The Overutilization of Diagnostic Imaging
The Overutilization of Diagnostic Imaging
Over and over again I have patients come to me in clinic demanding that I look at their MRIs and X-rays to see their “ripped bulging out of place disc”, “bone on bone knee”, “arthritis in the spine”, etc. I like to look at imaging and test my anatomy skills just as much as the next guy, however I have now started immediately responding to the patient that “I don’t really need to see that Mrs. Jones. It isn’t going to change anything I do, and this is why….” I will get to the why later on in this article, but first I would like to talk about the value that diagnostic imaging adds to clinical practice, the cost, and the overutilization.
Diagnostic imaging is a great invention. One that when used appropriately can be extremely beneficial to medical practice. However, imaging has the potential to be very easily abused, over utilized, and also actually harm the patient by giving them a poor outlook on their potential to recover based on findings such as joint/disc degeneration, atraumatic rotator cuff tears, and disc bulges to name a few.
First I would like to start stating a fact that nearly everyone in America needs to hear. JUST BECAUSE AN X-RAY OR MRI SHOWS THAT YOU HAVE A ROTATOR CUFF TEAR, MENISCAL TEAR, DEGENERATIVE JOINTS, OR BULGING DISC DOES NOT MEAN THAT YOU WILL HAVE PAIN FROM IT/ARE DOOMED/HAVE TO HAVE SURGERY/ETC. Okay, now that I’ve gotten that off my chest I would like to show some supporting research to validate my claim.
In one study of asymptomaticpatients aged ≥ 60 published way back in 1990 it was found that “36% had a herniated disc, 21% had spinal stenosis, and 90% had a degenerated or bulging disc.(3) This probably seem counterintuitive to what the vast majority of the population would think because everyone has an uncle bill who herniated a disc and was incapacitated until surgery!
Additionally, In a study of 68,000 radiographs, clinically unsuspected lesions occurred in 1:2500 patients aged 20 to 50 years. (8) This indicates that an astounding 2499 unnecessary radiographs were performed for every one that found something that wasn’t already suspected from clinical evaluation.
In another study examiners used CT scans in a group of 52 asymptomatic patients. They then had 3 independent neuro-radiologists examine these scans. The radiologists found that spinal disease was identified in an average of 19.5% (23.8%, 22.7%, and 12.5%) of the under 40-year-olds, and it was a herniated nucleus pulposus in every instance. In the over 40-year-old age group, there was an average of 50% (29.2%, 81.5%, and 48.1%) abnormal findings, with diagnoses of herniated disc, facet degeneration, and stenosis occurring most frequently.(9)
Another study in a group of patients over the age of 55 with symptomatic non-traumatic (think I didn’t fall down and get up with shoulder pain) rotator cuff tears demonstrated that “operative treatment is no better than conservative treatment with regard to non-traumatic supraspinatus tears, and that conservative treatment should be considered as the primary method of treatment for this condition.”(6) This study showed that even though the patients had a tear they were equally as likely, if not more likely, to reach a point of decreased pain and increased function with rehab alone vs surgery followed by rehab.
The same scenario can be seen yet again in the knee with meniscal tears. A 2013 randomized control trail with 351 subjects presenting with mild-moderate knee osteoarthritis and a meniscal tear was conducted by Katz et al. It was found that “symptomatic patients with a meniscal tear and imaging evidence of mild-to-moderate osteoarthritis who were randomly assigned to arthroscopic partial meniscectomy with postoperative physical therapy had improvements in functional status and pain at 6 months that did not differ significantly from the improvements in patients randomly assigned to a standardized physical-therapy regimen alone”(7)
In yet another study, patients who were enrolled in a trial of surgery versus conservative therapy, investigators (who were trained radiologist) were unable to determine which patients had favorable versus unfavorable outcome.(5) This suggests that degree of “damage” visible to highly trained radiologist on diagnostic imaging does not correlate well at all to how a patient will present regarding pain and ability to rehab.
Next, I would like to open another can of worms and address the cost and overutilization of imaging
Borczuk et al has found that:
“The overuse of imaging is a major contributor to the rise in the growing costs of low back pain care in the United States. It is not just the cost of the study itself, the downstream costs associated with additional tests, follow-up, and referrals. It is no surprise that the increased rate of spine imaging coincides with the increased rate of lumbar surgery.”(4)
Another systematic review conducted in 2013 by Sorenson et al found that:
“the initial use of imaging diagnostics (eg, x-rays, computed tomography, magnetic resonance) was initially targeted to specific organs and functions, but their application has extended to almost every part of the human body, resulting in increased spending”(1)
Additionally in a massive government review it was concluded that:
“Much of the growth in advanced diagnostic imaging has been concentrated in physician offices. This growth is partly attributed to physician self-referrals - defined as the referral of a patient by a physician to medical facilities in which the physician has a financial interest, or by patient self-referral. Physician self-referrals not only pose a conflict of interest, but also, in the case of diagnostic medical imaging, encourages inappropriate utilization of those services, and drives up health care costs. These types of arrangements may also limit competition and patient choice because patients may not be advised of other venues for obtaining imaging services, and adversely affect the practice of other health care providers.”(2)
“The Government Accountability Office (GAO) estimates that in 2010, providers who self-referred likely made 400,000 more referrals for advanced imaging services than they would have if they were not self-referring. These additional referrals cost Medicare about $109 million. The $109 million is just the effect from Medicare patients. If it is assumed that one-third of advanced imaging tests performed across the nation are unnecessary, the data strongly suggests that efficient radiology benefits management could cut America's radiology expenditures by $20 billion to $30 billion annually.”(2)
It is also important to note that Congress included a provision known as the Stark law in the Omnibus Budget Reconciliation Act of 1989 in order to stop the practice of physician self-referrals for clinical laboratory services under the Medicare program. However, they included an exception to this law that created an In-office Ancillary Services Loophole. The loophole for in-office ancillary services allows physicians to either open their own advanced imaging centers or lease or purchase such equipment for their office. These types of arrangements allow physicians to bill insurance providers and Medicare for both the technical and professional components of these expensive scans and studies. (2)
Following the enactment of Stark II, the Government Accountability Office released a study specifically illustrating the inappropriate utilization of diagnostic medical imaging resulting from self-referral. Its data clearly indicated that physician owners of diagnostic imaging devices referred their patients more frequently, for more expensive services, than non-owners, including 54% more MRI scans, and 27% more CT scans.(2) OH, BY THE WAY…DID I MENTION THAT PHYSICAL THERAPY IS A “SERVICE”(physical therapy is a profession not a subsidiary service) THAT ALSO FALLS IN THE LOOPHOLE OF THE STARK LAW. This is an example of another of referrals that, just as imaging, gets abused by physicians who have ownership and/or will make financial gain from referral. As I’m sure that you can guess this is a subject that I have passion for as a practicing physical therapist who is regularly fighting for patients from the physician groups that self-refer to their own in office PT.
Finally, and possibly most crucial, we are creating a fear driven society by the overuse of imaging and using intimidating terms like “bone on bone”, “arthritis”, and “spinal degeneration” when discussing a patients’ condition with them. Research in pain sciences has come a very long way over the last several years, and we now have a much better understanding of the role that the brain plays in experiencing pain. Using terms like these can create predetermined beliefs for patients that impair their ability to rehab and lead them down the road to pain medication abuse, depression, injection after injection, and unsuccessful surgeries. However, the subject of pain sciences, chronic pain, and central sensitization is a topic for a different blog post that I won’t delve into presently.
In conclusion, it is clear that we are functioning in a broken system that overuses unnecessary services and costs billions of dollars to a health care system that is already using more than twice GDP than the next closest developed country in the world. I don’t have the answers to this problem, but it appears that physicians need to be educated in the true value of diagnostic imaging/when is the most appropriate time to utilize these services, in office ancillary service loopholes need to be closed, and possibly most important we need a more educated public that doesn’t throw in the towel based purely on what is seen on diagnostic imaging. I am personally on a mission to educate patients one by one, and I hope that you will join in and fight the good fight as well.
As always continue to learn and work towards improving your practice with evidence!
References:
1. Sorenson C, Drummond M, Bhuiyan Khan B. Medical technology as a key driver of rising health expenditure: disentangling the relationship. ClinicoEconomics and Outcomes Research: CEOR2013;5:223-234. doi:10.2147/CEOR.S39634.
3. Boden SD, Davis DO, Dina TS, et al. Abnormal magnetic resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am.1990;72(3):403-408. (Prospective observational cohort)
4. Borczuk P. An evidence-based approach to the evaluation and treatment of low back pain in the emergency department. Emerg Med Pract. 2013;15(7):1-23.
5. Barzouhi A, Vleggeert-Lankamp CLAM, Lycklama à Nijeholt GJ, et al. Magnetic Resonance Imaging in Follow-up Assessment of Sciatica. New Engl J Med. 2013;368(11):999-1007.
6. Kukkonen J, Joukainen A, Lehtinen J, et al. Treatment of non-traumatic rotator cuff tears: A randomised controlled trial with one-year clinical results. Bone Joint J. 2014;96-B(1):75-81.
7. Katz JN, Brophy RH, Chaisson CE, et al. Surgery versus physical therapy for a meniscal tear and osteoarthritis. N Engl J Med. 2013;368(18):1675-84.
8. Nachemson A. The lumbar spine: an orthopedic chalenge.Spine (Phila Pa 1976). 1976;1:59-71.
9. Wiesel SW, Tsourmas N, Feffer HL, Citrin CM, Patronas N. A study of computer-assisted tomography. I. The incidence of positive CAT scans in an asymptomatic group of patients. Spine. 1984;9(6):549-51.
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