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Too Much of a Good Thing! The Uncritical Use of Medical Imaging Bruce J. Too Much of a Good Thing! The Uncritical Use of Medical Imaging Bruce J. Hillman, MD Eastern Radiological Society Southern Pines, North Carolina April 2013

Disclosures of Bruce J. Hillman, MD Founder and Chief Scientific Officer, ACR Image Metrix Disclosures of Bruce J. Hillman, MD 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)

Too Much of a Good Thing! The perception of overuse Use and misuse The Too Much of a Good Thing! The perception of overuse Use and misuse The impact of uncritical use Opportunities for change They say golf is like life, but don’t believe them. Golf is more complicated than that - Gardner Dickinson

Premises Modern cross-sectional imaging has made medicine: Safer More effective Broad economic concerns about Premises 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 3 x general medical inflation ▪ 5 x for high technology imaging Money doesn’t talk, it shouts - Bob Dylan

It’s All About the Money Cumulative Percent Change 70 Imaging Tests Other procedures All It’s All About the Money Cumulative Percent Change 70 Imaging Tests Other procedures All physician services Major procedures Evaluation & management 60 50 40 30 20 10 0 Source: Med. PAC 2000 2001 2002 2003 2004 2005

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

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

Much of the Growth Is Expected Imaging should be growing Aging population ▪ Burden Much of the Growth Is Expected 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

Less Acceptable Growth Patients desire more care Moral hazard of health insurance Direct-to-consumer TV Less Acceptable Growth 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

Less Acceptable Growth Busy physicians misuse advanced imaging as a screening/triage tool Humor patients Less Acceptable Growth 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

Least Acceptable Growth Principle agent moral hazard Fancy economic term for self-referral ▪ Physician Least Acceptable Growth 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

An Unholy Convergence Economically motivated imaging use meets patient desire for more and higher An Unholy Convergence 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

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

Least Acceptable Growth Defensive medical testing - radiologists Radiologists also overestimate malpractice risk A Least Acceptable Growth 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”

Uncritical Imaging The less acceptable rationales for imaging focus on possible benefit, though not Uncritical Imaging The less acceptable rationales for imaging focus on possible benefit, though not always for the patient BUT All imaging bears risks For appropriate exams: benfit/risk is high for marginal or inappropriate imaging There is low likelihood of patient benefit

The Risks of Uncritical Imaging Most physicians and patients concerned about radiation and contrast The Risks of Uncritical Imaging 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

True Negative Result The test is negative and the patient truly has no disease True Negative Result The test is negative and the patient truly has no disease ________ What the patient is hoping for Patient feels less anxious about their symptoms and may (for a short while) pursue healthful behaviors Cost plus benefit

False Negative Result The patient has important disease but the test incorrectly indicates no False Negative Result 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

False Positive Result The imaging interpretation is positive but the patient is actually normal False Positive Result 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

True Positive Result Possibility #1 The patient has a serious condition, which is treatable, True Positive Result 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

True Positive Result Possibility #2: Pseudodisease Patient has the condition for which she is True Positive Result 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

True Positive Result Possibility #3: Incidentaloma Finding unrelated to the symptoms leading to testing True Positive Result 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

The Root Cause of Uncritical Use Uncritical use due to multiple synergistic influences derived The Root Cause of Uncritical Use Uncritical use due to multiple synergistic influences derived from a single root cause.

The Root Cause The quixotic pursuit of unattainable clinical certainty The Root Cause The quixotic pursuit of unattainable clinical certainty

Education and Culture All physicians educated and most trained in academic medical centers High Education and Culture 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

Education and Culture Academic faculty distracted by multiple missions Clinical service Education and training Education and Culture 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? !

Education and Culture “Supervise” students and house staff Conduct morning rounds Make assignments Entrust Education and Culture “Supervise” students and house staff Conduct morning rounds Make assignments Entrust house staff to make management decisions at off-hours

Education and Culture Housestaff: Have variable but usually lesser expertise Also are torn among Education and Culture 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

Education and Culture Housestaff adopt a shotgun approach to imaging exams that fails to Education and Culture 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

Hang ‘em High An example made of one individual is a lesson taught to Hang ‘em High An example made of one individual is a lesson taught to all

The Root Cause Even in high frequency, high acuity environments, these practices are wasteful The Root Cause 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

Education and Culture Learned practice style persists and is even encouraged by other physicians Education and Culture 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 system Even 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

Opportunities for Change Low Hanging Fruit Correct lawyers’ incentives Current incentives encourage frivolous suits Opportunities for Change Low Hanging Fruit 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

Opportunities for Change Low Hanging Fruit Terminate the in-office ancillary services exception allowing high-tech Opportunities for Change Low Hanging Fruit 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

Change the Referring Physician Mindset For future referring MDs Teach “elegant diagnosis” Encourage critical Change the Referring Physician Mindset For future referring MDs Teach “elegant diagnosis” Encourage critical reading of the medical literature Gear teaching toward: ▪ Appropriate use of imaging ▪ Consultation with radiologists

Require the Following Considerations Before Imaging Did the patient already have the test? Why Require the Following Considerations Before Imaging 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

If Not Us, Someone Will Ask Radiology benefits management firms (RBMs) hired by insurers If Not Us, Someone Will Ask 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

Current Radiologists Must Be Role Models Be a role model to trainees and newly Current Radiologists Must Be Role Models 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

Summary Uncritical imaging is related to a combination of educational, cultural, and economic factors Summary 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

Contact: bjh 8 a@virginia. edu Golf is a game invented by the same people Contact: bjh 8 [email protected] edu Golf is a game invented by the same people who think music comes out of a bagpipe. - unattributed