Too many CT scans?

Are CT scans being overused? More to the point, are they being overused in hospital emergency rooms?

The flames seem to be finally dying down after a contentious online debate sparked by Dr. Robert Centor, who blogged recently about a study showing increased use of CT scanning in hospital emergency departments, and suggested this is most likely due to the patient load and pressures on emergency-room doctors.

“It appears that too often CT scanning takes the place of a careful history and examination,” he observes. “This can occur when the emergency physician is drowning in patients.”

The ensuing discussion was argumentative – one poster accused Dr. Centor of being “smug” – but it shed some interesting light on an issue that’s far more complicated than it appears on the surface.

The No. 1 cause of excess CT scans is fear of litigation, one physician said. Someone else stated, “We order too many scans because we can.”

In the high-stakes emergency setting, physicians can’t afford to miss a diagnosis because they’ve decided to skip a test, wrote another physician: “My experience doing emergency medicine is that a lot of CT scanning is ordered either to rule out conditions where we are expected to have 100% certainty not to miss (subarachnoid hemorrhages are one example already mentioned), or where the demand for certainty is being driven by the patient or our inpatient colleagues.”

The debate continued in a second post, where one of the key questions became: How do we know patients are receiving too many CT scans, and how do you define “too many”?

So why should the average person care about this issue? There’s no question that imaging technology has aided greatly in diagnosing what’s wrong with the patient. It has helped reduce uncertainty and in many cases eliminated the need for expensive and potentially risky exploratory surgery. But in much of the public discussion, the focus has been on the benefits rather than the down side. We talk about the certainty of diagnosis and less about the incidental findings that can lead to more testing and possible harm to patients. We talk about how beneficial it is to obtain high-definition images of what’s happening inside the body and not so much about the long-term impact of all that radiation exposure.

There are some signs the tide may be turning. The risks vs. the benefits of medical imaging are being discussed more often, especially among health care professionals, in ways that are thoughtful and evidence-based. Consider Dr. Bob Wachter, one of the leading patient safety gurus in the U.S., who blogged recently about the potential harm inherent in CT scanning. “Even if the risks turn out to be less than we fear, most skeptics now agree that we’re causing a lot of cancers, and that many could be prevented if we took a few sensible steps,” he wrote.

Dr. Wachter concludes the medical community needs to “Just Say No more than we ever have before.”

While this is a sound clinical concept, I suspect it’s easier said than done. According to a study published in December in the Annals of Emergency Medicine and conducted with a cross-section of patients who came to the ER with abdominal pain, patients felt more confident about the care they were receiving if a CT scan was part of the medical evaluation. They also underestimated how much radiation is contained in the average CT scan, and many couldn’t accurately recall their previous history of CT scans.

Patients aren’t the only ones contributing to the overuse of CT scans in the United States, but their expectations clearly are among the factors. A little education and awareness by the public certainly wouldn’t hurt and it might even help lead toward a more judicious, restrained use of CT scans.

West Central Tribune photo by Ron Adams

The technology boom

Raise your hand if you’ve never undergone a CT or MRI scan, never taken a statin to lower your cholesterol or never had a joint replacement. If your hand is still in the air after reading this, you’re either in a healthy minority or just haven’t caught up yet with the odds.

American health care is very good – a world leader, in fact – at developing and using technology. Just how prevalent our technologic interventions have become is demonstrated in a report recently issued by the National Center for Health Statistics, which takes a look at this technology boom by the numbers.

The findings are rather eye-opening. Take, for instance, the report’s summary of the growth of medical imaging over the past couple of decades:

Despite the significant costs of acquiring advanced imaging capability, the availability and use of imaging technologies in the United States has substantially increased since their introduction in the early 1980s. In 2006, there were more than 7,000 sites offering MRI, with an estimated 27 million MRI procedures performed. In 2007, more than 10,000 CT units were in operation at more than 7,600 hospital and nonhospital sites, and the availability of PET and other imaging modalities has been steadily increasing. The site of imaging services has diffused from hospital inpatient and outpatient settings to nonhospital settings such as physician offices or radiology centers. During the past decade, the number of freestanding diagnostic imaging centers owned by radiologists, other specialists, private investors, or for-profit companies has more than doubled.

The report found that from 1996 to 2007, the number of advanced imaging scans ordered during outpatient office visits tripled in number. In emergency rooms, the use of advanced imaging grew fivefold between 1996 and 2007 for patients under the age of 65 and quadrupled for patients 65 and older.

The number of joint replacement surgeries has grown substantially. At least one analysis estimates the demand for total hip replacements could grow by 175 percent in the next 20 years, while the demand for knee replacements could increase sixfold.

The rate of kidney transplantation increased 31 percent between 1997 and 2006. Liver transplants increased 42 percent during this same period. The use of assisted reproductive technology has risen, especially among women younger than 35. From 1988-1994 to 2003-2006, the use of statins to treat high cholesterol rose almost 10-fold, while the use of antidiabetic medications as a replacement for insulin rose by 50 percent.

None of this is necessarily bad. As the report points out, it’s “almost inconceivable to think about providing health care in today’s world without medical devices, machinery, tests, computers, prosthetics or drugs.” Joint replacement surgery has enabled countless people to remain mobile, independent and pain-free. Angioplasties and organ transplants save lives. Drug therapies have staved off illnesses that might otherwise have been fatal and allowed patients to return to normal life.

The flip side to this is that it costs money. A lot of money. Even interventions that are less costly can add up as they become more widely used. From the report:

Technologies applied to new populations and conditions generally come at a cost to individuals and to society as a whole. Technologies can be very expensive (e.g. heart transplants, chemotherapy) or very inexpensive (e.g. the Band-Aid). Total expenditures for a given technology, however, are determined by both use and cost; consequently, widely used inexpensive technologies can often have higher aggregate expenditures than rarely used expensive ones. Some new technologies can be cost-saving – for example, annual influenza vaccinations in high-risk children. Many technologies, however, contribute to increases in overall health care expenditures because they increase utilization (e.g. more doctor visits may be needed to monitor new drug therapies); they may be used on a larger number of patients; they may be more expensive than technologies they replace; or they may increase life expectancy in populations and thus their lifetime health care costs.

In one of the most telling sentences in the entire report, the authors point out: ”In general, Americans – both providers and consumers – appear to be more willing and eager to adopt and use new technologies than people in other countries.”

This whole issue came to mind when I recently read a New York Times article about robotic surgery. It costs more per patient – $1,500 to $2,000 more. It’s not clear if the results are any better than more traditional surgery. But, as the article explains, hospitals and surgery centers are marketing it and patients are asking for “the robot,” in some cases walking away from surgeons who don’t do robotic surgery.

Readers chipped in with comments. Several said they’d had robotic surgery and couldn’t be happier with the results. Others were more skeptical. “Follow the money,” one person scoffed.

Last weekend my Sunday paper was accompanied by this article in Parade magazine: “Revealing the body’s deepest secrets.” It described several new forms of gee-whiz medical imaging technologies that are “transforming medicine.” One is the use of MRI for diagnosing heart attacks; another is a fiber-optic probe that can help detect oral cancer. To be fair, there could well be an appropriate niche for these technologies – but at what cost, not only in dollar terms but also in the ratcheting-up of people’s expectations? On some online message boards, I’ve seen people criticize their physician’s competence for not ordering a specialized test they felt they should have.

Finally, here’s yet another look at the issue, this time from Kaiser Health News, in an article titled “High-Tech Medicine Contributes to High-Cost Health Care”:

Just before Christmas, 41-year-old Michael Kelley decided he wanted a whole-body imaging exam, the heavily advertised service touted on television by celebrities like Oprah Winfrey. He didn’t smoke, wasn’t overweight, and didn’t have elevated cholesterol. “I’m pretty normal for a guy my age,” he said.

No matter. The electrical engineer scheduled a full-body X-ray computed tomography or CT scan at Virtual Physical, a radiology clinic located in a glass-enclosed office building on a busy commercial strip not far from the headquarters of the National Institutes of Health. The clinic’s name, plastered in large red letters on the building’s exterior, served as a billboard aimed at cars exiting the high-end shopping mall across the street.

About an hour after checking in, Kelley left the clinic clutching a manila envelope with high-resolution 3-dimensional images of most of his major body systems, including the insides of the major coronary arteries pumping blood to and from his heart. “They said I was fine, no plaque,” he said. Kelley paid $1,400 for a CT scan to confirm what he and his doctor already knew – he was perfectly healthy.

The rest of the article delves into some of the difficult issues surrounding the use of medical technology. When does the technology genuinely benefit patients and when does it reach the point of diminishing returns? Is “better” always the best thing? How should we weigh the potential benefit to the patient vs. the risk of harm?

The article concludes that in the long run, technology will probably help save money, but we’re not there yet:

When robotic doctors are able to perform micro-surgeries; when arm and leg replacements function as well if not better than the original parts; when pharmacology replaces more expensive treatments and therapies, the U.S. may actually be able to use technology to bend the cost curve of health care downward. Until that time comes, we’re stuck with ever-increasing costs and left to wonder whether the investment is greater than the payoff.

What’s remarkable about this whole discussion is that it’s happening on a wider, more public stage. Ten years ago, maybe even five years ago, I’m not sure the average person was ready to contemplate the down side of technology. More and more, however, these questions are being asked and debated – not just within policy circles but among the public. We might not have the answers, but the sheer fact that we’re willing to acknowledge it and talk about it is surely a sign of progress.

West Central Tribune photo by Anne Polta

The fallout zone

The headlines earlier this week were rather startling: Radiation from medical imaging, particularly from CT scans, might be exposing people to unnecessary risk and contributing to an increased likelihood of getting cancer.

The news appeared in the latest edition of the Archives of Internal Medicine. In an accompanying editorial, the question was raised: Although computed tomographic scans have aided greatly in visualizing the interior of the body, have we become so carried away with the benefits that we’re minimizing the risks? From the editorial:

Every day, more than 19,500 CT scans are performed in the United States, subjecting each patient to the equivalent of 30 to 442 chest radiographs per scan. Whether these scans will lead to demonstrable benefits through improvements in longevity or quality of life is hotly debated. What is becoming clear, however, is that the large doses of radiation from such scans will translate, statistically, into additional cancers. With CT scan use increasing annually, it is imperative that clinicians take into account the radiation risks when assessing the benefits to their patients.

Two new studies published in this week’s Archives of Internal Medicine underscore the point. One of these studies attempts to quantify the future risk of cancer from CT scan exposure, using 2007 as a baseline and analyzing the risk based on age, gender and type of scan. The conclusion: As many as 29,000 future cancers might be related to the use of CT scans. The risk appeared to be higher for CT scans of the chest and abdomen, and for patients who were younger.

Some interesting figures from this study: Approximately one-third, or 35 percent, of the projected cancers from CT exposure were among the 35-to-54-year-0ld age group. Since there’s a long latency – as much as 20 to 30 years – between radiation exposure and the potential development of cancer, it stands to reason that exposure from CT scans would pose a higher risk to younger people whose life expectancy is comparatively longer. Lung cancer was the most common projected cancer, followed by colon cancer and leukemia. Women also appeared to be at higher risk, possibly because they have a higher frequency of CT scans than do men.

There’s also dose, scan type and technology to take into account. The second study published in the Archives of Internal Medicine examined CT scans done at four institutions in California last year and found that, depending on the scan and the equipment, the amount of radiation varied by anywhere from 6-fold to 13-fold. Whole-body scans, for instance, subject the patient to more radiation than more limited scans. The researchers also found that in many cases, the radiation amount was substantially higher than previously thought. "It is important to understand how much radiation medical imaging delivers, so this potential for harm can be balanced against the potential for benefit," the study’s authors wrote.

Do consumers need to worry? I admit to cringing over some of the alarmist headlines that have appeared this past week: "CT scans blamed for surge in cancers." "CT scans more dangerous than previously assumed." "Thousands of new cancer diagnoses predicted, due to soaring use of CT."

It’s true that CT scans deliver considerably more radiation than the average X-ray. It’s also true that this form of medical imaging is widely used and is to some extent overused.

But concern over radiation exposure from medical imaging is by no means a new issue. Multiple studies have documented that there has always been some level of risk. This study, for instance, addresses the safety of doing CT scans of the head among children. Here’s another study that takes a look at the use of CT scans for detecting coronary artery calcification among asymptomatic adults.

Some caution also is warranted in interpreting the statistics contained in the Archives of Internal Medicine study. First of all, the projections are the result of computer modeling, not actual cases. Secondly, even if the projections are accurate, they still represent only 1.5 to 2 percent of new cancers diagnosed annually in the United States.

None of this should be taken to mean that CT scans are dangerous or that people should stop having them. The American College of Radiology weighed in this week with its own statement, pointing out that medical imaging has greatly improved the ability to diagnose disease and injury and is far cheaper and less invasive than surgery.

What it seems to come down to is whether the technology is being used appropriately. From the ACR’s statement:

The American College of Radiology advises that no imaging exam should be performed unless there is a clear medical benefit that outweighs any associated risk. The ACR supports the "as low as reasonably achievable" concept which urges providers to use the minimum level of radiation needed in imaging exams to achieve the necessary results.

This message of moderation is one we’ve been hearing rather often lately, first with mammography and cancer screening, and now with CT imaging. While it might be confusing and possibly alarming to people, overall it’s not a bad thing to insert these issues into the public discussion. Medical intervention often involves a balance between benefit to the patient and potential risks. The more we understand that it’s not entirely risk-free, the better we’ll be able to make good decisions.

Then there were 3: Cost, choice and the medical arms race

The landscape of the local medical community shifted several degrees last week with the announcement that three clinics – Family Practice Medical Center, Janning ENT Center and the Willmar Asthma and Allergy Specialty Clinic – have formed a medical imaging joint venture with the Center for Diagnostic Imaging.

It’s not the first time the players have rearranged themselves on this particular chessboard. In fact, medical imaging services have been at the center of a series of moves and countermoves among local health providers for at least the past seven or eight years.

For years, medical imaging was dominated by Rice Memorial Hospital, which provided most of the services and also had Kandiyohi County’s only CT and MRI scanners. Then, in 2001, Affiliated Community Medical Centers acquired its own CT and MRI. For the next six years the two organizations operated their medical imaging services more or less independently of each other. Late in 2007 they decided to cooperate, signing an agreement to fold medical imaging into a new joint venture known as Willmar Medical Services and owned by the hospital and ACMC, which share the profits and losses 50-50.

And that’s how the picture looked until now, with the arrival of the Willmar Center for Diagnostic Imaging this fall. Construction is already under way in the Lakeland Health Center building to accommodate a new CT scanner, ultrasound, X-ray, bone density imaging, digital mammography and interventional radiology. The partners in Willmar CDI say they might add MRI services at some future point, if there’s enough need or demand.

So what does this mean for patients? What does it mean for the community? The answers, as it turns out, are not at all easy to pin down. In fact there seem to be more questions than answers.

On many levels, it’s hard to argue with the decisions that have been made. In each case, providers have seemed sincerely motivated by a wish to provide good care for their patients and to ensure there’s local access to high-quality imaging technology. Given the importance of medical imaging as a diagnostic tool, it’s not inappropriate for them to want to make it available to their patients.

But we’re now going to have three CT scanners in Willmar, and maybe three MRIs as well. If you do the math, this works out to one CT unit for every 6,000 city residents. Is this adequate? Or is it too much for a rural community of 18,000?

People come to Willmar’s medical facilities from a much larger geographic area, of course. If you look at Kandiyohi County as a whole, the ratio increases to one CT scanner for every 14,000 or so county residents – the equivalent of a good-sized town. Is this a better, more accurate yardstick?

How do we know when enough is enough? There doesn’t seem to be any objective way to measure this because, as far as I know, no one has ever determined what the ideal, most cost-effective ratio should be.

And let’s not forget the region’s small rural hospitals. Several of them – Benson, Litchfield and Olivia, to name a few - have CT units of their own, many within a 30-mile radius of Willmar. Is this a reasonable investment on behalf of the communities they serve? Or is it good enough to send their patients somewhere else if they need a CT scan, or for smaller rural hospitals to rely on mobile imaging services that come once or twice a week?

What should the expectations be for rural health care? Is the cost of buying and maintaining high-tech medical imaging equipment a worthwhile tradeoff for having it readily available in rural communities?

For rural Minnesota, the Willmar medical community is somewhat of an anomaly. There are two dominant players: a regional referral hospital and a regional multi-specialty clinic system. There’s one medium-sized player, the family practice clinic. In recent years a handful of smaller, independent specialty clinics also have sprung up.

What should the relationships among them look like? Should they compete in some areas and cooperate in others? Compared to many towns, there’s a good track record of cooperation among Willmar’s medical providers. At times they have disagreements (who doesn’t?), but for the most part they’ve worked well together – until something comes along that reveals the underlying faultlines. 

For better or worse, the local medical community is highly interdependent. When someone makes a strategic decision, it tends to reverberate.

Here’s an example: When ACMC started its own CT and MRI service in 2001, hospital officials worried the market wasn’t big enough to sustain two such services. They feared Rice Hospital would lose patient volume – and revenue – for these two types of imaging and, as it turned out, that’s exactly what happened. Rice also found itself competing in a tight employment market for qualified technologists. The hospital’s high-tech imaging program never really recovered until the joint venture went into effect at the beginning of 2008.

How much do we value the ability of medical providers to make strategic decisions they believe will benefit their patients and their business? Should smaller clinics be forced to refer patients to services that financially benefit their competitors? Is there a benefit to offering services that are locally owned and help keep money in the local economy?

How much do we value choice? There’s an increasing push for consumers/patients to participate more in the decision-making and to “shop” for their care on the basis of cost and quality. How is this supposed to work in a rural market with a limited number of providers? Are we willing to accept that there might be only one game in town?

For that matter, what role have consumers/patients played in the medical technology arms race? Have we contributed to it by having expectations of easy, convenient access and a whole menu of options?

How should we view medical technology? There’s no question that medical imaging helps save lives and effectively treats disease. But it’s also expensive; the price for a new CT scanner, for instance, starts at around $1 million. It’s easy for patients, and sometimes health care professionals as well, to be wowed by the gizmos and high-tech trappings. Is it desirable, though, to have the best and latest? Does it mean we’re getting better care? Or do we need to be more skeptical and less credulous?

Overall, the use of medical imaging has been on the rise. The majority of these tests are probably appropriate but some of the time they are not. There’s some evidence that as high-tech medical imaging and other services become more widely available, they’re also used more often, which pushes up overall costs. As for competition, in the health care industry it generally has not led to lower costs; in fact, the opposite is usually true. 

We might not want government telling us how to do health care, but it’s not clear whether the private sector has been any better or more effective at holding down health care costs and expensive duplication of services and technology. If we value a market-driven health care system, are we prepared to accept what this entails? Are we OK with the competition? Are we OK with the fact that at times there will be winners and losers?

Finally, when do we say no? To whom do we say it? Who gets to decide? How should these decisions be made?

I don’t have any answers. Maybe these questions are impossible to answer, or impossible for achieving any kind of consensus. But the questions need to be asked. Nationally, we’re on the brink of health care reform. All the key issues – cost, access, quality, effectiveness – are playing out right here in our own back yard. We can’t afford to not talk about it.

West Central Tribune photo by Ron Adams

Additional reading:

- Factors and Incentives Driving Investment in Medical Facilities, a 2007 report by the Minnesota Department of Health

- The Medical Arms Race Syndome, by the National Institute of Health Policy

This article is from Medical News Today on the relationship between quality and competition in health care. This article, also from Medical News Today, explores the cost and overuse of medical imaging tests. Finally, here’s a thoughtful look at regulation, the free market and inefficiency.