Imaging Idolatry - Department of Radiology

Imaging Idolatry - Department of Radiology

EDITORIAL
Imaging Idolatry
The Uneasy Intersection of Patient Satisfaction,
Quality of Care, and Overuse
M
EDICAL IMAGING IS A GROWTH INDUS-
try. A 2008 report by the Government Accountability Office (GAO)
noted that in just 7 years, from 2000
through 2006, Medicare spending for
imaging more than doubled to approximately $14 billion. Most of the growth was in advanced imaging such
as computed tomography (CT) and magnetic resonance
(MR) imaging.1 In the particular case of lumbar spine
imaging, MR images covered by Medicare increased 307%
between 1994 and 2005.2 The GAO linked spending
growth, in part, to a shift of more advanced imaging from
hospitals into physician offices. It also noted wide geographic variability in the use of imaging, “suggesting that
not all utilization was necessary or appropriate.”1(p5)
See also page 972
Spine imaging has come under particular scrutiny because both evidence and expert opinion suggest it is overused.3-5 On the one hand, the yield of unexpected findings is low: a 10-year Swedish study estimated that among
adults younger than 50 years, 1 in 2500 plain lumbar spine
films uncovered something that was not expected on clinical grounds.6 On the other hand, the yield of irrelevant
findings is alarmingly high. Studying MR images in adults
younger than 60 years with no history of back pain or
sciatica, Boden and colleagues7 found that approximately half had bulging discs and degenerative discs and
nearly a quarter had herniated discs. In adults older than
60 years, all findings were even more common, and both
bulging and degenerative discs were almost ubiquitous.7 Similar studies by others have produced remarkably similar results.8,9 Plain radiographs and CT scans
among asymptomatic individuals have shown similar high
rates of anatomic abnormalities.10,11
PATIENT OUTCOMES
What about patient outcomes? Ultimately, the goal of
imaging is to uncover abnormalities that guide the choice
of specific therapies, improving patient outcomes. Spine
imaging is one of the few areas in diagnostic imaging for
which we have multiple randomized trials to test whether
this is true. Unfortunately, spine imaging in patients with
no indication of underlying systemic disease or major neurologic compromise appears not to improve patient outcomes. A new systematic review12 of these studies identified 6 randomized trials comparing some spine imaging
strategy to usual care without imaging. These trials in-
volved 1804 patients and failed to show any advantage
of imaging with regard to pain or function, in either the
short term or the long term.12
Going yet a step further, we might ask: Could there be
any harms associated with spine imaging? Unlike, for example, chest radiography, lumbar spine radiography or CT
scanning deliver radiation directly to the gonads, creating a small risk of carcinogenesis or mutagenesis. Beyond
this, however, there is evidence that simply knowing about
some abnormality in the spine may adversely affect patient behavior. Ash and colleagues13 studied 246 patients
with acute back pain or sciatica with MR imaging and randomized them to receive the imaging results or not. Both
groups improved over the subsequent year, with similar
clinical outcomes. However, self-rated general health improved significantly more in the group that remained blind
to the MR imaging results.13 In a British randomized trial,
421 patients with at least 6 weeks of back pain were randomized to receive plain radiography or not. Those who
received radiography reported more pain and lower overall health status at 3-month follow-up and were more likely
to have seen their physicians during follow-up.14
Finally, in a randomized trial comparing MR imaging
with plain radiography as a first imaging test, patients
in the 2 groups had equivalent health outcomes, but those
receiving MR imaging were more than twice as likely to
undergo surgery in the subsequent year.15 The notion that
imaging might drive surgery is reinforced by studies of
geographic variations, showing that spine surgery rates
are highest when spine imaging rates are the highest. This
correlation held even if the images specifically associated with surgery were factored out.16 Thus, it appears
that imaging, and findings of dubious clinical importance, have the potential to diminish patient selfperceptions of their health and drive potentially unnecessary visits and surgery.
Given the drawbacks of routine imaging, professional guidelines consistently recommend against imaging
patients in the absence of clinical “red flags” that suggest systemic disease or major neurologic deficits.17,18 Even
when age or other risk factors may increase the risk of
underlying systemic disease, strategies that make use of
plain radiography and inexpensive laboratory tests uncover most malignant conditions, infections, and inflammatory spondylopathies.19-21
PATIENT SATISFACTION
For many clinicians, the conundrum is this: despite the
strong evidence against routine spinal imaging, patients
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like it and sometimes demand it. Patients are often desperate for an explanation of their pain, and visual evidence is particularly compelling.22,23 In the British randomized controlled trial of plain radiography, those in
the radiography group were significantly more satisfied
with their care, despite having worse outcomes.14 In the
randomized controlled trial of MR imaging vs plain radiography, those in the MR imaging group felt significantly more reassured and were more satisfied with their
care, despite no advantage in outcomes.15 For physicians who want to be patient oriented, whose performance ratings depend on patient satisfaction, or who may
be anxious about medicolegal risks, the pressure to order imaging—despite evidence and guideline recommendations to the contrary—can be enormous. In a survey
of US physicians, 36% said they would order an MR image for a first episode of acute back pain (2 days) that
began during work around the house if the patient was
insistent, even after explaining that the test was unnecessary.24 Thus, patient expectations and convictions in
the value of high technology may subvert efforts at judicious and cost-effective use of imaging. Physician anxiety and similar attitudes toward technology may contribute to overuse. When disability claims are involved,
attorneys and patients are likely to insist on advanced
imaging regardless of clinical guidelines, and the likelihood of discovering an anatomic anomaly is high.
QUALITY IMPROVEMENT
In this context, the National Center for Quality Assurance (NCQA) has taken the bold step of proposing a quality performance criterion based on the overuse of spine
imaging.25 This is unique, as nearly all other quality performance criteria call for increased use of screening, testing, monitoring, use of vaccines, or treatments. Nonetheless, reducing wasteful expenditures is an important agenda
for quality improvement and, in addition to reducing costs,
holds the potential for improving quality of care. To the
extent that unnecessary imaging and the subsequent cascade of clinical events divert resources from more effective forms of care, they contribute to the frustrating performance and high cost of the entire health care system.
In this issue of the Archives, Pham and colleagues26
examined how well current practice conforms to the
NCQA recommendation on limiting the use of lumbar
spine imaging. Their study made use of Medicare claims
data to examine how quickly imaging is ordered in the
face of acute back pain and how often this included CT
or MR imaging rather than plain radiography. The authors excluded patients with diagnosis codes indicating
neurologic deficits, trauma, cancer, low impact injuries,
infections that might lead to osteomyelitis, nonspecific
anemias, or constitutional symptoms suggestive of increased infection or cancer risk (eg, fever, weight loss,
fatigue, injection drug abuse).
Despite these exclusions, 28.8% of patients received
some form of imaging within 4 weeks and a third within
6 months. Among the patients who underwent imaging,
11.8% received CT or MR imaging as the initial study.
Patients had more rapid imaging and more advanced
imaging if the primary care physician was exposed to pa-
tient satisfaction–based financial incentives or worked in
large group practices. In contrast, clinical quality-based
incentives were associated with less advanced imaging.
Other patterns, perhaps predictably, were the reverse of
those observed for quality criteria aimed at underuse. Deviations from the recommendations were more common for well-insured and white patients than for Medicaid recipients and patients of minority races.26
The authors argue correctly, in my view, that new quality metrics targeted at overuse “may complement current
underuse measures and suggest new areas of focus for quality improvement.”26 This seems especially important in an
era when medical costs are rising rapidly, and insurance
coverage is shrinking as a result. Indeed, excessive enthusiasm for imaging and other “high-tech” services may account in part for the poor US performance in comparison
with other developed countries in regard to both health
outcomes and health care costs.
PRACTICE IMPLICATIONS
What are the study’s implications for clinical practice?
First, it seems unwise to equate patient satisfaction with
better health outcomes, and satisfaction-based incentives may foster overuse. Second, it may be necessary to
redouble our efforts at patient education. There is at least
a shred of evidence that brief patient education can help
to maintain patient satisfaction when imaging is not recommended.27 Avoiding imaging may itself be part of this
education: when radiography was performed for lowrisk patients with back pain, expectations for imaging increased.27 In essence, performing imaging may teach patients that it should be expected. Finally, if quality of care
is defined in part by avoiding overuse, we have a challenging task that may require more innovative strategies. That task is to convince our patients that more is
not always better.
Richard A. Deyo, MD, MPH
Correspondence: Dr Deyo, Department of Family Medicine and Department of Medicine, Oregon Health and Science University, Mail Code FM, 3181 SW Sam Jackson
Park Rd, Portland, OR 97239 ([email protected]).
Financial Disclosure: None reported.
Funding/Support: Research for this editorial was supported in part by grant 1 UL 1 RR024140-01 from the
National Institutes of Health (National Center for Research Resources), a Clinical and Translational Science
Award, and by grant 1 ROI AR054912-01A2 from the
National Institutes of Arthritis and Musculoskeletal and
Skin Diseases.
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©2009 American Medical Association. All rights reserved.