Too many US physicians over-recommend mammography

Physicians in the United States are guilty of over-recommending mammography to women, according to a survey published in the Journal of the American Medical Association (JAMA) Internal Medicine. Conflicting recommendations from imaging societies and regulatory bodies, fee-for-service payment systems and fear of malpractice litigation are major factors, according to the authors.

Breast screening has come under fire in recent years for high numbers of false-positives, causing additional imaging, unnecessary biopsies and additional anxiety for women. While prior studies have shown mammograms catch cancer and save lives, it’s a delicate balancing act, made more difficult by inconsistent recommendations on what age to start regular mammograms.

Researchers from Johns Hopkins University mailed surveys to 2,000 physicians randomly sampled from the American Medical Association Physician Masterfile, asking about their personal mammography recommendation patterns. The results were dispiriting, according to an editorial co-written by JAMA Internal Medicine editor Rita F. Redberg, MD.

A large majority (81 percent) of physicians recommended screening to women aged 40 to 44, and 88 percent recommended screening to women aged 45 to 59. This flies in the face of the best recommendations, according to the editorial.

“In our view, the most evidence-based, transparent and conflict-free guidelines are from the USPSTF,” wrote Redberg et al. “Physicians inexplicably trusted other guidelines more than the USPSTF, which is publicly funded, uses strict methods and carefully supports recommendations with evidence.”

Further, the set of guidelines physicians reported trusting the most had a measurable impact on screening practices. Doctors looking to the American Cancer Society or the American College of Obstetricians and Gynecologists were significantly more likely to recommend screening than to those trusting the USPSTF, according to the authors of the survey.

Other contributing factors are fee-for-service payment systems, which can encourage physicians to order procedures instead of talking to patients about the risks of imaging or screening. Thankfully, initiatives to reform US payment models are underway, producing legislation such as the Medicare Access and CHIP Reauthorization Act of 2015.

Certain provisions in MACRA’s October 2016 final ruling are beneficial to radiologists, allowing some radiologists to qualify for non-patient facing exemptions from reporting requirements. In addition, new episodic payment models introduced in 2016 give radiologists a chance to be reimbursed under the Advanced Alternative Payment Model (APM) program, rather than Merit-Based Incentive Payment System (MIPS)

Defensive imaging is another reason physicians over-recommend mammography. At least 30 percent of U.S. healthcare spending goes to overused or unnecessary treatments, with diagnostic imaging making up a sizeable chunk of that figure. Some states have implemented tort reform to limit physician liability, which decreased imaging utilization according to a study published in the Journal of the American College of Radiology.

However, quantifying medical error and assigning the optimal amount of liability can be exceedingly difficult. It’s a fine line between a missed diagnosis and one so obfuscated that the physician couldn’t have reasonably caught it, so a careful approach to tort reform is required, said study author Danny R. Hughes, MD, senior director for health policy research at the Harvey Neiman Health Policy Institute.

Simple strategies at the organizational level can also reduce unnecessary imaging. Ensuring physicians use appropriateness criteria through checklists or fully-fledged clinical decision support systems can help reduce waste imaging. However, Redberg et al. believe wholesale reform will be much more impactful than the small steps (education, feedback of performance metrics, changes to order sets) that have been taken in the past.

“Perhaps the most effective way to discourage overuse is an evidence-based payment system,” they wrote. “Limiting coverage of tests known to be harmful is a win-win for patients and the national health care system. Limiting coverage would reduce the harms of such tests, including radiation exposure, adverse effects, over-diagnosis and the risks and anxiety associated with inevitable downstream additional testing, biopsies, and procedures related to false-positive test results. Limiting coverage for harmful tests would also save money for patients, the healthcare system, and ultimately the taxpayer.”