More is not always better in medical imaging


Imaging Idolatry. That's what Dr. Rick Deyo describes in the Archives of Internal Medicine with a subhead of "The Uneasy Intersection of Patient Satisfaction, Quality of Care, and Overuse."

Background: "A 2008 report by the Government Accountability Office (GAO) noted that in just 7 years, from 2000 through 2006, Medicare spending for imaging more than doubled to approximately $14 billion. Most of the growth was in advanced imaging such as computed tomography (CT) and magnetic resonance (MR) imaging. In the particular case of lumbar spine imaging, MR images covered by Medicare increased 307% between 1994 and 2005. The GAO linked spending growth, in part, to a shift of more advanced imaging from hospitals into physician offices. It also noted wide geographic variability in the use of imaging, "suggesting that not all utilization was necessary or appropriate."

And outcomes aren't necessarily improved by more imaging.

Key points from Deyo's summary:

• Just because patients want imaging doesn't mean it's good medicine. Deyo writes: "First, it seems unwise to equate patient satisfaction with better health outcomes, and satisfaction-based incentives may foster overuse. Second, it may be necessary to redouble our efforts at patient education. There is at least a shred of evidence that brief patient education can help to maintain patient satisfaction when imaging is not recommended. Avoiding imaging may itself be part of this education: when radiography was performed for low-risk patients with back pain, expectations for imaging increased. In essence, performing imaging may teach patients that it should be expected. Finally, if quality of care is defined in part by avoiding overuse, we have a challenging task that may require more innovative strategies. That task is to convince our patients that more is not always better."


MRI imaging for back pain is one of the best examples of how our high tech and overly expensive applications get misused and overused.

From the providers standpoint, you have no legitimate reason to deny the test to a patient. To use an argument of cost is to expose yourself as to who's interest you are looking out for; the patient or the insurance company. I try to tell patients that they should wait and engage in conservative therapy, but many have jobs they have to get back to. Do you risk having the patient forgo scanning only to find they have a disc that needs surgery several weeks later? You then have a potentially angry patient who wonders why you did not order the test earlier.

It is a completely innocuous test with no downside to the patient with the exception of claustrophobia from the machine. Throw in the fact that insurance pays handsomely for the test and you have the perfect recipe for overuse and abuse.

I would reject the idea that this all relates to physicians opening their own MRI centers. Hospitals tend to be just as greedy when it comes to MRI income which is a profit center for many hospitals as well.

Is it really always that black and white? Is reason to order an MRI simply because a patients have "jobs they have to get back to"? Quite often an MRI is ordered not in the light of "life or death". Geez, give me a break! A conservative therapy from someone that is QUALIFIED to provide an evidence-based evaluation is truly the first step for low back pain. Do the research and it is quite easy to see whom that provider should be.

I am not able to access the article you link to, possibly they cover this question in the article.

My question is, what part of the increase in CT and MR imaging, was simply replacement of other methods?

For instance, in some cases CT scans are replacing other methods of diagnosis: (this article talks about CT scans being used in place of stress test) .

Assuming that a hypothetical article on heart CT scans was done, but without controlling for the "swapping" of one test for another, an article could leave someone with the impression that more tests are being done than before.

About this Entry

This page contains a single entry by Gary Schwitzer published on May 26, 2009 8:29 AM.

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