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A Case for Changing the Way We Utilize MR Imaging: A Societal Perspective
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A Case for Changing the Way We Utilize MR Imaging: A Societal Perspective Aseem Sharma, MD For society to benefit most from technological advancements in the field of health care, we should adopt practices that utilize technology in a least wasteful manner so that maximum benefits of technology are extracted at minimum cost to the society. In context of expensive diagnostic imaging equipment, such as CT and MR scanners, this means minimization of unwarranted scans, as well as optimization of scanning protocols, to extract the diagnostic information in a least resource- intensive manner. A number of efforts, including the development and dissemination of ACR Appro- priateness Criteria Ò and imple- mentation of utilization management in radiology [1], target the first objective, namely, minimizing in- appropriate utilization of scanners. However, specifically in the case of MR imaging, the current utilization and reimbursement model does not encourage more efficient use of this expensive resource. Identifying re- dundancy in the current model of MR imaging utilization can help us take care of the imaging needs of our society in a more efficient and, thereby, more cost-conscious manner. Of many factors taken into consideration for setting the tech- nical reimbursement rate for an MR scan, one of the key considerations is the average time it takes to perform a particular scan, as defined by Current Procedural Terminol- ogy (CPT) code. As is the case for CT scans, the CPT code (and thereby, reimbursement) for MR imaging is determined by the anatomic region being scanned, with additional consideration given to intravenous contrast usage. Herein lies a problem that, in my view, has prevented a more efficient utiliza- tion of MR scanners. In contrast to CT scanning that mainly pro- vides anatomic information based on a single type of tissue contrast (namely, the attenuation value), MR imaging provides multiple ways of looking at the anatomic region of interest. For example, MR imaging of brain is a collection of multiple individual sequences differing in the type of tissue con- trast (T1-weighted, T2-weighted, fluid-attenuated inversion re- covery, diffusion-weighted imaging, susceptibility-weighted imaging) and/or the imaging plane (axial, coronal, or sagittal). Some of these sequences may be repeated after administration of intravenous con- trast. Each sequence is acquired individually, thereby adding to the time for which the MR scanner re- mains occupied. Because all these sequences provide different images of the same region of interest (e.g., brain, abdomen, orbit, etc.), there is some overlap in the information provided by these, adding varying degree of redundancy. The extent to which differences in individual sequences end up proving useful often depends both upon the clinical question to be resolved (known before scanning), as well as the type of pathology, if any, revealed by the scan (often not known before scanning). There are many clinical scenarios in which the clinical question at hand can be easily answered by only a single sequence. Take the example of a patient in whom MR imaging is requested mainly to exclude a small possibility of recent brain infarction. Core diagnostic information in this case will be present in a single diffusion-weighted sequence, that can often be obtained using only a couple minutes of scanner time. Similarly, MR imaging is often used to monitor the size of abnormalities to define their growth rate. In such a scenario, if the abnormality under consideration is readily evident on a particular sequence, core diagnostic information can easily be extracted by only obtaining that sequence. In both these scenarios, the clinical need itself makes it evident that a much less time-intensive use of the MR scanner can answer the clinical question. Other investigators have identified similar situations previ- ously [2-4]. Even in some circumstances in which a single sequence may not be sufficient to provide complete diagnostic information in all pa- tients, it may identify the patients who might actually benefit from additional sequences. We have demonstrated the feasibility of such a two-tiered approach to MR imaging for patients presenting with headache [5] or sensorineural hearing loss [6] in achieving sig- nificant reductions in scanner time without affecting the sensitivity for detection of pathologic processes. Although such opportunities for providing useful and often complete diagnostic information in a shorter time exist, there is no mechanism in place for clinicians to request—and for radiologists to provide—such abbreviated scans in a transparent manner. This means that this expensive technology either ends up being used in a wasteful manner (by doing many redundant se- quences when 1 would have suf- ficed) or the financial benefits of less ª 2014 American College of Radiology 1 1546-1440/14/$36.00 http://dx.doi.org/10.1016/j.jacr.2013.12.014 OPINION
Transcript of A Case for Changing the Way We Utilize MR Imaging: A Societal Perspective
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OPINION
A Case for Changing the Way We Utilize MRImaging: A Societal PerspectiveAseem Sharma, MD
For society to benefit most fromtechnological advancements in thefield of health care, we should adoptpractices that utilize technology ina least wasteful manner so thatmaximumbenefits of technology areextracted at minimum cost to thesociety. In context of expensivediagnostic imaging equipment, suchas CT and MR scanners, this meansminimization of unwarranted scans,as well as optimization of scanningprotocols, to extract the diagnosticinformation in a least resource-intensive manner. A number ofefforts, including the developmentand dissemination of ACR Appro-priateness Criteria� and imple-mentation of utilizationmanagementin radiology [1], target the firstobjective, namely, minimizing in-appropriate utilization of scanners.However, specifically in the case ofMR imaging, the current utilizationand reimbursement model does notencourage more efficient use of thisexpensive resource. Identifying re-dundancy in the current model ofMR imaging utilization can help ustake care of the imaging needsof our society in a more efficientand, thereby, more cost-consciousmanner.Of many factors taken into
consideration for setting the tech-nical reimbursement rate for anMRscan, one of the key considerationsis the average time it takes toperform a particular scan, as definedby Current Procedural Terminol-ogy (CPT) code. As is the casefor CT scans, the CPT code (andthereby, reimbursement) for MRimaging is determined by theanatomic region being scanned,with additional consideration givento intravenous contrast usage. Herein
2014 American College of Radiology
46-1440/14/$36.00 � http://dx.doi.org/10.1016/j.jacr
lies a problem that, in my view, hasprevented a more efficient utiliza-tion of MR scanners. In contrastto CT scanning that mainly pro-vides anatomic information basedon a single type of tissue contrast(namely, the attenuation value),MR imaging provides multipleways of looking at the anatomicregion of interest. For example,MR imaging of brain is a collectionof multiple individual sequencesdiffering in the type of tissue con-trast (T1-weighted, T2-weighted,fluid-attenuated inversion re-covery, diffusion-weighted imaging,susceptibility-weighted imaging)and/or the imaging plane (axial,coronal, or sagittal). Some of thesesequences may be repeated afteradministration of intravenous con-trast. Each sequence is acquiredindividually, thereby adding to thetime for which the MR scanner re-mains occupied. Because all thesesequences provide different imagesof the same region of interest (e.g.,brain, abdomen, orbit, etc.), there issome overlap in the informationprovided by these, adding varyingdegree of redundancy.The extent to which differences
in individual sequences end upproving useful often depends bothupon the clinical question to beresolved (known before scanning),as well as the type of pathology, ifany, revealed by the scan (often notknown before scanning). There aremany clinical scenarios in whichthe clinical question at hand can beeasily answered by only a singlesequence. Take the example of apatient in whom MR imaging isrequested mainly to exclude a smallpossibility of recent brain infarction.Core diagnostic information in this
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case will be present in a singlediffusion-weighted sequence, thatcan often be obtained using only acouple minutes of scanner time.Similarly, MR imaging is often usedto monitor the size of abnormalitiesto define their growth rate. In such ascenario, if the abnormality underconsideration is readily evident on aparticular sequence, core diagnosticinformation can easily be extractedby only obtaining that sequence. Inboth these scenarios, the clinicalneed itself makes it evident that amuch less time-intensive use of theMR scanner can answer the clinicalquestion. Other investigators haveidentified similar situations previ-ously [2-4].
Even in some circumstancesin which a single sequence may notbe sufficient to provide completediagnostic information in all pa-tients, it may identify the patientswho might actually benefit fromadditional sequences. We havedemonstrated the feasibility ofsuch a two-tiered approach to MRimaging for patients presentingwith headache [5] or sensorineuralhearing loss [6] in achieving sig-nificant reductions in scanner timewithout affecting the sensitivity fordetection of pathologic processes.
Although such opportunities forproviding useful and often completediagnostic information in a shortertime exist, there is no mechanism inplace for clinicians to request—andfor radiologists to provide—suchabbreviated scans in a transparentmanner. This means that thisexpensive technology either ends upbeing used in a wasteful manner(by doing many redundant se-quences when 1 would have suf-ficed) or the financial benefits of less
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resource-intensive scans, when ob-tained, are not passed on to theconsumer/payer.Rather than encouraging more
efficient scanner utilization, lack ofa standard (and, thereby, accepted)mechanism for obtaining shorterMR scans creates a disincentivefor doing so. Under the currentmodel, in which it is consideredstandard for an MR scan to have amultitude of individual sequences,an abbreviated scan would give theperception of a suboptimal study,even if it answered the clinicalquestion at hand. This becomesespecially problematic, becauseunder the current model, suchan abbreviated study would becharged at the same price asanother seemingly more “compre-hensive” (and partly redundant)scan. In addition, imaging oftenends up showing unexpected inci-dental findings that may not beequally evident on all sequences. Itshould not be our policy to ensuredetection of all “incidentalomas.”However, fear of missing these maymake radiologists particularly wary
of performing abbreviated scans,unless such scans became well-accepted standard of care.MR scanners are expensive. The
cost of the scanner is thought toaccount for up to 90% of technicalreimbursement for acquiring anMR scan [7]. By setting the CPTcodes primarily based upon theanatomic regions of interest, withan inherent assumption that amultitude of sequences are alwaysneeded to provide the clinicallyuseful diagnostic information, wehave allowed significant redun-dancy to be built within the MRimaging. Overall effect of thisredundancy is that the diagnosticneeds of our society are being metusing a much higher number ofMR scanners than what is neces-sarily needed. Our society is directlypaying for these extra scanners bypaying a higher per-scan cost thanwhat could be achievable. We cando better. It would be helpful tohave a standard mechanism whichallows for clinical questions that canbe answered using shorter scannertime to be answered at a lower cost.
REFERENCES
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3. Kovacsovics B, Davidsson L, Harder H, et al.MRI screening of the cerebellopontine angleand inner ear with fast spin-echo T2 tech-nique. Archiv Ital Biol 2000;138:87-92.
4. Johnson AJ, Kido DK, Shannon WD, et al.Evaluation of a reduced MR imaging seq-uencing protocol in adult patients withstroke. Radiology 2001;218:791-7.
5. Sharma A, Reis M, Parsons MS, et al. Two-tiered approach to MRI for headache: acost-effective way to use an expensive tech-nology. AJR Am J Roentgenol 2013;201:W75-80.
6. Sharma A, Viets R, Parsons MS, Reis M,Chrisinger J, Wippold FJ 2nd. A two-tieredapproach to MR imaging for hearing loss:incremental cost of comprehensive MR im-aging over high-resolution T2-weighted im-aging. AJR Am J Roentgenol 2014;202:136-44.
7. Winter A, Ray N. Paying accurately forimaging services in medicare. Health Aff(Millwood) 2008;27:1479-90.
Aseem Sharma, MD, Mallickrodt Institute of Radiology, Washington University School of Medicine, Campus Box 8131, 510 S.Kingshighway Blvd, St. Louis, MO 63110-1013; e-mail: [email protected].
