Feature: U.S. needs national strategy to curb imaging overutilization

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Medical imaging overutilization--a growing concern in the U.S.--exposes patients to unnecessary radiation, while also adding to rising healthcare costs, according to a study published online Aug. 24 in Radiology. In an interview, William R. Hendee, PhD, lead author, reviewed various methods by which medical imaging could be curtailed.

Between 1980 and 2006, the annual U.S. population radiation dose from medical procedures increased seven-fold, noted Hendee, professor of radiology, radiation oncology, biophysics and bioethics at the Medical College of Wisconsin in Milwaukee, and his colleagues.

Increasing imaging utilization parallels rising healthcare costs. “Current healthcare costs equal about 16 percent of the gross domestic product (GDP) of the country. If this growth rate is left unchecked, healthcare costs will equal 20 percent of the GDP by 2015 and, according to the Congressional Budget Office, 47 percent of the GDP by 2082,” the authors explained.

Hendee addressed findings reached by the American Board of Radiology Foundation (ABRF) two-day summit held last year, in which individuals representing healthcare accreditation entities, foundations, government agencies, hospital and health systems, insurers, medical societies and healthcare quality consortia discussed the causes and effects of imaging overutilization.

Past publications have suggested that as many as 20 to 50 percent of advanced imaging procedures may represent unnecessary imaging, but Hendee posed that it is very difficult to identify the extent to which overutilization occurs. Many studies do not take into account the value of negative imaging studies in influencing decisions about patient treatment and management, he said.

“Often times a study is negative and doesn’t show particular pathology but it clarifies the diagnosis. A rule-out type of study is an important study to conduct, even if there’s no positive finding in the study,” Hendee said.  However, “we also have plenty of examples of situations were studies were done and they were not necessary,” he added. “We just don’t know magnitude.”

Causes and solutions
“Advances in medical technology are one of the primary drivers of the increase in healthcare costs,” promulgated the authors. Other factors--IT gaps, lack of communication and the profit motive--also contribute. It isn't uncommon for physicians to order duplicate studies because they are unaware of previous exams at other facilities. They also refer patients to an imaging center in which they have a financial interest and conduct in-office studies.

However, radiologists don't bear the full problem-solving burden."[Some factors contributing to overutilization] are outside our purview as a discipline to correct because they require changes in healthcare reimbursement or are more global,” Hendee said.

For example, overutilization caused by self-referral is not correctable by the efforts of the radiology community alone. “It must be addressed either by the physician community acting in concert to place appropriate restrictions on self-referral or by legislative action that addresses the abuses coincident with self-referral.”

“It’s a problem that presently, reimbursement functions on procedure basis,” said Hendee.  "Reimbursement should be on the basis of the course of care for the patient, and the financial incentive should be on the best quality of care or the best outcome, at the least cost to payor,” he offered.

Appropriateness criteria and practice guidelines should also come into play, stated Hendee. “We currently have guidelines for many situations, and they primarily focus on diagnosis, which is a limitation,” he said. “They should be based upon signs and symptoms ... so they would be a little more universal.”

In addition, Hendee noted the importance of having guidelines readily available for referring physicians on decision support systems. “When the physician makes an imaging study request, the decision support system can offer a friendly reminder that there might be an alternative, possibly less expensive, exam that is less traumatic to the patient and more effective,” he explained. 

Decision support systems have been well received by referring physicians in institutions that have implemented them, he noted. 

Another solution offered at the ABRF summit is for the radiologist to serve as the “gatekeeper” for imaging studies and approve study requests by referring physicians. But the gatekeeper model is an unrealistic solution in many cases, said the authors. Radiologists do not have the same background knowledge of the patient as the referring physician, putting the radiologist in a compromising position, noted Hendee. In addition, should the radiologist refuse the exam, the referring physician could send the patient to another imaging center at the inconvenience of the patient and loss of business for the institution, he said.

While the authors called upon radiologists to spearhead the initiative to reduce imaging overutilization, “a national strategy should be developed to increase accountability in radiology and the other healthcare professions for the appropriate utilization of medical imaging and radiation,” they concluded.