Rising imaging utilization? Not so fast, says imaging community

When a study published June 12 in the Journal of the American Medical Association (JAMA) demonstrated a surge in advanced imaging use within integrated healthcare systems, many headlines focused on how the high utilization was driving healthcare costs and increasing radiation doses received by patients. The medical imaging community, however, was quick to put these results in context.

The study, conducted by Rebecca Smith-Bindman, MD, of the University of California, San Francisco, and colleagues, showed that since 1996, the use of CT nearly tripled and the use of MRI nearly quadrupled in managed care systems, but statements from the American College of Radiology (ACR), Medical Imaging & Technology Alliance and the Access to Medical Imaging Coalition noted this is only half the story. While it’s certainly true that imaging use has increased since the mid-90s, Medicare data has shown that imaging use started to level off in the late 2000s and is actually down since 2008. Medicare spending on scans is at the same level it was in 2003, according to the ACR.

In an interview with Health Imaging, David C. Levin, MD, of the department of radiology at Thomas Jefferson University Hospital in Philadelphia, said that by emphasizing the overall imaging growth since 1996, and not the recent slowdown in utilization, the study from Smith-Bindman et al is actually “misleading.”

Another concern of Levin’s was the study’s discussion of increasing radiation doses. In the JAMA article, the authors pointed out use of CT was associated with a rise in average per capita effective dose from 1.2 mSv in 1996 to 2.3 mSv in 2010, and the percent of managed care enrollees receiving doses higher than 20 mSv in a given year approximately doubled during the study period.

“All of this talk about radiation exposure is a certain amount of hysteria,” said Levin. Discussions about radiation are important in some ways, he said, but it must remain in context. Levin noted that the lifetime risk of developing cancer is somewhere around 21 percent, though it varies based on a myriad of factors. In contrast, the added risk of cancer from imaging is quite small and the benefits of getting a scan far outweigh the risks of not getting one if it is clinically indicated.

“You could say to yourself, ‘Geez, I better not ever get into a car because 50,000 people a year in the country die in automobile accidents.’” Levin quipped.

The Society of Nuclear Medicine also articulated this point in a position statement on nuclear medicine and molecular imaging procedures it released in response to the JAMA study. “The Society of Nuclear Medicine (SNM) and the SNM Technologist Section (SNMTS) recognize that the use of low levels of radiation in these procedures entail some possible risk…SNM and SNMTS also recognize that if an appropriate procedure—one that can provide the physician with clinical information essential to the patient’s treatment—is not performed when necessary due to fear of radiation, it can be detrimental to the patient.”

Others painted the increase in imaging use in a slightly different light. William T. Thorwarth, Jr., MD, RSNA board of directors liaison for publications and communications and radiologist at Catawba Radiological Associates in Hickory, N.C., told Health Imaging he felt the most interesting message of the study “is that in managed care systems, despite no financial incentive for volume, the requesting providers (physicians and mid-level) who order the imaging exams have found these valuable tools critical to what they feel is necessary for high quality care for their patients.”

Thorwarth noted that public recognition of imaging growth has been driven largely by anecdotal reports of high radiation dose incidents and increased scrutiny of healthcare costs. “Often missing is the fact that the imaging exams eliminate the need for riskier and more costly invasive procedures.”