Dalhousie UniversityHalifax, Nova ScotiaMay 2014

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)

Medical Advisory Board, MTR-Target

The perception of overuse Use and misuse The impact of uncritical use Opportunities for change

Modern cross-sectional imaging has made medicine:

Safer

More effective

Broad economic concerns about imaging

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: MedPAC

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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 – estimated 30%

Whenever a friend succeeds, a little something in me dies

- Gore Vidal

Prevalent attitude that growth in imaging is necessarily bad and requires policy initiatives to reduce rate of rise

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 with less morbidity and shorter convalescence▪ Improved temporal, spatial, and contrast resolution

▪ New cohorts of patients who did not qualify for more invasive testing

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 service 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”

Requesting an imaging examination without properly considering:

A priori likelihood of the patient having a condition that might be diagnosed by imaging

▪ Imaging most efficient when p<.80 and >.20

The performance characteristics of the test

▪ Sensitivity

▪ Specificity

▪ Predictive values

The less acceptable rationales for imaging focus on possible benefit, but not necessarily for the patient

BUT

All imaging bears risks Risk exists for marginal or inappropriate imaging

but 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

RisksFalse positive diagnosesPseudodisease

- Slow growing disease- Highly aggressive

diseaseIncidentalomas

_______________ All add cost and may cause unnecessary anxiety without benefit

BenefitsLow but finite chance of detecting unexpected serious yet treatable disease

______________High cost/benefit ratio

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

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 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 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

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

CDS required for Medicare/Medicaid patients beginning 2017 Based on organizational ‘appropriateness criteria’ Transparent to providers

Future radiologists

Teach critical reading and listening

Improve understanding of the dangers of over-sensitivity

Discourage reporting findings of low importance

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

I’m not sure I want popular opinion on my side. I’ve noticed those with the most opinions have the fewest facts.

-Bethania McKenstry