Three studies, one call for imaging ‘more wisely’

The time has come for patient-facing physicians to collaborate more closely with radiologists in deciding whether or not to image. And, going forward, the decision must incorporate patients’ values about “the pressing need to perform imaging tests more wisely.”

So write Rebecca Smith-Bindman, MD, and Andrew Bindman, MD, both of UC-San Francisco, in a JAMA Internal Medicine editorial published online Dec. 28.

The piece accompanies three studies running in the same edition of JAMA IM that, taken together, serve to amplify the authors’ call for healthcare providers to more forcefully implement ACR’s Image Wisely campaign, the national effort to cut out unnecessary imaging and use minimal ionizing radiation:

• Mathew Mercuri, PhD, of McMaster University and colleagues found that, in myocardial perfusion imaging (MPI, aka “nuclear stress test”), radiation use varied widely across the U.S.—and the typical patient received a dose that was, on average, 20 percent higher for the same test performed in some 64 other countries. “There is no obvious benefit of using higher radiation doses to perform this test,” write Smith-Bindman and Bindman, adding that the harm of the higher radiation dose per MPI test is compounded by “our markedly greater use of this imaging test compared with other countries.”
• In a related analysis, Mercuri and team found that the U.S. is using lower-radiation stress-first imaging at rates well below those seen elsewhere (7.7 percent here and in Canada vs. 84.4 percent in Europe). “Adopting a practice of stress-first imaging among patients undergoing MPI in the United States could result in a dramatic decrease in the average radiation dose without loss of clinical information,” Smith-Bindman and Bindman point out.
• Frank Drescher, MD, and Brenda Sirovich, MD, of Dartmouth’s Geisel School of Medicine found that the rates of CT scanning for patients visiting an emergency department with respiratory symptoms quadrupled between 2001 and 2010. “Imaging increased in every severity group but rose most steeply among patients with low-acuity symptoms (such as those with nasal congestion), who are the least likely to benefit from such testing,” write Smith-Bindman and Bindman. “The authors found no measurable health benefits of greater CT scan use and concluded that a great deal of the increase in the use of CT scanning in the emergency department is unnecessary.”

Smith-Bindman and Bindman maintain that, while clinical judgment makes for an appropriate starting point, performance measures must be established on evidence.  

Noting that existing decision support tools for medical imaging tests rely largely on ACR appropriateness criteria tracing to expert opinion, the authors state that these criteria have not reduced the use of inappropriate imaging tests or improved the safety of imaging studies “in large part because their criteria, while a step in the right direction, do not go far enough in explicitly stating that imaging tests are not necessary even when the data clearly support this conclusion.”

Smith-Bindman and Bindman stress the importance of including patients in the decision-making process around imaging.

“Patients are the ones who these tests are designed to help, and their viewpoints on the value they place on different outcomes must be incorporated into every measure,” they write.

Meanwhile, they continue, referring physicians can inform and reinforce patients’ understanding of how to best balance potential harms of a given radiation-based imaging procedure against its potential benefits.

For their part, radiologists “have an important role to play in developing performance metrics by informing physicians about the best test option, when tests are likely to yield important as well as incidental results, and what is practical with respect to minimizing radiation exposures while ensuring accurate diagnoses.”

Smith-Bindman and Bindman conclude with a heads-up on the Protecting Access to Medicare Act, which will soon require physicians to consult appropriate-use criteria (aka “decision rules” or “clinical decision support tools”) before ordering and billing for advanced diagnostic imaging tests for Medicare patients.

They also cite the march of the in-development Medicare Incentive Payment System (MIPS), which will judge physician performance by quality metrics as part of the U.S. healthcare system’s move toward pay-for-performance reimbursement.

“The establishment of meaningful measures of performance in combination with payment reform,” they write, “offers the best hope of improving the value and safety of medical imaging studies.”

ACR’s Image Wisely program followed from the 2012 launch, by the American Board of Internal Medicine Foundation, of the Choosing Wisely initiative aimed at reducing wasteful or unneeded medical tests, treatments and procedures across the board.