The B Reader Program, Silicosis, and Physician Workload Management

Abstract

Artificial intelligence (AI) technologies hold considerable potential as healthcare tools. Their pattern recognition features, in conjunction with their speed and increasingly high-fidelity analysis, promise to redefine conventional diagnostic paradigms. These characteristics readily lend themselves to labor-intensive pulmonary imaging; a number of AI products have already received FDA clearance for this purpose and are currently marketed in the United States.1 These new technologies may find particular application filling an old regulatory compliance need – the B Reader Program. Administered by the Centers for Disease Control and Prevention's (CDC) National Institute for Occupational Safety and Health (NIOSH) for over half a century, the B Reader Program is tasked with monitoring pneumoconiosis among exposed industrial workers. However, it faces long-declining physician participation and a recently broadened mandate – two factors which may render compliance increasingly difficult. Moreover, a number of emerging reports have drawn attention to potential financial conflicts of interest (COI) which may bias independent B Readers toward overreporting positive findings, and employer-retained physicians toward underreporting them.2 Emerging AI technologies can offer a solution to both COI and supply-demand mismatch. Leveraging their innate machine learning capabilities to reduce physician workload, efficiently process large volumes of imaging data, and lower rates of human error, AI-enabled radiology tools may breathe new life into an ailing program. FROM PATHOLOGY TO POLICY Pneumoconiosis comprises a series of interstitial lung diseases which ultimately result in lung parenchymal fibrosis, often after protracted occupational or environmental exposure.3 At the cellular level, it is brought on by the chronic inhalation of airborne particulates, prompting alveolar macrophages to engulf foreign material and induce fibrosis.4 The resultant changes to lung architecture are progressive, irreversible, and dose-dependent. Over time, pneumoconiosis may produce a slew of downstream pathologies, including lung cancer, increased susceptibility to tuberculosis, and collagen vascular disease.5–8 Pneumoconiosis is generally classified according to the type of particulate matter implicated; chief among them are silicosis, asbestosis, and coal workers’ pneumoconiosis (CWP), also known as “black lung disease.”9 To mitigate the untoward effects of CWP, Congress passed the Federal Coal Mine Health and Safety Act in 1969, which among other actions directed the Department of Health and Human Services (then the Department of Health, Education, and Welfare) to establish a routine screening radiography program for coal workers.10 The Coal Workers’ Health Surveillance Program, administered by NIOSH, was developed to this end. The NIOSH B Reader system finds its origins in this program, which aimed to identify, certify, and engage qualified physicians in a national CWP screening endeavor.11 As its name implies, “B” Readers were initially called upon to confirm suspected features of pneumoconiosis in a second-opinion capacity.12 The program today dispenses with the preceding “A” Readers and instead relies upon a cadre of highly trained B Readers to independently establish findings of CWP.13 Since 1976, the program has sought to minimize interobserver variability through a rigorous certification process, evaluating candidates on the basis of their ability to categorize images according to the International Labour Organization (ILO) International Classification of Radiographs of Pneumoconioses.14 WINDS OF CHANGE In 2018, OSHA (the Occupational Safety and Health Administration) issued new regulations aimed at protecting individuals at risk of silicosis, specifying that employers have a “duty to exercise reasonable care to prevent and detect violations of the silica standard.”15 Just as NIOSH does with CWP, OSHA requires that at-risk individuals receive triennial