Majority of MRIs for back pain not needed or of questionable value: study – Life – Times Colonist

Majority of MRIs for back pain not needed or of questionable value: study

MARCH 25, 2013 01:18 PM

A technician operates an MRI machine at a private clinic in Calgary Wednesday, Jan. 12, 2005. A new study suggests that fewer than half of MRIs ordered to look for the cause of lower back pain are an appropriate use of the imaging machines. THE CANADIAN PRESS/Jeff McIntosh

TORONTO – Fewer than half of MRIs ordered to look for the cause of lower back pain are appropriate uses of the imaging machines, a new Canadian study suggests.

In fact, only about 44 per cent of MRIs ordered for the lumbar spine were appropriate, the study found. The rest were deemed to be either inappropriate or of questionable value. Lead author Dr. Derek Emery said “inappropriate” in this case means unlikely to benefit the patient.

Emery said the study, which was published Monday in the journal JAMA Internal Medicine, was undertaken because there is a suspicion in medical circles that a lot of ordered MRIs are actually a waste of the resource and of the patient’s time.

“There’s a lot of talk out there and it’s even mentioned in the literature that a lot of imaging is used inappropriately. Or a lot of imaging is unnecessary. But this has really not been rigorously studied,” said Emery, a neuroradiologist in the faculty of medicine and dentistry at the University of Alberta.

Cutting back on unnecessary MRIs would help pare long waiting lists for access to the costly machines.

“MRI’s a limited resource in most of Canada. Certainly it is in Alberta. And if we can eliminate some of the unnecessary scans, that will give us capacity to scan more patients who really need it,” Emery said.

The study was done by researchers from the University of Alberta, the University of Calgary, the University of Toronto, and the Ottawa Hospital Research Institute.

They looked at MRI orders for two conditions — lower back pain and recurrent headaches — from the University of Alberta Hospital and the Ottawa Hospital. A panel of experts studied requisitions as they came in, assessing the appropriateness of 500 from each institution for each procedure. They used an existing nine-point scale for measuring appropriateness.

They also looked at who was doing the ordering, assessing how well different medical specialties were doing when it came to requisitioning appropriate MRIs. The acronym stands for magnetic resonance imaging, a type of scan that is particularly useful for soft tissue imaging.

Family physicians had the lowest rate of appropriate MRI orders for lower back pain, with only about one-third of the scans they requisitioned qualifying as appropriate. Neurologists and orthopedic surgeons were better, but were still under 50 per cent.

MRIs for the lumbar spine ordered by neurosurgeons were appropriate three-quarters of the time. But Emery noted neurosurgeons generally order MRIs for problems after surgery, when it’s clear there may be an issue. They are not doing the basic sifting of lower back pain cases that other types of doctors are doing.

When the group studied the use of MRIs for recurrent headaches, they found a different story. Just over 80 per cent of ordered MRIs were deemed to be appropriate. That may be because most of the people who had MRIs for headaches were essentially pre-screened, having already undergone a CT scan, Emery said.

The research was funded by the Canadian Institutes of Health Research.

© Copyright 2013

Interoperability and Population Health Management: Unlocking the Data – ImagingBiz


Interoperability and Population Health Management: Unlocking the Data

Mike TilkinAs health care moves from fee-for-service to value-based medicine, and, eventually, to population health management, imaging is facing the imperative to redefine its role in the care continuum. “We’ll be focused closely on value and outcome measures in the environment we’re calling imaging 3.0,” says Mike Tilkin, CIO of theAmerican College of Radiology (ACR). “Radiologists will play pivotal roles throughout the care process—from the time a study is ordered to being engaged as a consultant throughout the care cycle to being a resource to the patient.”

The IT needs of radiology practices and departments, as well as the health systems they serve, have evolved in concert with clinical advances in care, Tilkin notes. “If you look at the evolution of imaging IT systems, the phase we call 1.0 supported the initial use of analog imaging modalities,” he says. “Then there was the 2.0 phase, in which we saw the digitization of imaging and the growing use of technologies like CT. In that phase, IT systems evolved to facilitate rapid turnaround and keep up with expanding health care needs.

“Now, as radiologists seek to contribute to patient-centered, value-based care models, they are guiding the development of IT systems that support imaging information integration with the electronic medical record,” he continues. “Imaging reports, clinical and quality data and financial metrics will be key to radiology’s support of population health management.”

Projecting the Future

Tilkin envisions imaging—with the help of next-generation IT tools—enhancing population health through multiple touchpoints. As examples, he cites exam ordering, where the radiologist would help the referring physician understand the most appropriate study through decision support tools and online consultation; exam results, which would be delivered with the help of actionable reporting tools and full EMR integration; and exam follow-up, in which the radiologist would be a valued consultant in determining next steps in care. “The data captured throughout will support the creation of standardized treatment protocols, delivering higher quality care at lower costs,” he says.

Integration between disparate systems will be critical to achieving this vision. “You want to be able to provide the physician and the patient with easy access to data,” Tilkin says. “That includes making imaging reports and studies from prior visits available regardless of where the previous encounters occurred.”

To progress beyond care coordination for the individual patient and into population health management, better access to integrated data sources that can be used for monitoring and data mining will be needed, Tilkin says. “Some of the challenges include system interoperability and data standardization,” he notes. “We’re making inroads into these areas with good results from our first-generation data registries and reporting systems, but there’s still more ground to cover. Effective data analysis is the start of developing evidence-based care protocols that can be used across the health care system.”

How to Get There

As Tilkin’s comments indicate, lack of interoperability between IT systems is one of the biggest obstacles to achieving true population health management. “Unlocking the potential of data residing in disparate systems is the initial challenge,” he says. “We need both access and semantic interoperability so that we can aggregate data and provide meaningful results. Once we start bringing these data to bear at the point of care, we can also create a feedback cycle that will continue to inform standards development.”

Tilkin is optimistic: He points out that the technology options, as well as the incentives to develop better tools, are increasing daily. “There isn’t a simple way get at these data, but there’s a lot happening in industry, health systems, government and standards bodies to make data more accessible,” he says. “There are also increasingly sophisticated tools for performing analysis across geographically disparate data sets.”

Specifically, Tilkin highlights some of the newer RESTful web standards coming out of DICOM and HL7, the formation of vendor groups like the CommonWell Health Alliance and the deployment of clinical decision support tools like ACR Select. “The ACR Select architecture is built to deliver evidenced-based decision support at the time of study order, as well as to capture feedback during the care process,” he says. “It grows the evidence base supporting appropriate and effective ordering of imaging studies, helping radiologists redefine their role as imaging information consultants.”

With deeper integration between systems, progress in this and other enhancements to the clinical care cycle will be rapid, Tilkin predicts. “As you begin to integrate and get access to data, you start to create a very powerful cycle of capture, analysis, application and workflow modification across enterprises,” he says. “You can then capture results of your actions, evaluate what’s most effective, and feed that data back through the evidence creation process. From a population health management standpoint, the potential to leverage the increasing amount of data we’re capturing is very exciting and can make a meaningful difference to patient care.”

Cat Vasko is editor of HealthIT Executive Forum.

What role can radiology play in reducing healthcare costs? – FierceMedicalImaging

What role can radiology play in reducing healthcare costs?

A recent study in the journal Health Affairs clearly illustrates the price that the U.S. pays due to the high costs associated with healthcare.

The study is based on a survey of more than 20,000 adults from 11 countries–including the U.S., U.K., Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden and Switzerland–which found that 37 percent of American respondents often did not seek out recommended care or medical care when they were sick due to cost concern. This compared unfavorably to the other nations surveyed for the study. For example, just 4 percent of adults in the U.K. reported having the same kinds of issues.

While the fact that the U.S. has a healthcare cost problem is no secret, a survey like this drives home the effect costs can have on patient care. With that in mind, there are steps that healthcare organizations–and the radiologists working within those organizations–can take to provide high quality, yet cost-effective services.

One of the more visible efforts of radiologists focuses on imaging appropriatenessEmbracing imaging appropriateness initiatives can help to ensure that imaging systems are always available for necessary studies and that patients have access to the right scans at the right times. Vijay Rao, M.D. radiology chair of Thomas Jefferson University, has written extensively on this topic, and suggests that radiologists make every effort to ensure that their hospitals adopt clinical decision systems tied to order entry.

At the hospital level, organizations are focusing on the concept of providing better patient care and improved safety at a lower cost. Radiologists certainly can do their part to ensure that happens. For example, as imaging experts, radiologists can be more efficient managers of equipment. They can standardize supplies and procedures, and assist with technology assessments, as well.

Effective management of radiology personnel can also help to reduce costs. For example, having technologists who are cross-trained in multiple modalities can reduce not only staffing needs, but on-call and overtime needs, as well. What’s more, cross training can provide technologists with advancement possibilities.

It’s important for radiologists to remember that working to contain costs is worthwhile on multiple fronts. Not only does it serve broader healthcare affordability goals, but it also demonstrates to hospitals that imaging professionals are true partners when it comes to such efforts. And with the implementation of the Affordable Care Act and the adoption of new payment models like accountable care organizations, anything that can be done to demonstrate added value by radiologists will help the profession in the long run. – Mike (@FierceHealthIT)

Related Articles:
Breast MRI use on the rise, but is it being used appropriately?
The value of imaging appropriateness criteria
Choosing Wisely initiative a step forward in effort to curb unnecessary imaging

New Radiologists: Time to Re-Image Your Profession?

November 23, 2013

New Radiologists: Time to Re-Image Your Profession?

By Mark Hagland

Quality Outcomes in a Pay-for-Performance World


November 15, 2013

Quality Outcomes in a Pay-for-Performance World

By Joe Marion


Radiology Today Magazine – Congress Proposes SGR Fix That Starts Move Away From Fee for Service


Congress Proposes SGR Fix That Starts Move Away From Fee for Service

By Jim Knaub

The latest draft proposal to eliminate Medicare’s sustainable growth rate (SGR) “fix” would freeze physician reimbursement for 10 years but add the possibility of additional payments beginning in 2017. Those additional payments would be tied to value-based criteria currently being studied in various Medicare physician quality programs. The objective is to transition away from the current fee-for-service system that rewards procedure volume. The discussion draft was released October 31 and has support from both the Senate Finance and House Ways and Means committees.

“The framework would repeal the SGR and instead hold doctors’ pay at current levels as alternative payment models are developed and tested,” wrote Mary Agnes Carey for Kaiser Health News. “It would combine some existing Medicare physician quality programs into a new initiative starting in 2017 that would offer doctors additional pay based on their performance on value-based criteria, such as making more same-day appointments for urgent needs and enhancing their use of electronic medical records.”

The comment period for the draft language ended November 12, so further details should come soon. Unless Congress acts, Medicare reimbursement would drop approximately 25% on January 1, 2014, because of the existing SGR formula. Congress has passed annual patch fixes to avoid the formula-driven cuts since the SGR’s inception in 2007.

The draft also includes language that would “require ordering physicians to consult appropriateness criteria for advanced imaging services provided to Medicare patients,” according to a release from the ACR. If enacted as drafted, the change would deny Medicare payment for the exam if the ordering physician didn’t consult appropriateness criteria and also would require prior authorization for providers whose ordering patterns are inconsistent with those of their peers.

The ACR did not comment on the reimbursement portion of the draft but supports the use of appropriateness criteria, presumably hoping they would reflect the appropriate criteria developed by the ACR.

“Use of appropriateness criteria in the ordering of exams can educate providers regarding which scan is best for the patient’s given condition and even when no exam is warranted at all,” said ACR spokesperson Paul H. Ellenbogen, MD, FACR, chair of the ACR’s board of chancellors, via press release. “This can help ensure that every patient who needs imaging care gets the right exam at the right time for the right indication and avoids care that they may not need. This is what modern imaging care is all about. We look forward to working with Congress to help move this process forward.”

— Jim Knaub is editor of Radiology Today.

Aunt Minnie: Can social media improve communication in healthcare?

Can social media improve communication in healthcare?

By Erik L. Ridley, AuntMinnie staff writer

November 19, 2013 — Social media has transformed the way many people communicate and interact. Could technologies used for social media platforms also improve communication within healthcare organizations? They just might, according to a team from the University of Pittsburgh Medical Center (UPMC).

In an article published online October 23 in the Journal of Digital Imaging, a group led by Brian Kolowitz shared their experience with software they developed called Unite, which makes use of technology used in social media with the goal of closing the gap in existing healthcare communication processes and systems.

“The Unite system combines social technologies’ features including push notifications, messaging, community groups, and user lists with clinical workflow and applications to construct dynamic provider networks, simplify communications, and facilitate clinical workflow optimization,” wrote a team led by Brian Kolowitz, a principal architect at UPMC.

Inefficient communication

Communication within healthcare organizations is always problematic. Thanks to inefficient communication systems and difficulties identifying appropriate providers to contact, clinicians spend a significant amount of time every day on these tasks, Kolowitz told

In addition, inefficiencies in communication can prolong patient discharge, delay treatment, and potentially impact patient care, he said.

“EMR [electronic medical record] and other HIT systems do a great job of managing the patient record, but don’t currently have a solution for all aspects of communication within the organization,” Kolowitz said. “Limitations include vendor dependency and transactional triggers (e.g., HL7, DICOM, etc.). Providers use many systems while providing care, and no single EMR system can solve the entire communication need.”

For example, while off-the-shelf products can do a fine job of delivering a message to known individuals, they aren’t set up to deal with situations in which the exact recipient may not be known (such as needing to contact the neurology resident), Kolowitz said. Modes of communication also differ.

“That’s where Unite comes in, by focusing on intelligent connections rather than secure delivery of content,” he said. “Privacy and security is always a risk, but minimizing noise and maximizing relevance will allow us to gain efficiencies that are not available today.”

The Unite project aimed to connect everyone who participates in the care of a specific patient from the onset. Unite’s developers designed the software as an extensible platform that consists of both standalone applications and widgets that can be embedded within existing clinical applications on platforms including Windows, iOS, and Android.

Unite aims to promote physician mobility through the tracking and delivery of important clinical events, as well as enabling communication on mobile devices, the researches noted. Unite’s most important feature appears to be Provider Timeline, which, supported by Unite’s Provider Presence indicator, allows users to quickly identify the correct provider and their status within the context of a patient, according to the group.

“These features are supported by mobile device integration and timely delivery of notifications,” the authors wrote.

By developing a social network that’s integrated with healthcare information systems, researchers can also capture and study the way in which providers communicate, according to the team.

“With Unite, a rich set of usage data tied to clinical events may unravel alternative networks that can be leveraged to advance patient care,” the authors wrote. “It may be possible to determine (1) who providers communicate with most often, (2) under what clinical situations do these providers communicate, (3) what providers are on the critical communication path, and (4) what impact does latency in the communication process have on patient outcomes.”

Current status

After an initial rollout of Unite to a limited set of users about a year ago, the group elected following the trial period to expand their enterprise communication strategy, Kolowitz said.

“We’re back in the development phase and expect to deploy the next version within the organization early next year,” he said.

Unite will be deployed as both a platform and a standalone system in the first half of next year, and the team is also working on integrating Unite with a variety of other systems, Kolowitz said.


“Improved providers’ communication and automatic notification of clinical events are expected to improve patient outcomes, resource utilization, and workflow efficiencies,” said co-author Jim Venturella Jr., chief information officer of UPMC Physician and Hospital Services.

Mary’s Musings: Teamwork and proper exposure for radiologists – Aunt Minnie

Mary’s Musings: Teamwork and proper exposure for radiologists

By Dr. Mary Morrison Saltz, contributing writer

November 18, 2013

Dr. Mary Morrison Saltz

Dr. Mary Morrison Saltz.

That day, on a Sunday in Boston City Hospital, I sat nervous to hear the news from the OR. I knew the patient and his family, and had spent time back and forth with the team on how to best evaluate and treat our mutual patient.

I had long face-to-face interactions with the surgeons, discussions of what to do next, and the opportunity to do a hands-on evaluation of the patient during a contrast enema. By the time our patient went to the operating suite, I knew him, had met his family, and had really become a hands-on integral part of his care team.

When they found a life-threatening colonic obstruction, I was relieved to know I had not led the team astray, and was glad he was in good hands. That day the delivery of patient care promoted a true closeness to the team and the center of care, our patient. That was teamwork — and it happened without effort, part of the natural workflow.

How far we’ve come

Today, we have become more efficient, and certainly can provide a wealth of information unimaginable in the era of diagnostic enemas. Intestinal obstruction is no longer so primitively diagnosed — and imagine how much more valuable information is available on a pre-op CT.

Imaging is invaluable in patient care, and advanced imaging is a pillar upon which much care delivery is based. Yet, we have perhaps forgotten the importance of partnering closely with our referring clinicians to create a seamless care team.

Many radiologists say that their report is their “product,” and it must be perfect. Refining and redefining the nature of our reports is a key area of ongoing interest.1 Invaluable, but not in isolation — a report alone is not enough. Without being seamlessly integrated into the team looking after the patients, we may lose our role as a physician and become just that — a report generator. Efficiency and relative value units (RVUs) determine our revenues, but we must be careful to protect our place in the medical team.

A furor was created when Massachusetts General Hospital and Yale University sent imaging overseas a decade ago.2 Today, many hospitals outsource their nighttime reads. Hospitals may choose to outsource all image interpretation.

If imaging moves outside the hospital, how can we move with it and not lose our role? While we remain hospital-based, how can we increase our worth? Partnering with our colleagues as part of the care team is integral to cementing our role as invaluable resource.

Our future as a profession will be determined by our perceived value — and this is important to protect and nurture. The information explosion of imaging creates so much data that supercomputers are being used to analyze it!3

On a daily basis, thousands of images are routinely generated per case. The ability to reliably and competently analyze this information is incredible, a task for giants in our field and a central metric of our worth.

Comprehensive, comprehendible, and accurate radiology reports are the sine qua non of our specialty. Reports that impart relevant information to the care team in a meaningful way. Our reports alert our colleagues to critical findings, notify them when follow-up is needed, and transmit information in a way that is understood by those who need to care for the patient.

Going forward, our reports will also find their way directly to our patients via patient portals.4 Perfecting our reports is an ongoing work-in-progress, but our worth as doctors is more than this, and we must be aware that in order to care for the patient it takes a team, and we need to be part of that team. A report does not suffice.

As RSNA 2013 promotes the power of partnership, perhaps we should listen. Technology has served to isolate us from our team, but perhaps it can be used to bring back a personal touch? Check in when we are in the hospital, to signal our availability to our colleagues? Sort of a Foursquare5 meets telemedicine?

Develop interactive platforms to discuss cases, with integration of voice, video, and images for the times we are not there in person? Exploit the power of the iPad6 but not just for image transmission?

Proper exposure is not just for x-rays! Imagers need exposure too. We must not hide at our workstations or we risk losing our place on the team. Good medicine means teamwork, and we need to be there, in the game!


  1. Hall FM. The radiology report of the future. Radiology. 2009;251(2):313-316.
  2. Pollack A. Who’s reading your x-ray? New York Times. November 16, 2003.
  3. Saltz JH, Teodoro G, Pan T, et al. Feature-based analysis of large-scale spatio-temporal sensor data on hybrid architectures. Int J High Perform Comput Appl. June 9, 2013.
  4. Howell WLJ. Personalized radiology improves patient and provider experiences. Diagnostic Imaging website. Published September 17, 2013.
  5. Foursquare website.
  6. Saltz MM. The iPad, teleradiology and your practice-is the time right? Radiology Issues in a Changing World blog. Published August 1, 2012.

Dr. Mary Morrison Saltz is a board-certified diagnostic radiologist. She is currently chief clinical integration officer for community practice initiatives at Stony Brook Medicine and a member of their department of radiology. She is also CEO of Imagine Image Innovation, a company that uses big data to improve delivery of radiology services.

She has also served as chief medical officer for Hospital Radiology Partners and as radiology chair and service chief at hospitals in Florida, Ohio, and Georgia. Dr. Saltz is a member of the American College of Physician Executives, the American College of Radiology, and RSNA, and she sits on the Citizens Advisory Council of the Duke Cancer Institute.

A hands-on leader, Dr. Saltz’s expertise is working hand-in-hand with hospital administration to guide radiology teams to success. Dr. Saltz has led quality assurance programs in Florida and Ohio and she served as chief quality officer for community practice initiatives at Emory Healthcare. She also has more than 20 years of private-practice experience.

She is a graduate of McGill University, with a Bachelor of Science in Human Genetics, and Duke University, where she obtained her Doctor of Medicine. Her postgraduate education included a residency at Boston University, where she served as chief resident, and a fellowship in interventional abdominal radiology at Massachusetts General Hospital.

The comments and observations expressed herein do not necessarily reflect the opinions of

Copyright © 2013

Last Updated hh 11/15/2013 5:48:05 PM


A Little Less Conversation – ImagingBiz


A Little Less Conversation

Cat VaskoA study¹ published in the October 24 issue of the New England Journal of Medicineadds to the growing body of proof that physician self-referral for imaging continues to occur—in some cases, to a staggering degree. A Georgetown University researcher found that urologists with ownership interest in intensity-modulated radiation therapy (IMRT) services are significantly more likely to recommend the procedure for their patients than physicians are if they have no financial stake in IMRT.

In fact, a prostate-cancer patient visiting a self-referring urologist is 518% more likely to receive IMRT than one seen by a urologist at a best-practice–certified National Comprehensive Cancer Network center is, the study found. IMRT utilization among urologists increases 246% when they become self-referring; using difference-in-differences analysis, the study’s author concludes that self-referral is responsible for fully 93% of the growth in utilization of IMRT.

Why should legislators even need this most recent study, though, when a July Government Accountability Officereport² found similar results for exactly same procedure—or, for that matter, when the administration’s budget proposal for the coming year recommends closing the in-office ancillary-services loophole? It pegs the potential savings at $1.8 billion, over a decade.

The reason is that our community is terrible at mobilizing. We have no problem at all identifying obvious problems such as self-referral, and we’re experts at feeling victimized when the over utilization mantle is placed unfairly on our shoulders. Rarely, however, do we actually do anything: We’re all conversation—no action. Some of us are reticent or assume that others will advocate on our behalf, but I think that the majority of our community is simply unaware of what it could be doing to create positive change.

In a few weeks, you’ll be at RSNA, drowning in a deluge of information about radiology’s shaky reimbursement outlook and its undefined role in future delivery models. You’ll be shaking your head in sessions and commiserating with colleagues in the exhibit hall—but please, if you can, arrive at the culminating event of the year in imaging both armed with this information and ready to share it:

Only 12% of ACR® members contribute annually to the college’s political-action committee, RADPAC. RADPAC contributions, however, have been shown—again and again—to yield results on Capitol Hill; this year, for instance, RADPAC’s staff was able to push for the inclusion of language regarding both the multiple-procedure payment reduction and clinical decision support in legislation to repeal the sustainable–growth-rate formula. It doesn’t get much easier than making a donation, and even a little bit of support can make a big difference.

By getting involved with local politics and lawmakers, radiologists can have a surprisingly strong impact on policymaking at every level. RADPAC schedules congressional visits to practices and imaging centers that help educate lawmakers on the importance of radiology to the care cycle. All you have to do is ask, and the visits take very little time. Joining a local hospital’s board (or taking a city-council seat) is an even better way to influence the policy ecosystem.

Further, radiologists can and should be taking full- or part-time appointed positions in national agencies, including theNational Institutes of Health, the Centers for Disease Control and Prevention, CMS, and the FDA. Not only can they use these positions to increase the visibility of the profession in the eyes of important decision makers, but they also can subsequently educate the radiology community on what they learned, shaping future efforts.

Of course, it must be mentioned, yet again, that radiologists should be actively seeking roles on their hospitals’ various committees—especially those involved in the development of accountable-care organizations or integrated delivery networks. Physicians in practice environments where productivity is valued above all else will struggle to contribute effectively to these groups, so time needs to be carved out for those who want to step up and advocate for their field’s piece of the future reimbursement pie.

With a little less conversation and a little more action, we can make incredible progress for this invaluable profession.

Cat Vasko is editor of and associate editor of Radiology Business Journal.


1. Mitchell JM. Urologists’ use of intensity-modulated radiation therapy for prostate cancer. N Engl J Med. 2013;369(17):1629-1637.
2. US GAO. Medicare: higher use of costly prostate cancer treatment by providers who self-refer warrants scrutiny. Published July 2013. Accessed November 8, 2013.

JACR: How inappropriate is CT use, really? Aunt Minnie

JACR: How inappropriate is CT use, really?

By Kate Madden Yee, staff writer

November 13, 2013High use of CT scanning is of growing concern to healthcare providers, payors, and patients, noted the authors from the University of Minnesota and Arizona State University. One example is the increased use of CT in emergency departments, which can cause controversy given its cost, radiation exposure, and the likelihood of identifying incidental findings that may lead to further imaging exams.

“Since its introduction in the 1970s, CT scanning has become an important tool in medical imaging,” wrote lead author James Begun, PhD, and colleagues. “However, CT scans are not harmless procedures, and there are questions of appropriateness as well as overutilization.”

Begun’s group analyzed 310,467 CT scan claims from 2009 to 2010 in a health plan serving 1.5 million members. The researchers classified referring physicians and their patients who had CT scans into utilization categories, and they identified characteristics that distinguished categories with higher utilization from those with lower usage (JACR, November 6, 2013).

What did the group discover? Among patients receiving CT scans, factors that characterized higher from lower utilization included being male, older, and in poorer health; seeing more providers; using more prescription and total healthcare resources; and having government insurance. Among physicians ordering scans, factors that characterized higher from lower referrals for CT scans included being male, being board-certified, and being in group practice. High referral rates were not associated with the referring physician’s affiliation with the scan provider.

“In sum, none of the associations suggested an obvious problem with overutilization,” Begun and colleagues wrote.

The authors conceded that analyzing aggregate insurance claims may not be specific enough to identify CT overuse patterns, and they suggested that future research could concentrate on the following issues:


    • Special medical conditions: “Studies focused on conditions for which scans are elective would be useful in identifying factors that influence overuse,” Begun and colleagues wrote. “For such conditions, it would be possible to compare high-utilizing patients with similar patients to examine how higher and lower utilizing patients differ.”



    • Thorough review of claims by high utilizers: Identifying the patients and physicians who use CT the most and reviewing the data for these groups, particularly disease-specific data, could clarify reasons for high utilization.



    • Development and testing of ownership interest measures: Self-referral of scanning to facilities in which the physician has an ownership interest is a key concern. “Studying the effect of CT scan ownership interest on referral for scans requires accurate identification of the referring physician and a valid and reliable measure of ownership interest,” the authors wrote.



    • Investigating radiation risk reduction: “Interventions that encourage physicians and patients to consider radiation risk, such as the [American College of Radiology (ACR)] radiation safety messages, and evaluations of those interventions, would … be useful,” they wrote.


An unknown but substantial fraction of CT scans is unnecessary — making it all the more important that CT scan use patterns be explored and understood, the group concluded.

Copyright © 2013