A clinically meaningful approach to evaluating repeat medical imaging

{mosads}Without a clinically-based common lexicon of why MRI or CT scans, for
example, are “repeated,” policy makers and insurance companies are
making decisions based on a body of research using vague, ill-defined
ideas that seem to be based on the premise that anything repeated is,
by definition, wasteful. Where they should be focusing their
attention, instead, is on which diagnostic tests have higher value,
and will lead to better patient outcomes. Those are tests worth doing!
The others are often not. Operating solely on analyses of insurance
claims data, without considering the circumstances of individual
patients, serves neither patients nor the health care system well. Our
focus needs to be on patients, and not just on numbers.

This week, the Harvey L. Neiman Health Policy Institute seeks to fill
this void with a new report that provides guidelines to researchers
and policy makers on the effectiveness and appropriateness of repeat
medical imaging tests. The decision-making framework established by
the Neiman report could also be applied to multiple types of other
diagnostic tests as well.

Optimally, this report will dispel the notion that repeat testing is
automatically synonymous with excessive spending and health system
abuse. It categorizes different types of repeat testing and explains
how a repeat imaging exam can be essential to protecting patient
health and preventing even greater downstream health spending. It also
provides categories to help researchers and policy makers identify
those imaging examinations which provide less value—setting the stage
for the use of clinical decision support and electronic imaging record
integration as the nexus for system improvement.

Take the patient who undergoes a pre-operative chest x-ray. A vague
shadow raises the question of an early lung cancer—but this could just
as easily be a scar. If you were the patient, wouldn’t you want an
answer? If you’re a physician, and this was your patient, wouldn’t you
want a definitive answer, if at all possible? That’s where
supplementary imaging comes into play. Nominally, some researcher
could say that a chest CT scan was a “repeat test” but in a
circumstance like this, it’s the best test to determine whether this
is a benign nothing or an early cancer that needs to be treated
accordingly.

How about the woman with breast cancer who just completed
chemotherapy? Her CT scan shows her free of disease, but she’s sadly
involved in a car wreck the next day and flown to a trauma center. She
undergoes a “repeat” CT scan of the abdomen—for entirely different
circumstances. When she’s treated as a just a number in some big
research data file, some would argue that she got two CT scans in two
days and that must be wrong. When she’s treated as a human being,
however, she got darned good care.

I’m not suggesting that there aren’t tests that don’t meet standards
of effectiveness and necessity. That happens much more than we’d like.
And that’s why many of us see real time clinical decision support as
being part of the solution—just like better electronic imaging and
health record integration—in moving the imaging value proposition
forward. But, as the Neiman report makes clear, we’ll never have
meaningful and productive discussions about improving our system if we
paint repeat imaging with broad brush strokes.

Ideally, current health care reform initiatives will allow us to
achieve better individual patient care and improved population health,
all at less cost. Repeat medical imaging needs to be part of the
discussion—but that discussion needs to be a thoughtful one.

Richard Duszak, MD, FACR is the Chief Executive Officer and Senior
Research Fellow of the Harvey L. Neiman Health Policy Institute.