Imaging Study in JAMA Promising but Incomplete

June 25, 2012 — A study (Smith-Bindman et al) to be published in the upcoming Journal of the American Medical Association (JAMA) underscores that medical imaging use is down in the last several years, but includes information on current use of scans and their beneficial impact that may be incomplete, incorrect or easily misunderstood.

While opportunities remain to ensure appropriate ordering of scans, imaging use in Medicare is down since 2008. Medicare spending on scans is at the same level it was in 2003. Imaging is also the slowest growing of all physician services among privately insured Americans according to the Health Care Cost Institute. A multitude of studies show that medical imaging exams are directly linked to greater life expectancy, declines in mortality rates, and are generally safer and less expensive than the invasive procedures that they replace. Scans also reduce the number of invasive surgeries, unnecessary hospital admissions and length of hospital stays.

“Medical imaging use increased in the 1990s and early 2000s because doctors discovered that they could diagnose and treat illness and injury or rule out more serious conditions more safely, quickly and efficiently using scans than by exploratory surgeries or admitting patients to the hospital who did not need to be hospitalized,” said Paul Ellenbogen, M.D., FACR, chair of the American College of Radiology (ACR) Board of Chancellors. “National statistics from Medicare and private insurers demonstrate that imaging use has tightened in recent years as providers have become more educated about when and which scans should be ordered and radiation education efforts more widespread. Imaging scans have undoubtedly been proven to save lives, resources and time. That is the current state of imaging and where responsible efforts to address imaging policy should start.”

The government can help ensure appropriate imaging and lower the radiation dose that Americans receive from scans each year by instituting these quality and safety measures:

1. Requiring accreditation of all imaging facilities (including hospitals): ACR accreditation signifies that the equipment is surveyed regularly by a medical physicist to make sure that it is functioning properly and is taking optimal images without unnecessary radiation, that technologists are certified and that interpreting physicians have met stringent education and training standards. This avoids repeat imaging due to poor quality scans and associated radiation exposure.

2. Encouraging/incentivizing use of ACR Appropriateness Criteria-based decision support/exam order entry systems: These systems educate providers on which exam is best for a patient’s condition (or when no scan is warranted). This process is proven to improve quality and lower cost by ensuring appropriate imaging and that providers obtain needed information from the correct scan.

3. Encouraging/incentivizing participation in the ACR Dose Index Registry: Facilities contribute anonymized, HIPAA-compliant dose information on every scan and periodically compare their dose indices to national benchmarks. This ongoing and regular feedback enables facilities to adjust dose accordingly and gauge how their radiation reduction efforts are working over-time.

The JAMA article shows that imaging use increased in settings where there was no financial incentive to do imaging — demonstrating that imaging use is driven by a desire for better patient care. A Health Affairs study found that doctors consider scans the most valuable of medical innovations. The New England Journal of Medicine named medical imaging one of the top 10 medical advances of the last 1,000 years.

“Medicare and private insurer data show that imaging is not a primary driver of healthcare costs and use is streamlining with advancing protocols, guidelines and appropriateness criteria. Imaging is, however, a primary tool for saving and extending lives. Appropriate growth in imaging use is a good thing. We need to continue to educate providers to more appropriately use these lifesaving tools, not look backward and set arbitrary limits for care. Imaging is the future of medicine. We need to embrace, refine and promote these advances for the good of all of those needing care,” said Ellenbogen. 

The JAMA study cites that many patients in the health systems studied received higher doses of radiation. However, these were likely cancer patients or others with chronic conditions who required multiple scans to gauge progress of treatment and for which the immediate benefit of having the exams outweighed any long-term risk. The ACR advises that no imaging exam should be performed unless there is a clear medical benefit. The ACR supports the use of the optimal level of radiation needed in imaging exams to achieve necessary results.

Patients should keep a record of their X-ray history, and before getting a scan ask their physician:

• How will having this exam improve my care?
• Are there alternatives that do not use radiation which are equally as good?
• Will my child receive a “kid-size” radiation dose (if for pediatric exam)?
• Is this facility ACR-accredited?
• Is the physician reading/interpreting my scan board-certified?
• Is the doctor who will interpret my scan board-certified by the American Board of Radiology?

This approach is essential to ACR’s long history of efforts to ensure appropriate imaging and reduce Americans’ exposure to medical radiation, including:

1. Image Gently: ACR is a founding member of the Alliance for Radiation Safety in Pediatric Imaging along with the American Association of Physicists in Medicine (AAPM) and the American Society of Radiologic Technologists (ASRT). Image Gently educates providers on opportunities to lower radiation dose used in the imaging of children. The campaign, started in January 2008, now includes 70 medical organizations worldwide.

2. Image Wisely: ACR, along with the Radiological Society of North America (RSNA), AAPM and ASRT co-founded the initiative to educate physicians on opportunities to lower dose and ensure appropriate imaging. The initiative also provides patient education materials, including a patient medical imaging record card developed with the U.S. Food and Drug Administration (FDA).

3. Choosing Wisely: ACR identified a list of imaging exams whose necessity (and alternatives) should be discussed before ordering. The ACR partnered with Consumer Reports to distribute patient-friendly resources for consumers and physicians to engage in important conversations regarding these medical imaging exams. The ACR worked with the American Board of Internal Medicine Foundation and eight other organizations on the Choosing Wisely campaign.

“The benefit of a medically necessary scan always outweighs the small long-term risks. Imaging has undoubtedly saved and extended millions of lives in the last 20 years and serves a vital role in modern healthcare. It is only natural that these exams would be used. What we have to do is help ensure that each exam is appropriate. We have existing tools in place to do so. If the government will work with providers, we can improve quality and safety without interfering in the doctor-patient relationship and keep imaging care safe, effective and accessible to those who need it,” said Ellenbogen.

For more information: www.radiologyinfo.org