Finding the gaps in appropriate imaging

When it comes to encouraging appropriate utilization, radiology has come a long way. It’s been a focus in the field for years, appropriateness criteria have proliferated, and new tools, such as clinical decision support, aim to make the task much easier. That said, much more work remains.

That was the message from a couple of the top-read stories this week. The first, published in Annals of Internal Medicine, looked at utilization of cardiac stress tests with imaging and found the rate to have risen over the past 20 years, with many of such tests likely to be inappropriate.

Joseph Ladapo, MD, PhD, assistant professor in the Departments of Medicine and Population Health at NYU Langone Medical Center in New York City, and colleagues looked at data from a pair of national care surveys and showed that between the time periods of 1993-1995 and 2008-2010, the annual number of ambulatory visits in the U.S. in which a cardiac stress test was ordered or performed increased by more than 50 percent. The proportion of stress tests with imaging grew from 59 percent to 87 percent over this period.

Ladopo and colleagues said at least 34.6 percent of these tests were likely inappropriate. The price tag for this inappropriate imaging? $501 million annually (with an estimated 500 radiation-induced cancers on top of the financial costs).

Appropriateness criteria have been published as a tool to help providers avoid unnecessary testing, and another group from NYU Langone Medical Center wanted to put their institution to the test by reviewing one month’s worth of outpatient abdominal and pelvic CT and MRI exams and comparing them against American College of Radiology Appropriateness Criteria.

Andrew B. Rosenkrantz, MD, MPA, of the Department of Radiology at NYU Langone, and colleagues published their findings online in Academic Radiology, and showed that of the exams that had a matching variant in the appropriateness criteria, 92 percent of the studies performed were appropriate.

There was a problem, however. While the studies that had relevant criteria often checked out, only 45 percent of the cases had matching variants in ACR’s criteria that could be used to assess the appropriateness of the study. In particular, gaps existed in colon cancer follow up on CT and hepatocellular carcinoma screening on MRI.

As radiology looks to maximize the appropriateness of the imaging that is performed across the country, it will take a combined effort of providers leveraging tools such as clinical decision support, while ensuring that appropriateness criteria remain dynamic and ever-evolving.

-Evan Godt
Editor – Health Imaging