Eastern Radiological SocietySouthern Pines, North CarolinaApril 2013

Founder and Chief Scientific Officer, ACR Image Metrix (consultant) Imaging contract research organization owned by ACR▪ Consultant to numerous drug and device companies

Philips Healthcare Executive Team Advisory Board and Radiology Medical Advisory Network (consultant)

Author, The Sorcerer’s Apprentice: How Medical Imaging is Changing Health Care, Oxford University Press, 2010 (royalties)

The perception of overuse

Use and misuseThe impact of

uncritical useOpportunities for

change

They say golf is

like life, but don’t believe them. Golf is more complicated than that

- Gardner Dickinson

Modern cross-sectional imaging has made medicine: Safer More effective

Broad economic concerns about imaging Imaging represents about 12% of

health insurers’ outlays▪ 3-5% in 1995

2000-2005: Imaging growth 3x general medical inflation▪ 5x for high technology imaging

Money doesn’t

talk, it shouts -

Bob Dylan

Source: MedPACSource: MedPAC

70

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40

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02000 2001 2002 2003 2004 2005

ImagingTestsOther proceduresAll physician servicesMajor proceduresEvaluation & management

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The financial success has led to an anti-imaging bias Imaging has replaced others’

procedures Radiologists’ incomes have

risen faster then most others’ More money for imaging

means less for everyone else Too much of imaging is said

to be unnecessary

Whenever a friend succeeds, a little something in me dies- Gore Vidal

Prevalent attitude that growth in imaging is necessarily bad Reduced technical payments

mandated by 2005 DRA and 2010 PPACA

Attacks on professional payments

Increased imaging actually a combination of:

Appropriate growth Aberrant incentives Uncritical use

Where there is

mystery, it is generally suspected there must also be evil

- Lord Byron

Imaging should be growing Aging population▪ Burden of chronic illness▪ Imaging adept at diagnosis, staging, response to

treatment Technological improvement has enabled

new and valuable applications Less morbidity, shorter convalescence

Patients desire more care Moral hazard of health insurance Direct-to-consumer TV and print

advertisements Boomer interest in wellness and health Availability of (mis)information on the Web

Busy physicians misuse advanced imaging as a screening/triage tool Humor patients and retain their loyalty Diminishing time allotted per patient▪ Mandates for greater productivity▪ Faster to order a test than spend time:▪ Talking to patients▪ Considering the value of the test

Systemic pressures to perform imaging for financial gain

Principle agent moral hazard Fancy economic term for self-referral▪ Physician behavior changes with:▪ The need to cover their “nut”▪ The chance to enhance revenue

Stark in-office ancillary services exception (IOASE) enabled by canny industry innovations▪ Single purpose▪ Minification ▪ Simplification

Economically motivated imaging use meets patient desire for more and higher tech care Physician controls the

volume of referrals Patient is protected by

third party insurance from the cost of care

Large body of research confirms higher utilization

Defensive medical testing – referring physicians 2009 Massachusetts Medical Society survey:

28% of all CT referrals to reduce liability ▪ Tendency to overestimate small legal risks if

consequences to patient or physician are severe▪ Patients referred for imaging even when there is

low probability the test will benefit the patient▪ Very low or very high probability of disease▪ Poor test performance

Defensive medical testing - radiologists Radiologists also overestimate malpractice risk A “miss” much more likely to generate a suit

than an “overcall”▪ Adopt high sensitivity/low specificity approach to

interpretation▪ High false positive rate

Unnecessary follow-on tests and treatment▪ Recommend follow-on testing for▪ Low probability concerns

“Churning” or “auto-referral”

The less acceptable rationales for imaging focus on possible benefit, though not always for the patient

BUTAll imaging bears risks

For appropriate exams: benfit/risk is high for marginal or inappropriate imaging There is

low likelihood of patient benefit

Most physicians and patients concerned about radiation and contrast media reactions

BUT

The greatest risk of uncritical imaging is that something will be found

Three things can happen

when you pass a football,

and two of them are bad - Woody

Hayes

The test is negative and the patient truly has no disease

________________

What the patient is hoping forPatient feels less anxious about their

symptoms and may (for a short while) pursue healthful behaviors

Cost plus benefit

The patient has important disease but the test incorrectly indicates no problem exists

_________________

The patient and physician may be satisfied and fail to pursue further diagnostic efforts even if symptoms worsen Late and less effective treatment Cost, no (negative) benefit

The imaging interpretation is positive but the patient is actually normal

Patients receive f/u testing/treatment that does not improve health, adds cost, and may cause harm Anxiety Iatrogenic injury Radiation exposure

_______________

Cost, no benefit

Possibility #1 The patient has a serious condition,

which is treatable, and the outcome of treatment is a cure or other improvement in health ______________________

Why we test

Cost and benefit

Possibility #2: Pseudodisease Patient has the condition for which she is being

tested but will not be affected by the disease in her lifetime Slow growing Patient dies of something else Disease is resistant to treatment

Same outcome regardless of imaging finding__________________

Cost, no benefit

Possibility #3: Incidentaloma Finding unrelated to the symptoms leading to

testing Small fraction with a risk to future health and where

intervention improves outcome Much larger fraction receives a workup and/or

treatment for benign conditions

____________________________

Cost, small percent of patients benefit

Uncritical use due

to multiple synergistic influences derived from a single root cause.

The quixotic pursuit of unattainable clinical certainty

All physicians educated and most trained in academic medical centers High probability of disease High severity of illness

index High intensity of care

The only time my prayers are never answered is when I’m playing golf

- Billy Graham

Academic faculty distracted by multiple missions Clinical service Education and training Scholarly work Service and administration

Success in academics requires adaptive strategies How to handle time-consuming clinical work while

managing the responsibilities that advance a career? OR How to be two places at once?!

“Supervise” students

and house staff Conduct morning

rounds Make assignments Entrust house staff to

make management decisions at off-hours

Housestaff: Have variable but usually lesser expertise Also are torn among diverse responsibilities

▪ Clinical care▪ Read and study▪ Research and administration

Are under pressure to open beds▪ Crowded ERs▪ Maximize institutional profit from DRGs and capitation

Learn early-on that calling the attending is a weakness▪ Discouraged by fellow trainees

Housestaff adopt a shotgun approach to imaging exams that fails to consider Performance characteristics of the test Likelihood of disease Consequences to patients

Objectives are to minimize: Attending exertions “Wasted” time that could be used for more

concrete responsibilities The possibility of humiliation

An example made of one individual is a lesson taught to all

Even in high frequency, high acuity environments, these practices are wasteful and potentially harmful

BUT

Physicians take high intensity practice style learned in academic health centers to lower intensity settings in which the problems are magnified

Learned practice style persists and is even encouraged by other physicians in the practice▪ Saves time in patient encounters and improves throughput▪ Perceived as a safeguard against malpractice liability▪ May generate revenue for self-referral practices or for

horizontally integrated health systemEven when there is either near certainty or

near impossibility of a condition:▪ Referring physicians tend to request an exam▪ Radiologists err on the side of overcalls

Imaging begets more imaging

Correct lawyers’ incentives Current incentives encourage frivolous suits and

disenfranchise some with legitimate claims Alternatives▪ Malpractice suit fee schedule▪ Loser pays▪ Cap amount earned by contingency fees ___________________

Opposed by a powerful lobby

Terminate the in-office ancillary services exception allowing high-tech imaging in offices Never intended to sanction high-tech imaging The money is too big to be ignored Wasteful of public and personal resources Harmful to patients’ health _____________________

Opposed by large and powerful coalition

For future referring MDs Teach “elegant diagnosis” Encourage critical reading

of the medical literature Gear teaching toward:▪ Appropriate use of imaging▪ Consultation with radiologists

Did the patient already have the test? Why repeat? Can the previous test/result be obtained?

Will the test change patient care? What are the probability and negative

consequences of a FP test or pseudodisease? What is the short term danger of not

performing the exam? Is the reason for testing patient

expectations?▪ What else could be done?

- Laine, Ann Int Med, Jan. 2012

Radiology benefits management firms (RBMs) hired by insurers to reduce uncritical imaging Preauthorization required or the patient is charged ▪ “Black box” clinical guidelines▪ Sentinel effect▪ Barrier effect

Clinical decision support systems Based on guidelines Require major cultural change Must mandate a “hard stop” to be effective

Be a role model to trainees and newly minted radiologists Reinvigorate consultation with referring MDs

Avoid the appearance of self-interest▪ Support policies that benefit patients even if less revenue▪ Take the lead in reducing imaging exams that are unlikely to benefit patients▪ Contest marginal and unnecessary requests▪ Discourage imaging to reduce small uncertainties▪ Minimize indecisiveness over findings of low importance

Advocate valuable and underutilized imaging Establish direct communications with patients

Pre-exam consultation Direct reporting Post-exam consultation

Uncritical imaging is related to a combination of educational, cultural, and economic factors that promote marginal and unnecessary use

Decreasing the effects of external influences like financial incentives and fear of litigation are important but will not be sufficient to stem uncritical imaging

Physicians must adopt a different practice style emphasizing consultation with radiologists and critical thought before requesting imaging exams

Golf is a game invented by the same people who think music comes out of a bagpipe.

- unattributed