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Ordering High-cost Medical Imaging: A Right or a Privilege?
IMAGING FOR THE CLINICIAN SPECIAL SECTION EDITORIAL Robert G. Stern, MD, Section Editor
Ordering High-cost Medical Imaging: A Right or a Privilege? SEE RELATED ARTICLE p. 975
Imagine for a moment, a medical system composed of 3 groups of clinicians. One group has a high level of understanding of most high-cost imaging studies and generally orders studies appropriately. The second group has a pretty good understanding of some types of high-cost imaging studies but has serious gaps in knowledge regarding the appropriateness of some types of examinations, including those outside its area of clinical expertise. The third group is essentially clueless about what high-cost imaging studies can and cannot show and is incompetent in ordering them. Now imagine that the society in which these clinicians and their patients live is being financially crushed by the costs of medical care. Imagine further that in this society anyone with a medical degree has an inherent right to order any test, regardless of cost and whether it makes any clinical sense. A physician can order hundreds of useless computed tomography, magnetic resonance, ultrasound, or nuclear medicine studies without ever being asked to provide a rationale for them or even guess at their likely utility. In this imaginary system, the clueless physician has the same right to order as the competent physician. Just imagine. Consider how this differs from other aspects of medicine: Physicians, at least in hospitals, are required to demonstrate competence before being allowed (or granted privileges) to perform their duties, be they procedures, surgeries, consultations, or interpretations of electrocardiograms, laboratory studies, pulmonary function testing, vascular laboratory examinations, or even imaging studies themselves. But in this imaginary society, there is no need for any mechanisms to identify or rectify abuse of imaging studies. No need to show competence before being allowed to order multi-thousand dollar exams. No need to track any misuse of technology. No need to see which patients are being overtreated, over-radiated, overtaxed, or indeed, overcharged. Just not that important. And nobody would be rude enough to suggest that these clinicians might not be experts in highly specialized imaging options and could benefit from input from other, more knowledgeable Funding: None. Conflict of Interest: None. Authorship: The author is solely responsible for the content of this manuscript.
0002-9343/$ -see front matter Ó 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjmed.2013.05.011
subspecialists—input that would greatly help patients, save a boatload of money, and improve the overall quality of care. Then imagine that a well-intentioned person decided to create a computerized decision support system as part of an electronic ordering system for the very purpose of assisting clinicians to make informed judgments regarding high-cost imaging exams. The support system would probably incorporate decision criteria provided not by radiologists but by expert subspecialty clinical peers. And of course the system would be voluntary, because it seems obvious that intelligent physicians would not ignore evidence-based medicine that would help them care for their patients. Surely every physician would rejoice at having this powerful new tool. But the study by Prevedello et al1 in this month’s Imaging for Clinicians Special Section shows something pretty startling. It demonstrates that a voluntary decision support system basically did not work: The overwhelming majority of clinicians did not alter their patterns, continued to ignore expert input, and changed their behaviors not a whit. Why? Who knows! Could it be because there are no ramifications for people who are incompetent in the use of high-cost imaging studies or for the institutions that make money from these studies? It might make sense to ask the people who ignored expert advice why they did so, and the reasons would likely be all over the place, ranging from fear of malpractice suits to fear of uncertainty to assertions of autonomy and the like. But the key point is that the reasons really do not matter: The tools to improve performance are here already, and improved performance trumps explanations for bad performance. And, incidentally, adherence to expert guidelines would actually help in defending clinical decisions. In this imaginary world no one cares enough to create and enforce imaging use policies to help patients, physicians, and society in general. Why? Because in this bizarre world, doctors feel entitled to function as isolated, noncommunicating, disconnected cottage-industry prima donnas, are used to being above question, are unreasonably sure of their competence in areas where they have none, are accountable to nobody, and experience no downside for bad (ie, irrationally expensive) behavior. There is another little fact of life in this fantasy world: The players play with house money,
940
The American Journal of Medicine, Vol 126, No 11, November 2013
not their own. It is the patients who are paying, whether directly or through taxes and insurance premiums. Add to the arrogance of overconfident practitioners the endless overzealous media hyping of the latest breakthrough in the pursuit of eternal life, and the result is an ill-informed population who believe it is in their best interest to have every conceivable screening examination, with no understanding of the downside. As Woodward and Bernstein used to say, if you really want to know where the source is, follow the money—there is lots of it. It flows into the pockets of not only individual radiologists but also giant public institutions, private hospitals, and imaging centers and their investors. And why would the investors in high-cost imaging technologies ever want to limit reimbursable examinations? You, dear reader, are no doubt one of the few who take the high road and follow decision support recommendations. Odds are, though, that almost all your colleagues behave more like the 22 doctors who were above such assistance and less like the 3 who improved their performance by
listening to expert advice. Given that the evidence suggests that voluntary self-remediation will not work, restriction of image-ordering privileges needs to be on the table as a potential policy to clue in the clueless. Even those with a reasonable grasp of imaging options will encounter situations where they could benefit from a decision support system. But almost everyone will ignore it, unless there is some outside reason compelling them to pay attention to it. Read the article. Dem’s da facts. Robert G. Stern, MD Department of Medical Imaging University of Arizona College of Medicine Tucson
Reference 1. Prevedello LM, Raja AS, Ip IK, et al. Does clinical decision support reduce unwarranted variation in yield of CT pulmonary angiogram? Am J Med. 2013;126:975-981.
Ordering High-cost Medical Imaging: A Right or a Privilege? SEE RELATED ARTICLE p. 975
Imagine for a moment, a medical system composed of 3 groups of clinicians. One group has a high level of understanding of most high-cost imaging studies and generally orders studies appropriately. The second group has a pretty good understanding of some types of high-cost imaging studies but has serious gaps in knowledge regarding the appropriateness of some types of examinations, including those outside its area of clinical expertise. The third group is essentially clueless about what high-cost imaging studies can and cannot show and is incompetent in ordering them. Now imagine that the society in which these clinicians and their patients live is being financially crushed by the costs of medical care. Imagine further that in this society anyone with a medical degree has an inherent right to order any test, regardless of cost and whether it makes any clinical sense. A physician can order hundreds of useless computed tomography, magnetic resonance, ultrasound, or nuclear medicine studies without ever being asked to provide a rationale for them or even guess at their likely utility. In this imaginary system, the clueless physician has the same right to order as the competent physician. Just imagine. Consider how this differs from other aspects of medicine: Physicians, at least in hospitals, are required to demonstrate competence before being allowed (or granted privileges) to perform their duties, be they procedures, surgeries, consultations, or interpretations of electrocardiograms, laboratory studies, pulmonary function testing, vascular laboratory examinations, or even imaging studies themselves. But in this imaginary society, there is no need for any mechanisms to identify or rectify abuse of imaging studies. No need to show competence before being allowed to order multi-thousand dollar exams. No need to track any misuse of technology. No need to see which patients are being overtreated, over-radiated, overtaxed, or indeed, overcharged. Just not that important. And nobody would be rude enough to suggest that these clinicians might not be experts in highly specialized imaging options and could benefit from input from other, more knowledgeable Funding: None. Conflict of Interest: None. Authorship: The author is solely responsible for the content of this manuscript.
0002-9343/$ -see front matter Ó 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjmed.2013.05.011
subspecialists—input that would greatly help patients, save a boatload of money, and improve the overall quality of care. Then imagine that a well-intentioned person decided to create a computerized decision support system as part of an electronic ordering system for the very purpose of assisting clinicians to make informed judgments regarding high-cost imaging exams. The support system would probably incorporate decision criteria provided not by radiologists but by expert subspecialty clinical peers. And of course the system would be voluntary, because it seems obvious that intelligent physicians would not ignore evidence-based medicine that would help them care for their patients. Surely every physician would rejoice at having this powerful new tool. But the study by Prevedello et al1 in this month’s Imaging for Clinicians Special Section shows something pretty startling. It demonstrates that a voluntary decision support system basically did not work: The overwhelming majority of clinicians did not alter their patterns, continued to ignore expert input, and changed their behaviors not a whit. Why? Who knows! Could it be because there are no ramifications for people who are incompetent in the use of high-cost imaging studies or for the institutions that make money from these studies? It might make sense to ask the people who ignored expert advice why they did so, and the reasons would likely be all over the place, ranging from fear of malpractice suits to fear of uncertainty to assertions of autonomy and the like. But the key point is that the reasons really do not matter: The tools to improve performance are here already, and improved performance trumps explanations for bad performance. And, incidentally, adherence to expert guidelines would actually help in defending clinical decisions. In this imaginary world no one cares enough to create and enforce imaging use policies to help patients, physicians, and society in general. Why? Because in this bizarre world, doctors feel entitled to function as isolated, noncommunicating, disconnected cottage-industry prima donnas, are used to being above question, are unreasonably sure of their competence in areas where they have none, are accountable to nobody, and experience no downside for bad (ie, irrationally expensive) behavior. There is another little fact of life in this fantasy world: The players play with house money,
940
The American Journal of Medicine, Vol 126, No 11, November 2013
not their own. It is the patients who are paying, whether directly or through taxes and insurance premiums. Add to the arrogance of overconfident practitioners the endless overzealous media hyping of the latest breakthrough in the pursuit of eternal life, and the result is an ill-informed population who believe it is in their best interest to have every conceivable screening examination, with no understanding of the downside. As Woodward and Bernstein used to say, if you really want to know where the source is, follow the money—there is lots of it. It flows into the pockets of not only individual radiologists but also giant public institutions, private hospitals, and imaging centers and their investors. And why would the investors in high-cost imaging technologies ever want to limit reimbursable examinations? You, dear reader, are no doubt one of the few who take the high road and follow decision support recommendations. Odds are, though, that almost all your colleagues behave more like the 22 doctors who were above such assistance and less like the 3 who improved their performance by
listening to expert advice. Given that the evidence suggests that voluntary self-remediation will not work, restriction of image-ordering privileges needs to be on the table as a potential policy to clue in the clueless. Even those with a reasonable grasp of imaging options will encounter situations where they could benefit from a decision support system. But almost everyone will ignore it, unless there is some outside reason compelling them to pay attention to it. Read the article. Dem’s da facts. Robert G. Stern, MD Department of Medical Imaging University of Arizona College of Medicine Tucson
Reference 1. Prevedello LM, Raja AS, Ip IK, et al. Does clinical decision support reduce unwarranted variation in yield of CT pulmonary angiogram? Am J Med. 2013;126:975-981.