Too Much of a Good Thing! The Uncritical Use of Medical Imaging Bruce J. Hillman, MD

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

2. 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)

3. 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

4. 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 3x general medical inflation • 5x for high technology imaging Money doesn’t talk, it shouts - Bob Dylan

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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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”

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

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

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

25. 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

26. 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?!

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

28. 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

29. 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

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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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

40. Contact: bjh8a@virginia.edu Golf is a game invented by the same people who think music comes out of a bagpipe. - unattributed