Eastern Radiological Society Southern Pines, North Carolina April 2013.
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Transcript of Eastern Radiological Society Southern Pines, North Carolina April 2013.
Eastern Radiological SocietySouthern Pines, North CarolinaApril 2013
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)
The perception of overuse
Use and misuseThe impact of
uncritical useOpportunities for
change
They say golf is
like life, but don’t believe them. Golf is more complicated than that
- Gardner Dickinson
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
Source: MedPACSource: MedPAC
70
60
50
40
30
20
10
02000 2001 2002 2003 2004 2005
ImagingTestsOther proceduresAll physician servicesMajor proceduresEvaluation & management
Cum
ula
tive P
erc
ent
Ch
ange
Cum
ula
tive P
erc
ent
Ch
ange
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
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
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
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 services 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”
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
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
The test is negative and the patient truly has no disease
________________
What the patient is hoping forPatient feels less anxious about their
symptoms and may (for a short while) pursue healthful behaviors
Cost plus benefit
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
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
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
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
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
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
The only time my prayers are never answered is when I’m playing golf
- Billy Graham
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 institutional 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
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
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
Golf is a game invented by the same people who think music comes out of a bagpipe.
- unattributed