2006.
Address correspondence to N. Lester
(neil.lester{at}yale.edu).
WEBThis is a Web exclusive article.
Abstract
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MATERIALS AND METHODS. A five-question, scenario-based survey describing features of a hypothetic local radiology firm compared with those of its hypothetic overseas counterpart, international radiology, was sent by mail to 350 physicians from a broad range of medical and surgical specialties. One hundred nineteen physicians responded, for a response rate of 34%. Referring physicians were asked to indicate their preference for local versus international interpretation in each scenario using a 5-point Likert scale, with a score of -2 indicating a strong preference for international services, 0 indicating no preference, and 2 indicating a strong preference for local services.
RESULTS. When all variables are held to be equal, referring physicians strongly prefer local services (mean score, 1.77; SD, 0.77). When international teleradiology provides either a 2-day faster turnaround time for reports or a $30 lower out-of-pocket cost to the patient, referring physicians still prefer local services, although less than they did with all variables held equal (mean score, 0.42-0.44; SD, 1.30-1.40). When international teleradiology provides both a 2-day faster turnaround time and a $30 lower out-of-pocket cost to the patient, referring physicians preferred international teleradiology, albeit only slightly (mean, -0.25; SD, 1.50). Finally, when the credentials of the international radiologists are perceived to be less than those of the local radiologists, even in the face of faster turnaround time and $30 lower cost to the patient, referring physicians overall strongly prefer local services (mean, 1.51; SD, 0.86).
CONCLUSION. Referring physicians prefer local interpretation of radiologic images to international interpretation when all things are equal. However, the timeliness of image interpretation and the cost to the patient are important factors in this decision.
Keywords: practice of radiology • teleradiology
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In order for the international teleradiology model to work, acceptance and approval not only from the radiology community but also from referring physicians and their patients will be required because other physicians and patients are ultimately the consumers of the radiology community's productivity. To date, little has been published on referring physician attitudes toward the international interpretation of radiologic images. In this survey-based study, we examined the attitudes of referring physicians toward formal interpretations of non-emergent images via international teleradiology. This survey did not examine attitudes toward the more common nighthawk scenario, in which international teleradiologists provide informal preliminary interpretations of emergent images during the night followed by formal reports by local radiologists in the morning.
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The survey consisted of five written scenarios describing features of a local radiology firm compared with those of its overseas counterpart, "international radiology." Each scenario included variables that might influence a referring physician's choice of local versus international radiology services: out-of-pocket expenses to the patient, turnaround time for generating final reports, and both of these elements together. All of the scenarios except the last one, scenario 5, assumed an equivalent level of training and certification between the local and international radiologists, and all provided for full access to radiologists for consultation.
In scenario 1, both costs to patient and turnaround time for final reports are equivalent for both firms. In scenario 2, the costs to the patient remain the same but international radiology provides faster turnaround time for reports compared with 3 days for local. In scenario 3, costs to the patient are lower for international radiology compared with local, but report turnaround time is the same for both. In scenario 4, international radiology provides both lower out-of-pocket costs and faster turnaround time for reports. Finally, in scenario 5, international radiology provides both lower out-of-pocket costs and faster turnaround time for reports; however, the radiologists at international radiology are not American-trained or board-certified, although their work is supervised by an American-trained radiologist licensed to practice in the survey recipient's state, with appropriate credentials to practice in the survey recipient's hospital.
For each scenario, responding physicians were asked to rate their preference for where they would refer their nonemergent CT cases. Responses ranged on a 5-point Likert scale from -2 to 2. Response choices were as follows: -2, strongly prefer international; -1, somewhat prefer international; 0, little or no preference; 1, somewhat prefer local; and 2, strongly prefer local. Finally, the following demographic information was requested from the respondents: age, sex, primary specialty, year of graduation from medical school, number of years lived outside the United States, and portion of training received outside of the United States.
Participants
Survey recipients were drawn from three sources: referring academic
physicians in a major university teaching hospital, referring private practice
physicians, and referring physicians in a community hospital, all located in
the same Northeastern geographic region of the United States. The difference
between the second and third groups was that the private offices of physicians
in the third group were 10 or fewer miles from the community hospital included
in the study, whereas the private offices of the physicians in the second
group were more than 10 miles from the community hospital included in the
study. There were 350 survey recipients, with 113 survey recipients in the
academic group, 125 in the private practice group, and 112 in the community
hospital group.
We used predetermined lists obtained from the community hospital and from the academic medical center. To be included in those lists, a participant had to have referred a patient to Yale-New Haven Hospital or Bridgeport Hospital, a Yale affiliate, for at least one nonemergent CT of the abdomen or pelvis during 2003. The community hospital and private practice lists that we obtained contained 112 and 125 physicians, respectively, and the university hospital list we obtained contained more than 400 physicians. We included every physician from the community hospital and private practice lists because these lists were much shorter that the academic medical center list. We included a random sampling from the academic center list to arrive at a sample size comparable with the other two lists.
Methods
Before initiating the study, we decided that once a 30% response rate was
achieved in each group, the study would be closed. We chose 350 participants
and a 30% response rate because we estimated that this size study and response
rate would be manageable to perform, given our resources, and would still
yield significant results. Three separate mailings, between October 2004 and
January 2005, were required before this goal was achieved. Because the study
remained open for all three groups until each group had achieved the minimum
response rate, the pooled response rate for the entire sample was ultimately
34% because 119 of the 350 survey recipients responded. Each mailing was
identical to the previous mailing in terms of both content and recipients. The
only difference among mailings was that additional mailings occurred only if
no response had been received from a given participant.
Exemption from requiring consent from each participant was granted by the human subjects investigation committee. Survey recipients were given the opportunity to indicate whether they would be interested in receiving an abstract once the study was completed. In addition, participants were advised of their anonymity in a cover letter. To keep track of responses in order to remove respondents from future mailings, return mailing envelopes were coded. The code was used only for removing respondents from mailings, and all survey recipients were advised of this. One author performed data entry and deletion of demographic information.
Data Analytic Procedure and Statistics
Survey data were entered into an SPSS for Windows (version 12.0, SPSS)
database. The data were screened for missing values, outliers, and normality
using SPSS procedure Frequencies. Most of the variables were found to be
normally distributed, with minimal skewness and kurtosis. The number of
missing values for each variable was minimal (< 0.10 for each variable),
and no data imputations were required.
Data analysis consisted of five phases. Phase 1 examined the characteristics of the entire sample of physicians across all three settings. Descriptive statistics were produced using the SPSS Frequencies procedure. This provided the means and SDs for continuous demographic variables such as physician age, year medical degree was received, and time spent outside the United States. Frequencies and percentages were obtained for categoric variables such as physician sex, medical specialty, and portion of training received outside the United States.
Phase 2 compared physician preference for local United States-based versus international radiologic services for the entire pooled sample. Three statistical procedures were used in this analysis. First, means and SDs were obtained for each scenario using the SPSS procedure, Frequencies. Second, the SPSS procedure Paired-Samples Student's t Tests, was used to determine the overall significance of differences among the Likert-scale scenarios. Last, the SPSS procedure General Linear Model/Univariate was used to evaluate the significance of differences between the members of each pair of means.
Before analysis, the magnitude of the mean differences among all the scenarios was evaluated to limit the number of tests performed. The criterion for inclusion in the set of comparisons was based on a mean difference of 0.67 or more between a pair of means. The judgment was made that differences of this magnitude would be most likely to produce statistically meaningful results. This criterion was established to decrease the probability of spurious results (type 1 errors) and, with a Bonferroni correction applied to each test, to control for the overall type 1 error rate for the set of tests (familywise error rate). This procedure is best done when the total number of variables tested (i.e., the scenarios) is six or fewer [8]. The number of tests for this analysis was thus set at five; more specific information regarding the procedures is found in the relevant portion of the Results section.
Phase 3 examined the relationship between one demographic variable for the entire pooled sample—physician age—and preference for local, United States-based versus international radiology services. An analysis of variance procedure was performed along with post hoc means comparison tests with a Bonferroni correction to determine whether physician age was associated with a preference for either local or international radiology services.
The goal of phase 4 was to determine whether significant differences existed among physicians in each of the respective subgroup settings (academic, private practice, community hospital) based on demographic variables such as sex, age, number of years practicing (based on year medical degree received), number of years outside the United States, and portion of training received outside the United States. We wanted to know the extent to which physicians in each of the three settings were comparable to one another with respect to these characteristics, or whether they differed. Two types of analyses were used. Because physician sex and subgroup settings were nominal, or categoric, variables, their association was assessed using the SPSS procedure Cross Tabs to obtain a chi-square statistic, or measure of association. The relationship between subgroup setting and each of the remaining continuous variables (i.e., number of years practicing) was examined using the SPSS analysis of variance procedure, with Bonferroni-adjusted post hoc means comparisons.
Phase 5, the final phase, examined the relationship between physician subgroup setting (academic, private practice, community hospital) and preference for local, United States-based versus international radiology services. An analysis of variance was performed with Bonferroni-adjusted post hoc means comparisons to determine whether physician setting influenced preferences for local or international radiology services.
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Twenty-two respondents (18% of the sample of 119) spent an average of 20 years outside the United States. Approximately 10% of the sample (n = 9) completed a portion of their training outside the United States. This was coded so that 0 represented no training outside the United States and 1 represented some portion of training done outside the United States.
Responding physicians were drawn from 19 medical specialties or subspecialties, with internal medicine representing the largest number of physicians, followed by obstetricians-gynecologists and urologists. Descriptive statistics showing frequencies and percentages of physician specialty are shown in Table 1.
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Phase 2: Pooled Analysis—Physician Preference for United States-Based Versus International Radiology Services for the Entire Sample
Descriptive statistics—Means and SDs for the five scenarios
are presented in Table 2. With
equivalent services offered by both firms (scenario 1), none of the physicians
preferred international radiology to local. When international radiology
offered quicker turnaround time for reports (scenario 2), the mean score
declined, indicating a higher preference for international compared with
scenario 1. Forty-five physicians, or 37.8% of the total sample of 119, showed
a preference for international radiology over local when offered reports in 1
day compared with 3 days. Nevertheless, the mean score of 0.44 still showed an
overall preference for local.
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With both faster report time and lower patient costs (scenario 4), more than half (55.5%) the physicians (n = 66) of the total sample of 119 preferred international radiology, and the mean score tipped in favor of international. Scenario 4 was the only situation in which the overall preference was for international services. With scenario 5, however, the preference for international disappeared, with only 6% (n = 7) preferring international, given the differences in training and certification between the two types of services.
Inferential statistics—To identify possible significant differences among the five scenario means, a set of paired-samples Student's t tests with Bonferroni adjustment was conducted on those pairs of means for which a difference of at least 0.67 was identified. Figure 1 graphically depicts the means for all five scenarios so that the differences among them are evident. A set of five pairs of means was chosen on this basis for statistical analysis. The rationale for this approach was explained previously in the Data Analytic Procedure and Statistics section. The set of comparisons was as follows: pair 1, scenarios 1 and 2: mean difference, 1.035; pair 2, scenarios 1 and 4: mean difference; 1.730, pair 3, scenarios 2 and 4: mean difference, 0.696; pair 4, scenarios 4 and 5: mean difference, -1.791; and pair 5: scenarios 2 and 5, mean difference, 1.096.
To maintain a familywise error rate of 0.05 across all comparisons, a
Bonferroni correction was calculated (
= 0.05/5 = 0.01). This
represents a more stringent alpha level and meets the criterion for the
Bonferroni inequality that the overall alpha level for the set of analyses is
less than or equal to the sum of the alphas for each test. The first two
columns of Table 3 show the
results of the paired samples Student's t tests.
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Values of t'crit are critical values of Student's t test distribution adjusted to evaluate t'obt (the generic notation for the value of the Student's t statistic obtained in paired samples t tests) using Bonferroni's adjustment for multiple comparisons. The tabbed, computed values of the Student's t test distrubution are t'crit [9], which demarcate the significance level or rejection level of a given null hypothesis based on the value of t'obt. The value of t'obt is compared with that of t'crit, and if t'obt exceeds the tabled value of t'crit it is concluded that there is a statistically significant difference between the means of the populations from which the samples were drawn.
Following up this analysis of the overall significance of the mean differences for each pair, SPSS procedure GLM/Univariate was used to obtain pairwise comparisons based on the estimated marginal means. These comparisons assessed the significance of the magnitude of the difference between each member of a tested pair. Results of these tests, with Bonferroni adjustment for multiple comparisons, are displayed in the last column of Table 3. The comparisons indicate that the size of the difference between each member of a tested pair was significant at p < 0.001.
These results confirm that preference for international services increased significantly over local, United States-based services when report turnaround times were faster (1 day vs 3 days), and also when international services offered both lower out-of-pocket costs and faster report turnaround times. On the other hand, preferences for local, United States-based services increased significantly over preferences for international services when different levels of prevailed training and certification prevailed overseas. Despite quicker report turnaround times available with international services, physicians preferred local, United States-based services when training and certification levels overseas differed from those found in the United States.
Phase 3: Pooled Analysis—Relationship Between Physician Age and Preference for International Versus Local Radiology (Entire Sample)
Issues surrounding the physicians' age variable needed to be addressed
before this analysis could be done. Results of exploratory data analysis using
the SPSS procedure Explore identified 10 outliers that affected the normality
of the physicians' age variable. (Five of the physicians were age 32 years and
five were 78-80 years.) The Shapiro-Wilk normality statistic (which tests the
likelihood that the sample came from a normal population) was significant
(0.969, p = 0.008), signaling a poor fit of this distribution (i.e.,
that it may not have been drawn from a normal population). This situation is
sometimes handled by dropping outliers from the analysis. With a sample size
of 116 (three respondents did not provide their age) for this variable,
however, dropping 10 respondents would have meant losing about 8% of the
sample and would not have been the optimal solution to this problem.
We base this argument on our need to ensure that the preferences of physicians of all ages are included in the analysis. By deleting the outliers, the scope of the analysis would have been narrowed to such a degree that we might not have been able to generate a complete picture of physician preferences across all stages of their practice lifetime. Furthermore, we wanted to account for any possible cohort or age effects to which physicians, in their training, practice, and lifetime experience, may have been subject. These effects include changes in the economic, insurance, and social climates that may result in differences in beliefs and attitudes in physicians at different age levels but which often take years to become visible.
Using a continuous variable to represent age may not allow us to detect major shifts in attitudes and preferences with a relatively small unit of measurement (i.e., a year), whereas a grouped categoric variable may be more useful in allowing these differences to emerge. Therefore, physician age was categorized into the following three-group variable: (32-44 years, n = 41), (45-56 years, n = 39), and (57 years and older, n = 38). Structuring this categoric variable into three groups of approximately equal size helps to ensure against any violation of assumptions of equal variance in analysis of variance.
An analysis of variance procedure was performed, along with post hoc means comparison tests using a Bonferroni correction, to determine whether physician age influenced preferences for international versus local radiology. Results of this analysis showed a significant difference among the three age groups when a quicker turnaround time for reports was available from international services (scenario 2): Fobt = 3.96, Fcrit.05 = 3.07; df = 2, 115; p = 0.02. Fcrit are the tabled, computed values of the F distribution [9], which demarcate the significance level or rejection level of a given null hypothesis based on the value of Fobt (the value of F obtained in the analysis of variance.) The value of Fobt is compared with that of Fcrit, and if Fobt exceeds the tabled value of F crit it is concluded that there is a statistically significant difference between the means of the populations from which the samples were drawn.
The Bonferroni-corrected means comparison tests revealed that, with quicker turnaround time for reports, physicians 45-56 years old showed no preference (mean score [M] = -.0513) in contrast to physicians in the other two age groups: 32-44 years (M = 0.7805) and 57 years and older, (M = 0.5789), who showed a moderate preference for local. Physicians 45-56 years old scored 0.83 lower, however, than their younger counterparts, indicating a higher preference for international radiologists. We were unable to identify any statistically significant differences in preferences among the physicians in the three age groups with respect to the remaining four scenarios.
Phase 4: Subgroup Analysis—Comparing Physicians in Each Setting on the Basis of Demographic Variables
Of the 113 physicians in the academic sample, 36.3% (n = 41)
responded; of the 125 physicians in the private practice sample, 30.4%
(n = 38) responded; and of the 112 physicians in the community
hospital sample, 35.7% (n = 40) responded. Data were available for
analysis for a total of 119 physicians.
Cross-tabulations analyses (SPSS procedure Cross Tabs) were performed to examine the similarities and differences, if any, among the physicians in the three practice settings on the basis of sex and the categoric age variable. An analysis of variance was used to examine the relationship between physicians in the three practice settings and each of the following three variables: years practicing (since year MD degree was received), number of years spent outside the United States, and portion of training received outside the United States.
We were unable to identify any statistically significant differences among the physicians in each of the three settings based on any of the demographic variables. For example, the proportions of men and women physicians were about 75% versus about 25%, respectively, across all three subgroups. Of 91 male physicians, 30 were in each of the private and community samples and 31 in the academic sample. Of 28 female physicians, 10 were in the academic and community samples and eight in the private practice sample. The percentages are as follows: academic sample: 75.6% men, 24.4% women; community sample: 75.0% men, 25.0% women; and private practice sample: 78.9% men, 21.1% women. Furthermore, the percentages of physicians who lived outside the United States or received a portion of their training outside the United States did not differ significantly across each setting.
Phase 5: Subgroup Analysis—Relationship Between Physician Setting and Preference for International Versus Local Radiology
An analysis of variance procedure was performed, along with post hoc means
comparison tests (Bonferroni-adjusted), to determine whether physician setting
(academic, community hospital, or private practice) influenced preferences for
international versus local radiology. Results of this analysis showed a
significant difference among physicians in the three settings when services
were comparable (scenario 1): (Fobt = 4.26,
Fcrit.05 = 3.08; df = 2, 116; p <
0.05) and when a quicker turnaround time for reports was available (scenario
2): (Fobt = 3.18, Fcrit.05 = 3.08;
df = 2, 116; p < 0.05).
The post hoc means comparison tests revealed that, with both services comparable, academic physicians preferred local (M = 1.19) less than did community hospital physicians (M = 1.60) and private practice physicians (M = 1.63). Academic physicians scored 0.41 lower than the community hospital physicians on this measure (with mean difference significant at p = 0.05, with Bonferroni adjustment for multiple comparisons), and they scored 0.44 lower than private practice physicians. With quicker report turnaround time, academic physicians also preferred local (M = 0.0244) significantly less than did community hospital physicians (M = 0.7750); they scored more than 0.75 below the community hospital group. We were unable to identify any statistically significant differences in preferences among the physicians in the three settings with respect to the remaining three scenarios.
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Some points should be made regarding the demographics of the participants themselves. First, it is surprising that, in the absence of some selection bias, we should have obtained such nicely balanced demographic sets. The only way to account for this would be to take into account some predetermined bias inherent in our lists because we received them from the medical centers. In addition, it seems surprising that all of the physicians in the survey had been in practice for a minimum of 6 years. Two factors are probably at play here: a bias inherent in the lists that we received, and a 2-year delay between selection and survey. Perhaps these institutions or their respective geographic locales tend to have more experienced clinician populations.
Another limitation of this study is the lack of geographic diversity of the sample. Although there were three subgroups based on physician practice setting, nearly all of the physicians surveyed came from the same Northeastern geographic location, all within approximately a 50-mile (80-km) radius. Therefore, caution should be used in extrapolating from these data to the entire U. S. physician population. Replicating this study with a more geographically diverse sample would be instructive.
Finally, although the ideal scenario of the survey promised full access to interpreting teleradiologists, it may not be realistic to assume that this could always be ensured. Perhaps one could speak with a radiologist, but it is not certain that person would be the one who interpreted the report. In this sense, the survey device may have been inexact in replicating the realities of practice conditions.
Physician Preference for United States-Based Versus International Radiology Services for the Entire Sample
Our results show an overall preference for local radiologists, which is
mitigated by factors such as turnaround time and lower cost that make
international services more competitive. In addition, in the face of faster
turnaround time for reports and lower cost to the patient, referring
physicians overall greatly prefer local radiology providers when the
credentials of the outsourcing providers are perceived to be less than those
of the local radiologists. Although it is not certain, it is possible that the
non-American-trained, non-American-certified radiologists might be inferior to
their American-trained and -certified counterparts in interpreting radiologic
images. In addition, geographic distance prevents an adequate auditing of the
supervision being provided by the American-trained supervising radiologist.
Referring physicians might be concerned that the American-trained supervising
radiologist either is not doing his or her job or is simply not capable of
keeping up with the sheer volume of films interpreted by his or her
employees.
Relationship Between Age in the Entire Sample and Preference for International Versus Local Radiology
Our results showed that, given equivalent levels of training but
nonequivalent services in the form of international radiology offering a 2-day
faster turnaround time, physicians 45-56 years old preferred international
significantly more than physicians in either of the other two age groups, both
the youngest and the oldest. This suggests that there is not a direct
relationship between youth and willingness to use this technology, which might
have been otherwise expected. Rather, it seems that the relationship between
age and willingness to refer to international services is multifactorial.
Perhaps physicians in the middle age group possess a certain comfort with
technology that their older counterparts lack, together with a real-world,
practical perspective based in extensive experience that their younger
counterparts lack, allowing them to give greater weight to turnaround time.
The combination of these two factors may contribute to the middle age group's
greater willingness to outsource than either of the other two groups.
Relationship Between Physician Setting (Academic, Private Practice, Community Hospital) and Preference for International Versus Local Radiology
With both services and certification equivalent for local and international
radiology, academic physicians preferred international over local compared
with community hospital physicians, and they also preferred international to
local compared with private practice physicians. It is tempting to conclude
that this might be due to a difference in personality between academic
physicians and their nonacademic counterparts. Perhaps academics are more
curious and adventurous by temperament and thus show a greater willingness to
experiment with the current standard. Perhaps university-based physicians are
more amenable to teleradiology because their on-site university location
allows them convenient opportunities to discuss questions with on-site
radiologist colleagues. However, the difference observed here is more likely
the result of previous experience with, or even participation in,
teleradiology at this institution
[6-8].
Further studies at different institutions might confirm this.
In conclusion, this study concentrated on nonemergent, formal interpretations of images by teleradiologists and not on the more common nighthawk scenario, in which preliminary interpretations of urgent images are provided by teleradiologists overnight and followed by a formal interpretation by local radiologists in the morning. The nighthawk scenario is already standard practice for many hospitals around the United States. The current study explores referring physician attitudes to the larger, longer-term question of outsourcing of even nonemergent image interpretation. To the extent that referring physicians represent the gateway to our practices, it is important to interpret their preferences and to guide practice strategy accordingly. If one provides timely high-quality interpretation, the risk of having one's work outsourced by fiat is low.
APPENDIX 1: Survey of Physicians re International Interpretation of Teleradiology Images
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Please complete the following scenarios
in order and then the important demographic information found below.
Scenario #1:
Both Local and International provide their services at a cost of $50
out-of-pocket to your patient, and both will have a final report in your hand
within 3 days. Furthermore, anytime you wish to contact a radiologist to speak
about a report, both firms will have one available.
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Scenario #2:
Both Local and International provide their services at a cost of $50
out-of-pocket to your patient. Furthermore, anytime you wish to contact a
radiologist to speak about a report, both firms will have one available.
Local will have a final report in your hand within 3 days. International will have a final report in your hand within 1 day.
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Scenario #3:
Local provides its services at a cost of $50 out-of-pocket to your patient.
International costs $20 out-of-pocket.
Both provide full access to radiologists for consultation, and both will have a finalized report to you in 3 days.
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Scenario #4:
Local provides its services at a cost of $50 out-of-pocket to your patient
and will have a finalized report to you in 3 days.
International provides its services at a cost of $20 out-of-pocket and will have a finalized report to you in 1 day.
Both provide full access to radiologists for consultation.
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Scenario #5:
The radiologists at Local are American-trained, board-certified, and are
licensed to practice in your state. They are credentialed to practice in your
hospital.
The radiologists at International are trained in their home country and are not American-trained or board-certified. Their work is supervised by an American-trained, board-certified radiologist who is licensed to practice in your state and credentialed to practice in your hospital. This supervising radiologist completes the same level and amount of continuing medical education as the radiologists at Local.
Local provides its services at a cost of $50 out-of-pocket to your patient and will have a finalized report to you in 3 days.
International provides its services at a cost of $20 out-of-pocket and will have a finalized report to you in 1 day.
Both provide full access to radiologists for consultation.
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Demographics:
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TopAbstractIntroductionMaterials and MethodsResultsDiscussionAPPENDIX 1: Survey of...References |
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