Original Research
Policy, Quality, and Practice Management
August 24, 2022

Utilization of Chest and Abdominopelvic CT for Traumatic Injury From 2011 to 2018: Evaluation Using a National Commercial Database

Abstract

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BACKGROUND. Increases in the use of CT to evaluate patients presenting with trauma have raised concern about inappropriate imaging. The evolving utilization of CT for trauma evaluation may be impacted by injury severity.
OBJECTIVE. The purpose of this study was to explore patterns in utilization of chest and abdominopelvic CT among trauma-related emergency department (ED) visits across the United States.
METHODS. This retrospective study was conducted with national commercial claims information extracted from the MarketScan Commercial Database. Trauma-related ED encounters were identified from the 2011–2018 MarketScan database files and classified by injury severity score (minor, intermediate, and major injuries) on the basis of International Classification of Diseases codes. ED encounters were also assessed for chest CT, abdominopelvic CT, and single-encounter chest and abdominopelvic CT examinations. Utilization per 1000 trauma-related ED encounters was determined. Multivariable Poisson regression models were used to determine incidence rate ratios (IRRs) as a measure of temporal changes in utilization.
RESULTS. From 2011 to 2018, 8,369,092 trauma-related ED encounters were identified (5,685,295 for minor, 2,624,944 for intermediate, and 58,853 for major injuries). Utilization of chest CT per 1000 trauma-related ED encounters increased from 4.9 to 13.5 examinations (adjusted IRR, 1.15 per year; minor injuries, from 2.2 to 7.7 [adjusted IRR, 1.17]; intermediate injuries, from 8.5 to 21.5 [adjusted IRR, 1.16]; major injuries, from 117.8 to 200.1 [adjusted IRR, 1.08]). Utilization of abdominopelvic CT per 1000 trauma-related ED encounters increased from 7.5 to 16.4 (adjusted IRR, 1.12; minor injuries, 4.8 to 12.2 [adjusted IRR, 1.13]; intermediate injuries, 10.6 to 21.7 [adjusted IRR, 1.13]; major injuries, 134.8 to 192.6 [adjusted IRR, 1.07]). Utilization of single-encounter chest and abdominopelvic CT per 1000 trauma-related ED encounters increased from 3.4 to 8.9 [adjusted IRR, 1.16; minor injuries, 1.1 to 4.6 [adjusted IRR, 1.18]; intermediate injuries, 6.4 to 16.4 [adjusted IRR, 1.16]; major injuries, 99.6 to 179.9 [adjusted IRR, 1.08]).
CONCLUSION. National utilization of chest and abdominopelvic CT for trauma-related ED encounters increased among commercially insured patients from 2011 to 2018, particularly for single-encounter chest and abdominopelvic CT examinations and for minor injuries.
CLINICAL IMPACT. Given concerns about increased cost and detection of incidental findings, further investigation is warranted to explore the potential benefit of single-encounter chest and abdominopelvic CT examinations of patients with minor injuries and to develop strategies for optimizing appropriateness of imaging orders.

HIGHLIGHTS

Key Finding
Among commercially insured patients, national utilization of single-encounter chest and abdominopelvic CT per 1000 trauma-related ED encounters increased from 3.4 examinations in 2011 to 8.9 in 2018 (adjusted IRR, 1.16 per year; minor injuries, 1.1 to 4.6 [1.18]; intermediate injuries, 6.4 to 16.4 [1.16]; major injuries, 99.6 to 179.9 [1.08]).
Importance
Given cost and incidental finding detection with CT, strategies are needed to optimize order appropriateness, particularly for single-encounter chest and abdominopelvic CT for minor injuries.
In the United States, a national increase in emergency department (ED) visits has been accompanied by an increase in imaging utilization in the ED [1]. For example, one study showed that ED CT utilization per 1000 Medicare fee-for-service enrollees increased 153% from 2006 to 2016, including a 56% increase in the volume of body CT examinations [1]. Another study showed an approximate threefold increase in utilization of CT or MRI for injury-related ED visits from 1998 to 2007, with CT having the larger increase [2]. The increase in utilization of CT in the ED has been attributed to a range of factors, including technologic advances, greater scanner availability, lack of insurance preauthorization requirements in the ED, and concerns about malpractice litigation [1, 3, 4].
The increase in utilization of CT in the ED has raised a range of concerns. The growing use of CT contributes to increases in health care costs, downstream resource utilization, and potential care delays [1, 3, 5]. One study showed that the increase in CT and MRI utilization during injury-related ED visits was not associated with equal increases in injury-related diagnoses or hospital admissions, suggesting that the utilization increase may in part represent inappropriate imaging [2]. Another study showed that 44.5% of patients who underwent total-body CT (defined as imaging from vertex to pubic symphysis) for trauma evaluation had incidental imaging findings, and 5.6% of patients needed additional diagnostic workup [6].
CT has a well-documented role in the triage and management of patients presenting to the ED with trauma [711]. CT of patients with suspected traumatic injury to the chest, abdomen, or pelvis can be performed to evaluate a single anatomic region of concern (e.g., only the chest or only the abdomen and pelvis) or may include broader coverage (e.g., the chest, abdomen, and pelvis or possibly the entire body). Such decisions may reflect professional guidelines and local practice standards. Bunn et al. [12] reported increased use of whole-body CT (defined as CT of the head, chest, and abdomen) among patients with blunt trauma after a motor vehicle collision presenting to level I and II trauma centers from 2007 to 2015. In that study, the highest increase in utilization of whole-body CT relative to selective CT (defined as CT of only one or two of the aforementioned regions) was observed among patients with a low injury severity score (ISS). Nonetheless, evolving patterns in utilization of CT of the chest, abdomen, and pelvis in patients presenting after trauma remain poorly understood. Insight into these patterns could inform efforts to address examination appropriateness and optimize resource utilization. The aim of this study was to explore patterns in utilization of chest and abdominopelvic CT among trauma-related ED visits across the United States.

Methods

Data Extraction

Because deidentified health care claims data were used, this retrospective HIPAA-compliant study was deemed exempt from further institutional review board review. Data were extracted from IBM MarketScan Commercial Claims and Encounters files. These files contain claims from more than 300 insurance carriers, covering 26–56 million individuals annually among approximately 150 million commercially insured annually in the United States.
The annual MarketScan files from 2011 to 2018 were used. For each year's file, ED encounters were identified by means of the Current Procedural Terminology (CPT) evaluation and management service codes for ED services (codes 99281–99285). For ED encounters through September 30, 2015, those related to trauma were identified on the basis of International Classification of Diseases (ICD), 9th revision (ICD-9), Clinical Modification codes and the Barrell Injury Diagnosis Matrix, which provides a listing of ICD-9 codes related to trauma [13]. For encounters after September 30, 2015, ICD, 10th revision (ICD-10), codes were first converted to ICD-9 codes by use of the General Equivalence Mapping crosswalk tables from the National Center for Health Statistics [14]. The Barrell Injury Diagnosis Matrix was then used to identify trauma-related ED encounters.
CT examinations performed during trauma-related ED encounters were identified by means of CPT codes for chest CT (71250, 71260, 71270, 71275) and abdominopelvic CT (74176, 74177, 74178, 74174). The codes 71275 and 74174 correspond to CTA examinations, which may be performed for trauma evaluation depending on local practice patterns. CPT codes for CT examinations performed the day before or the day after the index ED evaluation and the management code were attributed to the same ED encounter given the possibility for the ED encounter to span across days. For patients who had ED evaluation and management claims billed on consecutive days, CT examinations were attributed to the ED encounter occurring temporally closest to the CT examination. Examinations were categorized as chest CT if only including the chest; as abdominopelvic CT if only including the abdomen and pelvis; and as single-encounter chest and abdominopelvic CT if including the chest, abdomen, and pelvis. The number of covered individuals was recorded for each year's data file.

Injury Severity Classification

For patients presenting with trauma, the ISS represents the sum of the square of the highest Abbreviated Injury Scale (AIS) code (1–6 scale) for the patient's three most severely injured body regions. The ISS is used to classify patients into one of three injury groups: minor trauma (ISS ≤ 3), intermediate trauma (3 < ISS ≤ 15), and major trauma (ISS > 15). The threshold of 3 or lower for minor injury, by definition, can only by attained when the highest AIS of any body region is 1. The threshold of greater than 15 for major injury has been found predictive of increased mortality [15, 16].
The ISS was originally determined from trauma registries that were based on clinical records [17]. For the purposes of this study, however, ISS was calculated from claims data including ICD codes [18]. This approach to ISS determination was validated and used in earlier investigations [1922].
A secondary analysis was performed to assess whether the transition from ICD-9 to ICD-10 on October 1, 2015, resulted in discontinuities in the incidence of trauma-related ED encounters or in the distribution of injury severity. This analysis constituted a qualitative assessment of quarterly data. No quarter-to-quarter discontinuities were observed for trauma incidence. However, an abrupt change (≈ 1 percentage point) was observed in the distribution of ISS at the time of the transition from ICD-9 to ICD-10. Specifically, the proportion of trauma-related ED encounters classified as injuries of intermediate and major severity increased from means of 0.4% and 31.7% during the ICD-9 period to 1.7% and 32.0% during the ICD-10 period; concurrently, the proportion of trauma-related ED encounters classified as minor decreased from a mean of 67.9% to 66.3%. To minimize bias in the estimates of the annual growth rate of imaging utilization potentially resulting from this coding change, the regression estimates (see Statistical Analysis) were adjusted by inclusion of a variable indicating whether the ED encounter occurred before or after the coding transition.

Statistical Analysis

Utilization was determined with respect to 1000 trauma-related ED encounters. Utilization was determined separately for chest CT, abdominopelvic CT, and single-encounter chest and abdominopelvic CT. Total utilization of chest and abdominopelvic CT was calculated as utilization of chest CT, abdominopelvic CT, or single-encounter chest and abdominopelvic CT.
To evaluate changes in utilization, we estimated annual adjusted incidence rate ratios (IRRs) using multivariable Poisson regression models of quarterly state-level utilization rates from 2011 to 2018, controlling for fixed effects of year quarter (as a marker of seasonality) and state. The IRR reflects the mean annual change in utilization. An IRR of 1 reflects constant utilization, and IRRs greater than 1 and less than 1 indicate increased and decreased utilization, respectively. Because the IRRs were derived from ICD codes, an indicator was included for whether the encounter occurred before or after the transition from ICD-9 to ICD-10, to control for rate inflation due to potential misclassification of severity levels. To assess whether temporal utilization changes differed across injury severity groups, we used additional models that included an interaction term between year and injury severity. Because Poisson regression estimates can be difficult to interpret, the delta method was used to produce directly interpretable marginal effects (e.g., directions, magnitudes, and standard errors of interaction terms). Although the IRRs were estimated with all 8 years of available data, the utilization rates at the start and end of the study period were also used to summarize the data to indicate the approximate scale of the data. Mean age per year was calculated at the levels of beneficiaries, ED visits, and trauma-related ED visits to assess for a possible effect related to an overall increase in age of the studied population.
In an additional analysis, heat maps were generated to depict the state-level utilization rates of single-encounter chest and abdominopelvic CT in 2011 and 2018 and the percentage change between these years. The states with the lowest and highest utilization rates in each year were also reported. In addition, the number of states with increases and decreases in utilization from 2011 to 2018 were determined for single-encounter chest and abdominopelvic CT, chest CT, and abdominopelvic CT. These analyses were not performed for 10 states for which the data use agreement did not allow reporting of state-level results (Connecticut, Idaho, Indiana, Kentucky, Louisiana, Maine, Montana, New Hampshire, New Mexico, and South Carolina), although data from these states were included in the previously described national results.
The analysis was conducted with SAS (version 9.4, SAS Institute), Stata statistical software (release 16.1, StataCorp), and Excel 365 (Microsoft) software.

Results

Trauma-Related Emergency Department Encounters

A total of 36,825,015 ED encounters were identified nationally from 2011 to 2018. Across years, there was a mean of 172.5 ED encounters per 1000 covered individuals (low, 158.5 in 2013; high, 178.6 in 2016). A total of 8,369,092 (22.7%) of all identified ED encounters were for trauma. Across years, there was a mean of 38.3 trauma-related ED encounters per 1000 covered individuals (low, 34.5 in 2018; high, 41.9 in 2012). A total of 5,685,295 (67.9%) of the trauma-related ED encounters were for minor injuries, 2,624,944 (31.4%) for intermediate injuries, and 58,853 (0.7%) for major injuries. The mean ages in 2011 and 2018 were 33.9 and 34.3 years at the beneficiary level, 33.1 and 34.6 years at the ED encounter level, and 28.3 and 29.9 years at the trauma-related ED encounter level.

Utilization of Chest and Abdominopelvic CT

Total utilization—Nationally, total utilization of chest and abdominopelvic CT per 1000 trauma-related ED encounters increased from 9.0 examinations in 2011 to 20.0 in 2018 (adjusted IRR, 1.12 per year [95% CI, 1.11–1.13]; p < .001). In patients with minor injuries, total utilization increased from 5.8 to 15.3 per 1000 trauma-related ED encounters (adjusted IRR, 1.14 per year [95% CI, 1.12–1.15]; p < .001). In patients with intermediate injuries, total utilization increased from 12.7 to 26.7 per 1000 trauma ED encounters (adjusted IRR, 1.14 per year [95% CI, 1.17–1.16]; p < .001). In trauma patients with major injuries, total utilization increased from 151.7 to 214.1 per 1000 trauma-related ED encounters (adjusted IRR, 1.06 per year [95% CI, 1.04–1.08]; p < .001).
Single-encounter chest and abdominopelvic CT—Of total utilization of chest and abdominopelvic CT, the proportion of single-encounter chest and abdominopelvic CT examinations increased from 38.7% (5333/13,792) in 2011 to 48.6% (5358/11,035) in 2018. Across injury levels, utilization of single-encounter chest and abdominopelvic CT increased from 3.4 to 8.9 examinations per 1000 trauma-related ED encounters (adjusted IRR, 1.16 per year [95% CI, 1.15–1.17]; p < .001) (Fig. 1). In patients with minor injuries, utilization of single-encounter chest and abdominopelvic CT increased from 1.1 to 4.6 (adjusted IRR, 1.18 per year [95% CI, 1.16–1.12]; p < .001) (Fig. 2A). In patients with intermediate and major injuries, utilization of single-encounter chest and abdominopelvic CT increased from 6.4 to 16.4 (adjusted IRR, 1.16 per year [95% CI, 1.14–1.19]; p < .001) (Fig. 2B) and from 99.6 to 179.9 (adjusted IRR, 1.08 per year [95% CI, 1.06–1.11]; p < .001) (Fig. 2C). Figure 3 shows the increase in utilization of single-encounter chest and abdominopelvic CT from 2011 to 2018 stratified by injury severity.
Fig. 1 —Graph shows adjusted annual total utilization rates of chest CT, abdominopelvic CT, and single-encounter chest and abdominopelvic CT per 1000 trauma-related emergency department (ED) encounters. Circles represent point estimates; ends of vertical bars, 95% CIs.
Fig. 2A —Adjusted annual total utilization rates of chest CT, abdominopelvic CT, and single-encounter chest and abdominopelvic CT per 1000 trauma-related emergency department (ED) encounters, stratified by injury severity. Circles represent point estimates; vertical bars, 95% CIs.
A, Graph shows results for minor injuries.
Fig. 2B —Adjusted annual total utilization rates of chest CT, abdominopelvic CT, and single-encounter chest and abdominopelvic CT per 1000 trauma-related emergency department (ED) encounters, stratified by injury severity. Circles represent point estimates; vertical bars, 95% CIs.
B, Graph shows results for intermediate injuries.
Fig. 2C —Adjusted annual total utilization rates of chest CT, abdominopelvic CT, and single-encounter chest and abdominopelvic CT per 1000 trauma-related emergency department (ED) encounters, stratified by injury severity. Circles represent point estimates; vertical bars, 95% CIs.
C, Graph shows results for major injuries.
Fig. 3 —Graph shows adjusted annual utilization rates of single-encounter chest and abdominopelvic CT per 1000 trauma-related emergency department encounters stratified by injury severity.
Chest CT—From 2011 to 2018, utilization of chest CT per 1000 trauma-related ED encounters increased from 4.9 to 13.5 examinations (adjusted IRR, 1.15 per year [95% CI, 1.14–1.16]; p < .001) across all injury levels (Fig. 1). In patients with minor injuries, utilization of chest CT increased from 2.2 to 7.7 (adjusted IRR, 1.17 per year [95% CI, 1.15–1.19]; p < .001) (Fig. 2A). In patients with intermediate injuries, utilization of chest CT increased from 8.5 to 21.5 (adjusted IRR, 1.16 per year [95% CI, 1.14–1.18]; p < .001) (Fig. 2B), and in patients with major injuries, from 117.8 to 200.1 (adjusted IRR, 1.08 per year [95% CI, 1.06–1.10]; p < .001) (Fig. 2C).
Abdominopelvic CT—From 2011 to 2018, utilization of abdominopelvic CT per 1000 trauma-related ED encounters increased from 7.5 to 16.4 examinations (adjusted IRR, 1.12 per year [95% CI, 1.11–1.13]; p < .001) across all injury levels (Fig. 1). In patients with trauma-related minor injuries, utilization of abdominopelvic CT increased from 4.8 to 12.2 (adjusted IRR, 1.13 per year [95% CI, 1.11–1.15]; p < .001) (Fig. 2A). In patients with intermediate injuries, utilization of abdominopelvic CT increased from 10.6 to 21.7 (adjusted IRR, 1.13 per year [95% CI, 1.11–1.15]; p < .001) (Fig. 2B), and in patients with major injuries, from 134.8 to 192.6 (adjusted IRR, 1.07 per year [95% CI, 1.04–1.08]; p < .001) (Fig. 2C).

State-Level Findings

Across 40 states and the District of Columbia (excluding states restricted from reporting of state-level results), utilization of single-encounter chest and abdominopelvic CT per 1000 ED-related trauma encounters ranged from a low of zero examinations in five states to a high of 8.0 (Pennsylvania) in 2011 and from a low of 3.0 (North Dakota) to a high of 17.5 in 2018 (Wyoming) (Figs. 4A and 4B). Figure 4C shows the percentage change in single-encounter chest and abdominopelvic CT from 2011 to 2018 at the state level. From 2011 to 2018, utilization of single-encounter chest and abdominopelvic CT per 1000 trauma-related ED visits increased in 39 states and the District of Columbia and showed no change in one state (Hawaii) (Fig. 4C). During this period, utilization of chest CT increased in 39 states and the District of Columbia and decreased in one state (Nevada), and utilization of abdominopelvic CT increased in 39 states and the District of Columbia and did not change in one state (Hawaii).
Fig. 4A —Utilization of single-encounter chest and abdominopelvic CT. Data for certain states (gray) cannot be shared individually because of data use agreement.
A, Charts show state-level variation in utilization of single-encounter chest and abdominopelvic CT per 1000 trauma-related emergency department encounters in 2011 (A) and 2018 (B). Values are numbers of CT examinations.
Fig. 4B —Utilization of single-encounter chest and abdominopelvic CT. Data for certain states (gray) cannot be shared individually because of data use agreement.
B, Charts show state-level variation in utilization of single-encounter chest and abdominopelvic CT per 1000 trauma-related emergency department encounters in 2011 (A) and 2018 (B). Values are numbers of CT examinations.
Fig. 4C —Utilization of single-encounter chest and abdominopelvic CT. Data for certain states (gray) cannot be shared individually because of data use agreement.
C, Chart shows percentage change in utilization from 2011 to 2018.

Discussion

Using a national commercial insurance claims database, we observed an increase in total utilization of chest and abdominopelvic CT for trauma-related ED encounters from 2011 to 2018. The increase was more pronounced for single-encounter chest and abdominopelvic CT examinations than for chest CT or abdominopelvic CT examinations and was more pronounced for minor trauma than for intermediate or major trauma. Specifically, the IRR for the increase in single-encounter chest and abdominopelvic CT for minor injury was 1.18. In addition, utilization of single-encounter chest and abdominopelvic CT increased from 2011 to 2018 in all but two states.
For purposes of this study, utilization was computed in terms of trauma-related ED encounters rather than in terms of covered individuals. Thus, the increases in utilization are not affected by temporal changes in frequency of trauma-related ED encounters but are fully attributable to a greater likelihood of performance of CT during such encounters. The increase in CT utilization per encounter raises concern about the appropriateness of such imaging and adherence to practice guidelines. In addition, with the increase in use of CT, we anticipate associated increases in cost and detection of incidental findings. Strategies such as clinical decision support may be warranted to guide referring physicians in ordering of CT of the chest, abdomen, or pelvis for trauma evaluation, particularly for single-encounter chest and abdominal CT examinations for minor trauma.
Prior studies have also shown increased utilization of CT during injury-related ED visits [2, 12, 19] and greater increases in utilization for minor than for intermediate and major injuries for cervical spine CT [19] and whole-body CT [12]. In comparison with the study by Bunn et al. [12] that showed increased utilization of whole-body CT in the trauma setting, our study had a larger sample size, a wider range of clinical settings (only trauma centers in their analysis), and a wider range of injuries (only motor vehicle collisions in their analysis). Strait et al. [23] used the National Trauma Databank from 2014 to 2016 and found substantial utilization of CT for minor trauma in the pediatric setting. In their study, the utilization rate of head CT in children with minimal head injury was 46% and that of abdominal CT in children with minimal abdominal injury was 30%.
The greater increase in utilization for minor injuries may be particularly impactful given that 67.9% of all trauma-related ED encounters were for minor injuries. Although a range of reasons have been speculated for increased CT utilization in the ED [1, 3, 4], the reasons for the disproportionate increase in utilization for minor injuries are unclear. The greater growth for minor injuries may relate in part to the lower baseline utilization of CT for such injuries. We also speculate that referring clinicians' increasing discomfort with diagnostic uncertainty [24], which likely is greater in the context of minor injuries, may be a contributing factor. Whole-body CT has been found to have advantages in the care of patients with severe trauma, including reduced ED turnaround times [25, 26], which has led to increased utilization in such patients. This shift in practice patterns may have been applied more broadly than only in patients with severe injuries, contributing to the additional observation of increased utilization of single-encounter chest and abdominopelvic CT in patients with minor trauma. Further research is warranted to understand the potential benefit of performing CT of multiple body regions, if not of the whole body, for patients with minor trauma, including the impact on clinical decision making and patient outcomes.
Our study had limitations. First, we used national claims data of commercially insured individuals and thus excluded most individuals eligible for Medicare or Medicaid and entirely excluded uninsured populations. The findings may not generalize to such populations. Second, given the lack of direct medical record access, we could not evaluate the appropriateness of the CT examinations, the clinical CT reports, or the impact on downstream patient outcomes. In particular, appropriateness was not evaluated with respect to any existing guidelines. Third, findings were not stratified on the basis of specific injuries or types of injury. Fourth, imaging and injury severity have a complex interaction in that CT findings inform the calculation of ISS and may impact a patient's assigned category (i.e., upstaging from minor to intermediate or from intermediate to major injury severity). Finally, data from some states could not be reported given restrictions of the data use agreement.
In conclusion, national utilization of chest CT and abdominopelvic CT for trauma-related ED encounters increased from 2011 to 2018. The increase was most pronounced for single-encounter chest and abdominopelvic CT for minor trauma. Further investigation should explore the potential benefit of such imaging and strategies to optimize order appropriateness.

Footnote

Provenance and review: Not solicited; externally peer reviewed.

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Information & Authors

Information

Published In

American Journal of Roentgenology
Pages: 265 - 271
PubMed: 36000666

History

Submitted: May 11, 2022
Revision requested: June 2, 2022
Revision received: July 5, 2022
Accepted: August 15, 2022
Version of record online: August 24, 2022

Keywords

  1. abdominopelvic
  2. chest
  3. CT
  4. emergency department
  5. injury severity score
  6. minor injuries
  7. utilization

Authors

Affiliations

Ninad V. Salastekar, MBBS, MPH [email protected]
Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA 30322.
Richard Duszak, Jr., MD
Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA 30322.
Stefan Santavicca, MS
Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA 30322.
Michal Horný, PhD, MSc
Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA 30322.
Patricia Balthazar, MD
Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA 30322.
Akram Khaja, MD
Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA 30322.
Danny R. Hughes, PhD
Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA 30322.
School of Economics, Georgia Institute of Technology, Atlanta, GA.
Tarek N. Hanna, MD
Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA 30322.

Notes

Address correspondence to N. V. Salastekar ([email protected], [email protected], @NSalastekar).
Version of record: Dec 14, 2022
The authors declare that there are no disclosures relevant to the subject matter of this article.

Funding Information

Supported in part by the Harvey L. Neiman Health Policy Institute (R. Duszak, Jr., S. Santavicca, M. Horný, D. R. Hughes).

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