- Email: [email protected]
Curbing the Urge to Image
Accepted Manuscript Curbing the Urge to Image Patricia E. Litkowski, MD, Gerald W. Smetana, MD, Mark L. Zeidel, MD, Melvin S. Blanchard, MD PII:
S0002-9343(16)30680-5
DOI:
10.1016/j.amjmed.2016.06.020
Reference:
AJM 13588
To appear in:
The American Journal of Medicine
Received Date: 26 April 2016 Accepted Date: 17 June 2016
Please cite this article as: Litkowski PE, Smetana GW, Zeidel ML, Blanchard MS, Curbing the Urge to Image, The American Journal of Medicine (2016), doi: 10.1016/j.amjmed.2016.06.020. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
AAIM Perspectives
RI PT
Curbing the Urge to Image
Patricia E Litkowski MD, Gerald W Smetana MD, Mark L Zeidel MD, Melvin S Blanchard MD
M AN U
SC
From the Department of Internal Medicine at Washington University School of Medicine (PL, MB) and the Department of Medicine, Beth Israel Deaconess Medical Center, and Harvard Medical School (GS, MZ) and 4-5 keywords. If there is no funding and/or no conflicts of interest, use “none” as your response (eg, Funding: None.) 1) Please add to your title page document:
Running Head: Curbing the Urge to Image
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Funding sources: None
Key words: High value care; healthcare policy; imaging; diagnostic tests; healthcare costs Conflict of interest statements: None
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All authors were involved in the conception, preparation, review and approval of the manuscript
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Corresponding Author: Melvin S Blanchard 660 South Euclid Ave. Campus Box 8121 St. Louis, MO 63110 314-362-8065 (office) 314-747-1080 (fax)
Word Count: 2299
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Abstract Health care costs in the United States have grown rapidly over the past several decades. As a result, there has been increasing interest in strategies to contain health care costs, without sacrificing the quality of medical care. While many factors contribute to rising costs, one major
RI PT
contributor to healthcare expenditure is diagnostic imaging. In this article, we address the
growth of diagnostic imaging, the financial and clinical adverse effects of over-utilization, and
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EP
TE D
M AN U
SC
discuss a variety of strategies to encourage appropriate use of diagnostic testing.
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Introduction The bill for health care in the United States in 2013 was $2.9 trillion or 19% of the GDP; this spending pattern has prompted national attention to health care expenditure and growth (1). An estimated 30% of these costs are unnecessary, one-half of which may be generated by
RI PT
physicians (2,3,4). One major area of health care cost growth is the increased use of diagnostic testing to identify the cause of a patient’s symptoms. In the early decades of modern medicine, physicians depended on the history, physical examination, clinical judgment, and a limited
battery of tests to confirm a diagnosis. Since then, the availability of laboratory and imaging
SC
tests has grown exponentially. While many of these advances have been revolutionary, the Alliance for Academic Internal Medicine (AAIM) accepts that their routine use may supplant a less costly approach to diagnosis, tempting clinicians to order testing in lieu of a careful clinical
M AN U
evaluation.
Advanced diagnostic tests bring the advantage of minimizing uncertainty about diagnosis. For example, to evaluate a patient with low back pain, clinicians now have the option of imaging the spine with plain x-rays, CT, or MRI. Although a patient’s history and physical examination may be reassuring, the provider’s worry about pathologic causes of low back pain may contribute to unnecessary testing. Failure to confirm a diagnosis of osteoarthrosis in the spine carries no
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consequence, but diagnostic uncertainty causes harm for patients with a pathologic cause of low back pain, such as malignancy or infection. Obtaining an imaging test may reassure the physician that a critical diagnosis was not missed. Despite this reassurance, imaging studies do not necessarily lead to diagnostic certainty. Many “abnormal” findings on imaging are not the
EP
cause of back pain and are present equally frequently among asymptomatic individuals (5). Health care providers who desire certainty may be compelled to order diagnostic tests that provide no added value. Patient expectations for imaging studies as part of their clinical
AC C
evaluation may also compel providers to order low-value studies. Unnecessary testing adds a substantial burden of cost to a health care system that is already bursting at the seams, may harm patients (for example: over-diagnosis, radiation exposure, etc.), and reduces the availability of resources for other patients. Physicians struggle daily with this dilemma – to provide optimal and compassionate medical care on the one hand, while limiting the unnecessary use of resources on the other. As the issue of growing health care costs has rightfully become a national concern, attempts to slow its growth have come from both medical and lay communities. Medical societies issue
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clinical practice guidelines that aim to foster the rational use of limited resources. The American Board of Internal Medicine, believing that overuse of diagnostic testing and procedures is an important source of waste in the health care system, launched the Choosing Wisely campaign in 2012 (6). The centerpiece of this effort is a list of five evidence-based recommendations from
RI PT
each specialty society regarding potentially unnecessary medical testing and procedures. These recommendations are meant to guide physicians and promote conversations between patients and clinicians about overuse of healthcare resources in evaluation and treatment. As an
example of one of these recommendations, the American College of Physicians, American Pain Society, American Academy of Family Physicians and the North American Spine Society all
SC
recommend avoiding image studies in patients with non-specific low back pain.
The Choosing Wisely Campaign is an attempt to reduce waste from the health care system by
M AN U
reducing the use of tests and procedures that add no value to patient care. However, its recommendations are voluntary and they are not intended to limit insurance coverage and payment for particular procedures. Some have opined that this campaign will not have a sustained impact on the use of advanced testing. So, how can we effectively reduce physician ordering low value tests and procedures? With this article, we hope to promote a dialogue about
TE D
approaches to effectively minimize low value testing and to provide a call to action.
The Burden of Unnecessary Testing
Innovations in diagnostic testing have enhanced our ability to diagnose illness and monitor
EP
response to treatment in a manner not previously possible. However, the temptation of these tests has also resulted in inappropriate use, driven by health care providers and influenced by
AC C
patients. Indeed, 30% of laboratory tests and 20 to 50% of “high tech” radiologic imaging ordered by health care providers may not be of value to the patient (5,7). The cost of imaging exceeds that of laboratory testing. In a MedPAC study of CMS spending in 2012, laboratory tests accounted for 9% of services and 4% of payments. In contrast, imaging accounted for 11% of services and 17% of payments (8). Incidental findings on diagnostic imaging studies may prompt further follow-up studies and additional cost. In a systemic review, the authors estimated that incidental findings occur in 31% of imaging studies. In this same study, most findings required follow-up although only a minority were clinically confirmed. (9). Thus, unnecessary imaging has significant initial and downstream financial costs.
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The cost of imaging is not only financial. Radiation exposure from diagnostic imaging confers a future price - the risk of malignancy. The estimated background annual radiation per person is 2.4 millisieverts (mSv); a single PA chest x-ray is 0.013 mSv. A chest CT angiogram to rule out pulmonary embolism provides a dose of 15 mSv or the equivalent of 1,154 chest x-rays (10).
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The National Council on Radiation Protection and Measurement (NCRP) estimated that Americans were exposed to more than seven times as much ionizing radiation from medical procedures in 2006 as in 1980 (11). It is estimated that, left unchecked, 1 to 3% of 1.4 million cancers annually could be related to CT scans (12). In addition to radiation risk, contrast MRI imaging with gadolinium in patients with renal insufficiency may cause nephrogenic systemic
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An Example – Low Back Pain:
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fibrosis while iodinated contrast for CT studies may cause acute kidney injury.
Eighty percent of all adults seek evaluation for low back pain at some point in their lives (13). According to the National Ambulatory Medical Care Survey, spinal disorders are the sixth most common reason for outpatient visits (14); it is estimated that low back pain may cost the health care system about $85 billion annually due to its high prevalence (15, 16)
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A broad range of providers evaluate back pain (internists, family practitioners, emergency medicine practitioners, orthopedists, neurologists, pain specialists, chiropractors); all must choose whether to image. Since the first Agency for Healthcare Research and Quality guidelines for assessment and treatment of acute low back pain in adults in 1994, clinical
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practice guidelines and research have established that in the vast majority of cases, acute back pain (symptoms less than one month) resolves spontaneously. Guidelines consistently recommend against imaging unless there are red flags such as known or suspected cancer,
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fevers, or acute neurologic findings (17). In the Choosing Wisely campaign, multiple medical societies recommend against routine imaging for acute low back pain (18). Despite this recommendation, 36% of family practitioners and 13% of general internists routinely image patients with acute low back pain (19). In another study of Medicare beneficiaries, almost 30% of patients with low back pain were imaged within 28 days (20). Imaging patients with acute low back pain who have no clinical features that suggest serious pathology contributes to cost in several ways. In addition to the direct expense of imaging, initial imaging is also a driver for more advanced imaging. Commonly, plain film findings, such as degenerative joint disease or loss of disc height, that may be unrelated to acute symptoms
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prompt advanced imaging such as CT and MRI. Patients at any age may have abnormalities that are unrelated to symptoms. In one study of asymptomatic individuals, 64% had an
Strategies for Reducing Unnecessary Diagnostic Imaging
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intervertebral disc abnormality visualized on imaging (21).
For this opinion piece, we reviewed studies that proposed a variety of strategies to reduce
unnecessary diagnostic imaging. Our radiology colleagues have likewise sought to reduce
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overutilization of diagnostic imaging (22-24). These strategies target various steps in the process of ordering diagnostic tests that range from limitations at time of order entry to
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physician feedback and are summarized in Table 1.
The first step is making the decision about whether to order an imaging test. This step is influenced by the physician’s knowledge of practice guidelines and the patient’s desires or expectations about their medical care (25). Making guidelines available at the point of care can facilitate decision and discussion with the patient. Additional strategies have been employed to educate providers about practice guidelines. Recently, the American College of Physicians and
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the Alliance for Academic Internal Medicine developed a high value care curriculum for internal medicine residents with the goal of encouraging physicians-in-training to make appropriate and cost-effective decisions. Another method to encourage compliance with guidelines is to integrate guidelines into the electronic medical record. In a systematic review of 35 studies,
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computerized clinical decision support systems effectively improved testing behavior and reduced ordering of unnecessary diagnostic tests (26).
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After choosing to image, the provider should determine if a previously performed imaging study exists. If available, with no change in the patient’s clinical status, repeat imaging may offer little. Repeated imaging is costly, exposes patients to unnecessary harmful radiation, and often provides no additional diagnostic yield. In the United States, the high prevalence of independent health care systems with electronic medical records (EMRs) that do not communicate with each other limits the ability of providers to access imaging studies obtained at another institution. Rather than requesting a physical copy of a previously completed study, which is both time and labor intensive, physicians often choose to repeat diagnostic imaging tests. Interventions to integrate electronic medical record systems could significantly reduce low-yield and costly
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repetitive testing. In one report, the simple act of enclosing a CD with imaging studies when transferring patients between two emergency departments resulted in a 17% reduction of repeat CT imaging (27). More recently, medical informatics companies have been established to facilitate the sharing of images across hospital systems in the form of health information
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exchanges. The estimated savings from eliminating duplicate testing may be as high as $30 billion (28). One recent meta-analysis identified eight studies of test utilization in the emergency department after implementation of health information exchanges and found mild to moderate reductions in both cost and frequency of repeated imaging studies (29).
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The next step for providers choosing to order a diagnostic imaging study is ordering the test, which most often occurs through an EMR. Strategies that target this step include the display of
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cost at time of order entry and automated feedback regarding low-yield diagnostic imaging tests. Many physicians do not know the true costs of the imaging tests that they order as diagnostic imaging prices are rarely transparent. Some researchers questioned if simply informing physicians of the cost of a given test would affect ordering habits and decrease over-utilization. While early studies suggested that informing physicians of the cost of a given lab test or imaging study decreased ordering frequency (30), more recent data regarding this strategy have been mixed (31, 32). One recent study used an EMR to display the cost of one-half of its most
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common diagnostic imaging tests and measured the ordering frequency of all tests over the course of one year (33). There was no difference in relative frequency of ordering diagnostic tests when the cost of tests were displayed compared with when costs were not displayed.
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More recently, health care systems have adopted clinical decision support mechanisms to curtail overutilization. When providers place electronic orders for diagnostic imaging studies, they are prompted with a series of questions to document their rationale for ordering a given
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test. Using evidence-based clinical guidelines, the clinical decision support systems can provide immediate feedback regarding the test’s appropriateness. One large retrospective study showed a decrease in inappropriate utilization rate after implementation of an electronic clinical decision support system that prompted providers with a series of questions at the time of ordering a diagnostic test (34). Other interventions target orders for tests that are low-yield based on scoring systems of appropriateness or provide physicians with an alert message if a similar imaging test has been ordered within the past 90 days (35, 36, 37). Clinical decision support strategies have demonstrated modest reductions in overall utilization of diagnostic imaging tests, but it is unknown if these interventions are lasting.
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Prior authorization is another strategy that aims to reduce low-yield diagnostic testing. The process of prior authorization requires physicians to obtain approval from insurance companies before a test is performed. These reviews are done by benefits managers, who apply standard
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appropriateness guidelines to determine whether to approve or reject an imaging study. Health care providers may challenge the decisions, appeal, or speak directly to a radiologist to select a more appropriate test. Physicians often perceive this strategy as creating hoops to jump
through, with the intended goal that they will eventually stop jumping due to fatigue and hassle. However, studies that have examined the effects of implementing prior authorization programs
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have generally shown statistically significant decreases in the number of imaging studies ordered, although it is unclear if the effects of these programs are enduring (38,39,40).
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Furthermore, some have criticized this method as it generates additional administrative work, delays tests, and limits physician autonomy.
Call to Action
Health care costs are high and growing at an unsustainable rate. Imaging studies contribute significantly to both direct and indirect costs. Current efforts to curb overuse of low value
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imaging studies are minimally effective. AAIM recommends funding of studies that seek innovative approaches to improve adherence to clinical practice guidelines beyond mere dissemination. In addition, AAIM endorses important to broadly educating clinicians, future clinicians, and consumers of medical care about the dangers of excessive testing and to set
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expectations that minimize patient dissatisfaction.
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Acknowledgments
The authors thank the Alliance for Academic Internal Medicine (AAIM) High Value Care Work Group for their support and assistance.
References (1) Centers for Medicare and Medicaid Services: National Health Expenditures 2013 Highlights. Available from: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trendsand-Reports/NationalHealthExpendData/downloads/highlights.pdf Accessed February 1, 2015.
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(2) Committee on the Learning Health Care System in America; Institute of Medicine; Smith M, Saunders R, Stuckhardt L, McGinnis JM, et al., editors. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Washington, DC: National Academies Press; 2013. (3) Rao VM, Levin DC. The Overuse of Diagnostic Imaging and the Choosing Wisely Initiative. Ann Intern Med. 2012;157(8):574-6. (4) Zhi M, Ding EL, Theisen-Toupal J, Whelan J, Arnaout R. The Landscape of Inappropriate Laboratory Testing: A 15-Year Meta-Analysis. PLoS ONE. 2013;8(11): e78962. (5) Jensen MC, Brant-Zawadzki MN, Obuchowski N, Modic MT, Malkasian D, Ross JS. Magnetic Resonance Imaging of the Lumbar Spine in People without Back Pain. N Eng J Med. 1994;331:69-73. (6) Cassel CK, Guest JA. Choosing Wisely: helping physicians and patients make smart decisions about their care. JAMA. 2012;307(17):1801-2. (7) America’s Health Insurance Plans. Ensuring Quality through Appropriate Use of Diagnostic Imaging. Washington, DC: America’s Health Insurance Plans; 2008. (8) Report to The Congress: Medicare Payment Policy. March 2012. Available from: http://www.medpac.gov/documents/reports/march-2012-report-to-the-congress-medicarepayment-policy.pdf?sfvrsn=0 Accessed February 1, 2015. (9) Lumbreras B, Donat L, Hernandez-Aguado I. Incidental findings in imaging diagnostic tests: a systematic review. Brit J Radiol. 2010;83:276-9. (10) Crownover BK, Bepko JL. Appropriate and safe use of diagnostic imaging. Am Fam Physician. 2013;87(7):494-501. (11) NCRP Report No. 160: Ionizing Radiation Exposure of the Population of the United States. Available from: http://www.ncrponline.org/Publications/Press_Releases/160press.html Accessed Feb 1, 2015. (12) Linet MS, Slovis TL, Miller DL, Kleinerman R, Lee C, Rajaraman P, et al. Cancer risks associated with external radiation from diagnostic imaging procedures. CA Cancer J Clin. 2012;62:75-100. (13) Andersson GB. Epidemiological features of chronic low-back pain. Lancet.1999;354(9178):581-5. (14) National Hospital Ambulatory Medical Care Survey: 2011 Outpatient Department Summary Tables. Available from: http://www.cdc.gov/nchs/data/ahcd/nhamcs_outpatient/2011_opd_web_tables.pdf Accessed April 14, 2015. (15) Ma VY, Chan L, Carruthers KJ. Incidence, prevalence, costs, and impact on disability of common conditions requiring rehabilitation in the United States: stroke, spinal cord injury, traumatic brain injury, multiple sclerosis, osteoarthritis, rheumatoid arthritis, limb loss, and back pain. Arch Phys Med Rehabil. 2014 May;95(5):986-995 (16) Childs, JD, Fritz JM, Wu SS, Flynn TW, Wainner RS, Robertson EK, et al. BMC Health Serv Res. 2015; 15:150:1-10. (17) Chou R, Qaseem A, Snow V, Casey D, Cross JT, Shekelle P, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147(7):478-491. (18) Choosing Wisely – An Initiative by the ABIM Foundation. Available from: http://www.choosingwisely.org/. Accessed February 1, 2015. (19) Di lorio D, Henley E, Doughty A. A survey of primary care physician patterns and adherence to acute low back problem guidelines. Arch Fam Med. 2000;9(10):1015-21. (20) Pham HH, Landon BE, Reschovsky JD, Wu B, Schrag D. Rapidity and modality of imaging for acute low back pain in elderly patients. Arch Intern Med. 2009;169(10):972-981.
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(21) Jensen MC, Brant-Zawadski MN, Obuchowski N, Modic MT, Malkasian D, Ross JS. Magnetic Resonance Imaging of the lumbar spine in people without back pain. N Eng J Med. 1994;331(2):69-73. (22) Bernardy M, Ullrich CG, Rawson JV, Allen B, Thrall JH, Keysor KJ et al. Strategies for managing imaging utilization. J Am Coll Radiol. 2009;6(12): 844–50. (23) Hendee WR, Becker GJ, Borgstede JP, Bosma J, Casarella WJ, Erickson BA, et al. Addressing overutilization in medical imaging. Radiology. 2010;257(1):240-5. (24) Duszak R, Berlin, J. Utilization management in radiology, part 1: rationale, history, and current status. J Am Coll Radiol. 2012;9(10):694–9. (25) Finestone AS, Raveh A, Mirovsky Y, Lahad A, Milgrom C. Orthopaedists’ and family practitioners’ knowledge of simple low back pain management. Spine. 2009;34(15):1600-3. (26) Roshanov PS, You JJ, Dhaliwal J, Koff D, Mackay JA, Weise-Kelly L. Can computerized clinical decision support systems improve practitioners’ diagnostic tests ordering behavior? A decision-maker-researcher partnership systematic review. Implement Sci. 2011;6:88. (27) Sodickson A, Opraseuth J, Ledbetter S. Outside imaging in emergency department transfer patients: CD import reduces rates of subsequent imaging utilization. Radiology. 2011;260(2):408-13. (28) lifeIMAGE Marks Five Years, One Billion Images Exchanged. 14 April 2014. Available from: http://www.lifeimage.com/press-releases/five-years-one-billion-images Accessed 3 February 2015. (29) Rudin RS, Motala A, Goldzweig CL, Shekelle PG. Usage and effect of health information exchange: a systematic review. Ann Intern Med 2014;161(11):803-11. (30) Tierny WM, Miller ME, McDonald CJ. The Effect on Test Ordering of Informing Physicians of the Charges for Outpatient Diagnostic Tests. N Engl J Med 1990; 322:1499-1504. (31) Feldman LS, Shihab HM, Thiemann D Yeh HC, Ardolino M, Mandell S, et al. Impact of Providing Fee Data on Laboratory Test Ordering: A Controlled Clinical Trial. JAMA Intern Med. 2013;173(10):903-8. (32) Bates DW, Kuperman GJ, Jha A, Teich JM, Orav EJ, M’luf N, et al. Does the Computerized Display of Charges Affect Inpatient Ancillary Test Utilization? Arch Intern Med. 1997;157(21):2501-8. (33) Durand DJ, Feldman LS, Lewin JS, Brotman DJ. Provider Cost Transparency Alone Has No Impact on Inpatient Imaging Utilization. J Am Coll Radiol. 2013;10(2):108-13. (34) Blackmore C, Mecklenburg R, Kaplan G. Effectiveness of Clinical Decision Support in Controlling Inappropriate Imaging. J Am Coll Radiol. 2011;8:19-25. (35) Sistrom CL, Dang PA, Weilburg JB, Dreyer KJ, Rosenthal DI, Thrall JH. Effect of Computerized Order Entry with Integrated Decision Support on the Growth of Outpatient Procedure Volumes. Radiology. 2009; 251(1):147-55. (36) Vartanians VM, Sistrom CL, Weilburg JB, Rosenthal DI, Thrall JH. Increasing the Appropriateness of Outpatient Imaging : Effects of a Barrier to Ordering Low-Yield Methods. Radiology. 2010; 255(3):842-9. (37) O’Connor SD, Sodickson AD, Ip IK, Raja AS, Healey MJ, Schneider LI, et al. Requiring Clinical Justification to Override Repeat Imaging Decision Support: Impact on CT Use. Am J Roentgenol. 2014;203(5):482-90. (38) Levin DC, Bree RL, Rao VM, Johnson J. A Prior Authorization Program of a Radiology Management Company and How It Has Affected Utilization of Advanced Diagnostic Imaging. J Am Coll Radiol. 2010;7(1):33-8. (39) Blachar A, Tal S, Mandel A, Novikov I, Polliack G, Sosna J, et al. Preauthorization of CT and MRI Examinations: Assessment of a Managed Care Preauthorization Program Based on the ACR Appropriateness Criteria and The Royal College of Radiology Guidelines. J Am Coll Radiol. 2006;3(11):851-9.
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(40) Mitchell JM, LaGalia RR. Controlling the Escalating Use of Advanced Imaging: The Role of Radiology Benefit Management Programs. Med Care Res Rev. 2009;66(3):339-51.
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Table 1
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Image Ordering
Potential Interventions Education about guidelines & recommendations Clinical decision support via electronic medical record Availability of prior imaging records through centralized image system Display the cost of imaging test at time of order entry Clinical decision guidance via electronic medical record Alert messages for duplicate studies Prior authorization for diagnostic studies
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Pre-imaging
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Perspectives Viewpoints Healthcare costs are high and growing at an unsustainable rate
•
Imaging studies contribute significantly to both direct and indirect costs
•
Current efforts to curb overuse of low value imaging studies are minimally effective
•
AAIM recommends funding studies that seek innovative approaches to improve
RI PT
•
AAIM endorses broadly educating clinicians, future clinicians, and consumers of medical
EP
TE D
patient dissatisfaction.
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care about the dangers of excessive testing and to set expectations that minimize
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•
SC
adherence to clinical practice guidelines beyond mere dissemination
S0002-9343(16)30680-5
DOI:
10.1016/j.amjmed.2016.06.020
Reference:
AJM 13588
To appear in:
The American Journal of Medicine
Received Date: 26 April 2016 Accepted Date: 17 June 2016
Please cite this article as: Litkowski PE, Smetana GW, Zeidel ML, Blanchard MS, Curbing the Urge to Image, The American Journal of Medicine (2016), doi: 10.1016/j.amjmed.2016.06.020. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
AAIM Perspectives
RI PT
Curbing the Urge to Image
Patricia E Litkowski MD, Gerald W Smetana MD, Mark L Zeidel MD, Melvin S Blanchard MD
M AN U
SC
From the Department of Internal Medicine at Washington University School of Medicine (PL, MB) and the Department of Medicine, Beth Israel Deaconess Medical Center, and Harvard Medical School (GS, MZ) and 4-5 keywords. If there is no funding and/or no conflicts of interest, use “none” as your response (eg, Funding: None.) 1) Please add to your title page document:
Running Head: Curbing the Urge to Image
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Funding sources: None
Key words: High value care; healthcare policy; imaging; diagnostic tests; healthcare costs Conflict of interest statements: None
EP
All authors were involved in the conception, preparation, review and approval of the manuscript
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Corresponding Author: Melvin S Blanchard 660 South Euclid Ave. Campus Box 8121 St. Louis, MO 63110 314-362-8065 (office) 314-747-1080 (fax)
Word Count: 2299
ACCEPTED MANUSCRIPT
Abstract Health care costs in the United States have grown rapidly over the past several decades. As a result, there has been increasing interest in strategies to contain health care costs, without sacrificing the quality of medical care. While many factors contribute to rising costs, one major
RI PT
contributor to healthcare expenditure is diagnostic imaging. In this article, we address the
growth of diagnostic imaging, the financial and clinical adverse effects of over-utilization, and
AC C
EP
TE D
M AN U
SC
discuss a variety of strategies to encourage appropriate use of diagnostic testing.
ACCEPTED MANUSCRIPT
Introduction The bill for health care in the United States in 2013 was $2.9 trillion or 19% of the GDP; this spending pattern has prompted national attention to health care expenditure and growth (1). An estimated 30% of these costs are unnecessary, one-half of which may be generated by
RI PT
physicians (2,3,4). One major area of health care cost growth is the increased use of diagnostic testing to identify the cause of a patient’s symptoms. In the early decades of modern medicine, physicians depended on the history, physical examination, clinical judgment, and a limited
battery of tests to confirm a diagnosis. Since then, the availability of laboratory and imaging
SC
tests has grown exponentially. While many of these advances have been revolutionary, the Alliance for Academic Internal Medicine (AAIM) accepts that their routine use may supplant a less costly approach to diagnosis, tempting clinicians to order testing in lieu of a careful clinical
M AN U
evaluation.
Advanced diagnostic tests bring the advantage of minimizing uncertainty about diagnosis. For example, to evaluate a patient with low back pain, clinicians now have the option of imaging the spine with plain x-rays, CT, or MRI. Although a patient’s history and physical examination may be reassuring, the provider’s worry about pathologic causes of low back pain may contribute to unnecessary testing. Failure to confirm a diagnosis of osteoarthrosis in the spine carries no
TE D
consequence, but diagnostic uncertainty causes harm for patients with a pathologic cause of low back pain, such as malignancy or infection. Obtaining an imaging test may reassure the physician that a critical diagnosis was not missed. Despite this reassurance, imaging studies do not necessarily lead to diagnostic certainty. Many “abnormal” findings on imaging are not the
EP
cause of back pain and are present equally frequently among asymptomatic individuals (5). Health care providers who desire certainty may be compelled to order diagnostic tests that provide no added value. Patient expectations for imaging studies as part of their clinical
AC C
evaluation may also compel providers to order low-value studies. Unnecessary testing adds a substantial burden of cost to a health care system that is already bursting at the seams, may harm patients (for example: over-diagnosis, radiation exposure, etc.), and reduces the availability of resources for other patients. Physicians struggle daily with this dilemma – to provide optimal and compassionate medical care on the one hand, while limiting the unnecessary use of resources on the other. As the issue of growing health care costs has rightfully become a national concern, attempts to slow its growth have come from both medical and lay communities. Medical societies issue
ACCEPTED MANUSCRIPT
clinical practice guidelines that aim to foster the rational use of limited resources. The American Board of Internal Medicine, believing that overuse of diagnostic testing and procedures is an important source of waste in the health care system, launched the Choosing Wisely campaign in 2012 (6). The centerpiece of this effort is a list of five evidence-based recommendations from
RI PT
each specialty society regarding potentially unnecessary medical testing and procedures. These recommendations are meant to guide physicians and promote conversations between patients and clinicians about overuse of healthcare resources in evaluation and treatment. As an
example of one of these recommendations, the American College of Physicians, American Pain Society, American Academy of Family Physicians and the North American Spine Society all
SC
recommend avoiding image studies in patients with non-specific low back pain.
The Choosing Wisely Campaign is an attempt to reduce waste from the health care system by
M AN U
reducing the use of tests and procedures that add no value to patient care. However, its recommendations are voluntary and they are not intended to limit insurance coverage and payment for particular procedures. Some have opined that this campaign will not have a sustained impact on the use of advanced testing. So, how can we effectively reduce physician ordering low value tests and procedures? With this article, we hope to promote a dialogue about
TE D
approaches to effectively minimize low value testing and to provide a call to action.
The Burden of Unnecessary Testing
Innovations in diagnostic testing have enhanced our ability to diagnose illness and monitor
EP
response to treatment in a manner not previously possible. However, the temptation of these tests has also resulted in inappropriate use, driven by health care providers and influenced by
AC C
patients. Indeed, 30% of laboratory tests and 20 to 50% of “high tech” radiologic imaging ordered by health care providers may not be of value to the patient (5,7). The cost of imaging exceeds that of laboratory testing. In a MedPAC study of CMS spending in 2012, laboratory tests accounted for 9% of services and 4% of payments. In contrast, imaging accounted for 11% of services and 17% of payments (8). Incidental findings on diagnostic imaging studies may prompt further follow-up studies and additional cost. In a systemic review, the authors estimated that incidental findings occur in 31% of imaging studies. In this same study, most findings required follow-up although only a minority were clinically confirmed. (9). Thus, unnecessary imaging has significant initial and downstream financial costs.
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The cost of imaging is not only financial. Radiation exposure from diagnostic imaging confers a future price - the risk of malignancy. The estimated background annual radiation per person is 2.4 millisieverts (mSv); a single PA chest x-ray is 0.013 mSv. A chest CT angiogram to rule out pulmonary embolism provides a dose of 15 mSv or the equivalent of 1,154 chest x-rays (10).
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The National Council on Radiation Protection and Measurement (NCRP) estimated that Americans were exposed to more than seven times as much ionizing radiation from medical procedures in 2006 as in 1980 (11). It is estimated that, left unchecked, 1 to 3% of 1.4 million cancers annually could be related to CT scans (12). In addition to radiation risk, contrast MRI imaging with gadolinium in patients with renal insufficiency may cause nephrogenic systemic
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An Example – Low Back Pain:
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fibrosis while iodinated contrast for CT studies may cause acute kidney injury.
Eighty percent of all adults seek evaluation for low back pain at some point in their lives (13). According to the National Ambulatory Medical Care Survey, spinal disorders are the sixth most common reason for outpatient visits (14); it is estimated that low back pain may cost the health care system about $85 billion annually due to its high prevalence (15, 16)
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A broad range of providers evaluate back pain (internists, family practitioners, emergency medicine practitioners, orthopedists, neurologists, pain specialists, chiropractors); all must choose whether to image. Since the first Agency for Healthcare Research and Quality guidelines for assessment and treatment of acute low back pain in adults in 1994, clinical
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practice guidelines and research have established that in the vast majority of cases, acute back pain (symptoms less than one month) resolves spontaneously. Guidelines consistently recommend against imaging unless there are red flags such as known or suspected cancer,
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fevers, or acute neurologic findings (17). In the Choosing Wisely campaign, multiple medical societies recommend against routine imaging for acute low back pain (18). Despite this recommendation, 36% of family practitioners and 13% of general internists routinely image patients with acute low back pain (19). In another study of Medicare beneficiaries, almost 30% of patients with low back pain were imaged within 28 days (20). Imaging patients with acute low back pain who have no clinical features that suggest serious pathology contributes to cost in several ways. In addition to the direct expense of imaging, initial imaging is also a driver for more advanced imaging. Commonly, plain film findings, such as degenerative joint disease or loss of disc height, that may be unrelated to acute symptoms
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prompt advanced imaging such as CT and MRI. Patients at any age may have abnormalities that are unrelated to symptoms. In one study of asymptomatic individuals, 64% had an
Strategies for Reducing Unnecessary Diagnostic Imaging
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intervertebral disc abnormality visualized on imaging (21).
For this opinion piece, we reviewed studies that proposed a variety of strategies to reduce
unnecessary diagnostic imaging. Our radiology colleagues have likewise sought to reduce
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overutilization of diagnostic imaging (22-24). These strategies target various steps in the process of ordering diagnostic tests that range from limitations at time of order entry to
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physician feedback and are summarized in Table 1.
The first step is making the decision about whether to order an imaging test. This step is influenced by the physician’s knowledge of practice guidelines and the patient’s desires or expectations about their medical care (25). Making guidelines available at the point of care can facilitate decision and discussion with the patient. Additional strategies have been employed to educate providers about practice guidelines. Recently, the American College of Physicians and
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the Alliance for Academic Internal Medicine developed a high value care curriculum for internal medicine residents with the goal of encouraging physicians-in-training to make appropriate and cost-effective decisions. Another method to encourage compliance with guidelines is to integrate guidelines into the electronic medical record. In a systematic review of 35 studies,
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computerized clinical decision support systems effectively improved testing behavior and reduced ordering of unnecessary diagnostic tests (26).
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After choosing to image, the provider should determine if a previously performed imaging study exists. If available, with no change in the patient’s clinical status, repeat imaging may offer little. Repeated imaging is costly, exposes patients to unnecessary harmful radiation, and often provides no additional diagnostic yield. In the United States, the high prevalence of independent health care systems with electronic medical records (EMRs) that do not communicate with each other limits the ability of providers to access imaging studies obtained at another institution. Rather than requesting a physical copy of a previously completed study, which is both time and labor intensive, physicians often choose to repeat diagnostic imaging tests. Interventions to integrate electronic medical record systems could significantly reduce low-yield and costly
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repetitive testing. In one report, the simple act of enclosing a CD with imaging studies when transferring patients between two emergency departments resulted in a 17% reduction of repeat CT imaging (27). More recently, medical informatics companies have been established to facilitate the sharing of images across hospital systems in the form of health information
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exchanges. The estimated savings from eliminating duplicate testing may be as high as $30 billion (28). One recent meta-analysis identified eight studies of test utilization in the emergency department after implementation of health information exchanges and found mild to moderate reductions in both cost and frequency of repeated imaging studies (29).
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The next step for providers choosing to order a diagnostic imaging study is ordering the test, which most often occurs through an EMR. Strategies that target this step include the display of
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cost at time of order entry and automated feedback regarding low-yield diagnostic imaging tests. Many physicians do not know the true costs of the imaging tests that they order as diagnostic imaging prices are rarely transparent. Some researchers questioned if simply informing physicians of the cost of a given test would affect ordering habits and decrease over-utilization. While early studies suggested that informing physicians of the cost of a given lab test or imaging study decreased ordering frequency (30), more recent data regarding this strategy have been mixed (31, 32). One recent study used an EMR to display the cost of one-half of its most
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common diagnostic imaging tests and measured the ordering frequency of all tests over the course of one year (33). There was no difference in relative frequency of ordering diagnostic tests when the cost of tests were displayed compared with when costs were not displayed.
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More recently, health care systems have adopted clinical decision support mechanisms to curtail overutilization. When providers place electronic orders for diagnostic imaging studies, they are prompted with a series of questions to document their rationale for ordering a given
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test. Using evidence-based clinical guidelines, the clinical decision support systems can provide immediate feedback regarding the test’s appropriateness. One large retrospective study showed a decrease in inappropriate utilization rate after implementation of an electronic clinical decision support system that prompted providers with a series of questions at the time of ordering a diagnostic test (34). Other interventions target orders for tests that are low-yield based on scoring systems of appropriateness or provide physicians with an alert message if a similar imaging test has been ordered within the past 90 days (35, 36, 37). Clinical decision support strategies have demonstrated modest reductions in overall utilization of diagnostic imaging tests, but it is unknown if these interventions are lasting.
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Prior authorization is another strategy that aims to reduce low-yield diagnostic testing. The process of prior authorization requires physicians to obtain approval from insurance companies before a test is performed. These reviews are done by benefits managers, who apply standard
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appropriateness guidelines to determine whether to approve or reject an imaging study. Health care providers may challenge the decisions, appeal, or speak directly to a radiologist to select a more appropriate test. Physicians often perceive this strategy as creating hoops to jump
through, with the intended goal that they will eventually stop jumping due to fatigue and hassle. However, studies that have examined the effects of implementing prior authorization programs
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have generally shown statistically significant decreases in the number of imaging studies ordered, although it is unclear if the effects of these programs are enduring (38,39,40).
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Furthermore, some have criticized this method as it generates additional administrative work, delays tests, and limits physician autonomy.
Call to Action
Health care costs are high and growing at an unsustainable rate. Imaging studies contribute significantly to both direct and indirect costs. Current efforts to curb overuse of low value
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imaging studies are minimally effective. AAIM recommends funding of studies that seek innovative approaches to improve adherence to clinical practice guidelines beyond mere dissemination. In addition, AAIM endorses important to broadly educating clinicians, future clinicians, and consumers of medical care about the dangers of excessive testing and to set
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expectations that minimize patient dissatisfaction.
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Acknowledgments
The authors thank the Alliance for Academic Internal Medicine (AAIM) High Value Care Work Group for their support and assistance.
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(2) Committee on the Learning Health Care System in America; Institute of Medicine; Smith M, Saunders R, Stuckhardt L, McGinnis JM, et al., editors. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Washington, DC: National Academies Press; 2013. (3) Rao VM, Levin DC. The Overuse of Diagnostic Imaging and the Choosing Wisely Initiative. Ann Intern Med. 2012;157(8):574-6. (4) Zhi M, Ding EL, Theisen-Toupal J, Whelan J, Arnaout R. The Landscape of Inappropriate Laboratory Testing: A 15-Year Meta-Analysis. PLoS ONE. 2013;8(11): e78962. (5) Jensen MC, Brant-Zawadzki MN, Obuchowski N, Modic MT, Malkasian D, Ross JS. Magnetic Resonance Imaging of the Lumbar Spine in People without Back Pain. N Eng J Med. 1994;331:69-73. (6) Cassel CK, Guest JA. Choosing Wisely: helping physicians and patients make smart decisions about their care. JAMA. 2012;307(17):1801-2. (7) America’s Health Insurance Plans. Ensuring Quality through Appropriate Use of Diagnostic Imaging. Washington, DC: America’s Health Insurance Plans; 2008. (8) Report to The Congress: Medicare Payment Policy. March 2012. Available from: http://www.medpac.gov/documents/reports/march-2012-report-to-the-congress-medicarepayment-policy.pdf?sfvrsn=0 Accessed February 1, 2015. (9) Lumbreras B, Donat L, Hernandez-Aguado I. Incidental findings in imaging diagnostic tests: a systematic review. Brit J Radiol. 2010;83:276-9. (10) Crownover BK, Bepko JL. Appropriate and safe use of diagnostic imaging. Am Fam Physician. 2013;87(7):494-501. (11) NCRP Report No. 160: Ionizing Radiation Exposure of the Population of the United States. Available from: http://www.ncrponline.org/Publications/Press_Releases/160press.html Accessed Feb 1, 2015. (12) Linet MS, Slovis TL, Miller DL, Kleinerman R, Lee C, Rajaraman P, et al. Cancer risks associated with external radiation from diagnostic imaging procedures. CA Cancer J Clin. 2012;62:75-100. (13) Andersson GB. Epidemiological features of chronic low-back pain. Lancet.1999;354(9178):581-5. (14) National Hospital Ambulatory Medical Care Survey: 2011 Outpatient Department Summary Tables. Available from: http://www.cdc.gov/nchs/data/ahcd/nhamcs_outpatient/2011_opd_web_tables.pdf Accessed April 14, 2015. (15) Ma VY, Chan L, Carruthers KJ. Incidence, prevalence, costs, and impact on disability of common conditions requiring rehabilitation in the United States: stroke, spinal cord injury, traumatic brain injury, multiple sclerosis, osteoarthritis, rheumatoid arthritis, limb loss, and back pain. Arch Phys Med Rehabil. 2014 May;95(5):986-995 (16) Childs, JD, Fritz JM, Wu SS, Flynn TW, Wainner RS, Robertson EK, et al. BMC Health Serv Res. 2015; 15:150:1-10. (17) Chou R, Qaseem A, Snow V, Casey D, Cross JT, Shekelle P, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147(7):478-491. (18) Choosing Wisely – An Initiative by the ABIM Foundation. Available from: http://www.choosingwisely.org/. Accessed February 1, 2015. (19) Di lorio D, Henley E, Doughty A. A survey of primary care physician patterns and adherence to acute low back problem guidelines. Arch Fam Med. 2000;9(10):1015-21. (20) Pham HH, Landon BE, Reschovsky JD, Wu B, Schrag D. Rapidity and modality of imaging for acute low back pain in elderly patients. Arch Intern Med. 2009;169(10):972-981.
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(21) Jensen MC, Brant-Zawadski MN, Obuchowski N, Modic MT, Malkasian D, Ross JS. Magnetic Resonance Imaging of the lumbar spine in people without back pain. N Eng J Med. 1994;331(2):69-73. (22) Bernardy M, Ullrich CG, Rawson JV, Allen B, Thrall JH, Keysor KJ et al. Strategies for managing imaging utilization. J Am Coll Radiol. 2009;6(12): 844–50. (23) Hendee WR, Becker GJ, Borgstede JP, Bosma J, Casarella WJ, Erickson BA, et al. Addressing overutilization in medical imaging. Radiology. 2010;257(1):240-5. (24) Duszak R, Berlin, J. Utilization management in radiology, part 1: rationale, history, and current status. J Am Coll Radiol. 2012;9(10):694–9. (25) Finestone AS, Raveh A, Mirovsky Y, Lahad A, Milgrom C. Orthopaedists’ and family practitioners’ knowledge of simple low back pain management. Spine. 2009;34(15):1600-3. (26) Roshanov PS, You JJ, Dhaliwal J, Koff D, Mackay JA, Weise-Kelly L. Can computerized clinical decision support systems improve practitioners’ diagnostic tests ordering behavior? A decision-maker-researcher partnership systematic review. Implement Sci. 2011;6:88. (27) Sodickson A, Opraseuth J, Ledbetter S. Outside imaging in emergency department transfer patients: CD import reduces rates of subsequent imaging utilization. Radiology. 2011;260(2):408-13. (28) lifeIMAGE Marks Five Years, One Billion Images Exchanged. 14 April 2014. Available from: http://www.lifeimage.com/press-releases/five-years-one-billion-images Accessed 3 February 2015. (29) Rudin RS, Motala A, Goldzweig CL, Shekelle PG. Usage and effect of health information exchange: a systematic review. Ann Intern Med 2014;161(11):803-11. (30) Tierny WM, Miller ME, McDonald CJ. The Effect on Test Ordering of Informing Physicians of the Charges for Outpatient Diagnostic Tests. N Engl J Med 1990; 322:1499-1504. (31) Feldman LS, Shihab HM, Thiemann D Yeh HC, Ardolino M, Mandell S, et al. Impact of Providing Fee Data on Laboratory Test Ordering: A Controlled Clinical Trial. JAMA Intern Med. 2013;173(10):903-8. (32) Bates DW, Kuperman GJ, Jha A, Teich JM, Orav EJ, M’luf N, et al. Does the Computerized Display of Charges Affect Inpatient Ancillary Test Utilization? Arch Intern Med. 1997;157(21):2501-8. (33) Durand DJ, Feldman LS, Lewin JS, Brotman DJ. Provider Cost Transparency Alone Has No Impact on Inpatient Imaging Utilization. J Am Coll Radiol. 2013;10(2):108-13. (34) Blackmore C, Mecklenburg R, Kaplan G. Effectiveness of Clinical Decision Support in Controlling Inappropriate Imaging. J Am Coll Radiol. 2011;8:19-25. (35) Sistrom CL, Dang PA, Weilburg JB, Dreyer KJ, Rosenthal DI, Thrall JH. Effect of Computerized Order Entry with Integrated Decision Support on the Growth of Outpatient Procedure Volumes. Radiology. 2009; 251(1):147-55. (36) Vartanians VM, Sistrom CL, Weilburg JB, Rosenthal DI, Thrall JH. Increasing the Appropriateness of Outpatient Imaging : Effects of a Barrier to Ordering Low-Yield Methods. Radiology. 2010; 255(3):842-9. (37) O’Connor SD, Sodickson AD, Ip IK, Raja AS, Healey MJ, Schneider LI, et al. Requiring Clinical Justification to Override Repeat Imaging Decision Support: Impact on CT Use. Am J Roentgenol. 2014;203(5):482-90. (38) Levin DC, Bree RL, Rao VM, Johnson J. A Prior Authorization Program of a Radiology Management Company and How It Has Affected Utilization of Advanced Diagnostic Imaging. J Am Coll Radiol. 2010;7(1):33-8. (39) Blachar A, Tal S, Mandel A, Novikov I, Polliack G, Sosna J, et al. Preauthorization of CT and MRI Examinations: Assessment of a Managed Care Preauthorization Program Based on the ACR Appropriateness Criteria and The Royal College of Radiology Guidelines. J Am Coll Radiol. 2006;3(11):851-9.
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(40) Mitchell JM, LaGalia RR. Controlling the Escalating Use of Advanced Imaging: The Role of Radiology Benefit Management Programs. Med Care Res Rev. 2009;66(3):339-51.
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Table 1
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Image Ordering
Potential Interventions Education about guidelines & recommendations Clinical decision support via electronic medical record Availability of prior imaging records through centralized image system Display the cost of imaging test at time of order entry Clinical decision guidance via electronic medical record Alert messages for duplicate studies Prior authorization for diagnostic studies
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Pre-imaging
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Perspectives Viewpoints Healthcare costs are high and growing at an unsustainable rate
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Imaging studies contribute significantly to both direct and indirect costs
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Current efforts to curb overuse of low value imaging studies are minimally effective
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AAIM recommends funding studies that seek innovative approaches to improve
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AAIM endorses broadly educating clinicians, future clinicians, and consumers of medical
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patient dissatisfaction.
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care about the dangers of excessive testing and to set expectations that minimize
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•
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adherence to clinical practice guidelines beyond mere dissemination