Heroes in Proving the Value of Imaging: G. Scott Gazelle, MD, MPH, PhD

Heroes in Proving the Value of Imaging is an occasional series about radiology professionals whose work demonstrates the value of the specialty through research, governmental affairs, humanitarian efforts, and more. In Part 2, ImagingBiz showcases the work of G. Scott Gazelle, MD, MPH, PhD, director of the Institute of Technology Assessment (ITA) at Massachusetts General Hospital (MGH), Boston.
G. Scott Gazelle, MD, MPH, PhD As the cost of health care continues its upward spiral and Congress begins to consider the riddle of widening access while controlling costs, there is a growing scrutiny of the value of diagnostic techniques and treatments. In the imaging field, no one has done more than Gazelle to deliver meticulously researched evidence.

“When we are spending hundreds of millions on imaging, if we can’t show that it improves outcomes, we’ve got a big problem.” —G. Scott Gazelle, MD, MPH, PhD

Radiology was not Gazelle’s first foray into medicine, but after two years of a surgical residency, he switched to radiology and finished a residency and fellowship at Case Western Reserve. He arrived at MGH in 1991 for a second fellowship in abdominal imaging and nonvascular intervention. Six months into the fellowship, he accepted a faculty research position, and he has been at MGH ever since. His initial research was in developing new contrast agents for CT, as well as the tumor models on which to test the contrast agents. That lab developed many of the techniques used in solid-organ tumor ablation today. Eventually, Gazelle became more interested in evaluating the new technologies than in developing them, so he applied for a fellowship from the American Roentgen Ray Society in 1995. He then began a master’s-degree program in public health; this led to a doctorate in health policy, with both degrees gained at Harvard. While pursuing the doctorate, Gazelle founded the Decision Analysis and Technology Assessment (DATA) Group in 1997. It became the ITA. ImagingBiz: You founded the ITA (then called the DATA Group) in 1997. Why, and what was its original mission? Gazelle: It started out as a research group focused around my own personal research interests, which were evaluating radiofrequency tumor-ablation technologies. For example, my first R01 grant [a type of research-project grant from the National Institutes of Health] was for evaluating therapies for liver tumors. We were small; we started with me, a statistician, and a person who was everything else for us: administrative assistant, systems manager, and program coordinator. We grew, over time, as we got more funding to bring on more people and expand the projects. In 2002, five years after we started the DATA Group, it became clear that we were doing projects well beyond just radiology. We were working with people from many departments in the hospital. That is when we became the MGH ITA. We met with the president of the hospital (James J. Mongan, MD, at that time) and made a proposal for becoming a hospital-wide institute, although still—and still today—formally within the department of radiology. We really grew at that point, in part because we had been space limited. We moved into larger new offices and grew from 8 or 10 people quickly up to about 25 or 30. We are now at about 50 or 55 people. It’s a moving target, because students, particularly, are coming and going. Fortunately, we have a steady stream of requests from people around the country and around the world to spend some time here. That has been good for us, and it has allowed us to grow and take on more projects. One of my strategies has always been to say yes anytime somebody asks for help or wants to collaborate on a project. For example, if someone from another department or another hospital says, “I have a fellow or a resident who needs some help with this project,” I say, “Yes, we’d love to help.” It does get overwhelming at times. The other reason we founded the ITA was because I believed we needed to create a resource in the department, in the hospital, and in the city for people doing the kind of work that we were doing. I think we were successful because we said yes. ImagingBiz: If you were to draw a timeline for the ITA, which celebrated its 10th anniversary in 2007, what would be the key events and turning points that would tell its story? Gazelle: We started it in 1997. In 1998, the first big thing that happened to us was that the Center for Integration of Medicine and Innovative Technology (CMIT), which was then know as the Center for Innovative Minimally Invasive Therapy, decided to fund us as its technology-assessment program. That allowed me to hire three people, one of whom (Pamela McMahon, PhD) is still with us, and recently became the associate director of the ITA. We doubled in size with the connection with CMIT, and we got involved with a lot of projects, some of which are still ongoing. That was our first big opportunity. Then we got a grant here and a grant there: Each one is a big deal when you don’t have many. The next turning point was in 2002, when we moved to our new office space and became the MGH ITA. Most recently, in 2007, right before we celebrated our 10th anniversary, we welcomed Steven D. Pearson, MD, and his institute, The Institute for Clinical and Economic Review (ICER), to come and be part of the ITA. ICER is now a program within the ITA, and it gave us a new dimension. Whereas previously we were principally a data-generating or research organization, Steve added a policy or payor-outreach component, and that has been really important for us. ImagingBiz: Payors, particularly the federal government, are increasingly looking for evidence that a technology or treatment improves patient care. While this is not a new development, there is also a greater attention to cost. Have these dual developments influenced the work at the institute, and if so, how? Gazelle: I think they’ve vindicated, or validated, the work at the ITA. We have been pretty singleminded in what we’ve done, and while we may be doing more of it, and maybe at a higher level, we’ve not changed direction from the start. This was my vision of what we wanted to do. I feel that the payor world and the policy world are coming around to realize that this is important, but it was something that we knew when we started the ITA. External forces haven’t changed what we do at all. ImagingBiz: The difficulty of linking outcomes to the method of diagnosis and the rapid advance of imaging technology have discouraged attempts to produce cost-effectiveness studies in imaging. How does ITA address those issues in its methodologies? Gazelle: We use a lot of modeling. One of the issues you refer to is that the outcomes from a lot of imaging studies are intermediate outcomes. For example, we do a CT scan and find a tumor, but the imaging study relates to ultimate outcomes through the rest of the management cascade: treatment, tumor biology, and everything else. Quite often, though, there is a lot known about the pathway between these intermediate outcomes and the final outcome. For example, if you are looking at imaging of liver metastases, or imaging and local treatment of liver metastases, a lot is known that permits us to connect long-term patient outcomes to liver tumor volume or the presence of tumor in other places. We create simulation models to reproduce the natural history of disease, and then we use the models to superimpose, on the natural histories, the interventions that we want to study. Probably two thirds of our work does not involve radiology, so we do the same approach for everything. Quite a lot of what we do is build these very complex microsimulation models to simulate the natural history of disease, and then look at the use of technologies or interventions in a particular disease and see how the use of those technologies will affect health outcomes and economic outcomes at population and subpopulation levels. We are not the only ones to do this, but we are certainly the largest group in the country now doing this. We have become known as a center for this type of work. ImagingBiz: According to your Web site, ITA has 34 projects currently underway, assessing everything from lung-cancer screening and the cost effectiveness of MRI for screening BRCA gene mutation carriers to the various methods of diagnosing vulnerable plaque in the coronaries. How do you decide what to investigate? Gazelle: We have our core research, which consists of projects that are of interest to people here. A faculty member is interested in lung-cancer screening or lung cancer in general, and one project will proceed to the next based on findings and everything else. If we are going to invest our own time or funds, we try to do that in areas that are of high public-health relevance, and we have tended to stick with three general areas: cancer, cardiovascular disease, and diagnostics. Investigators, though, are free to work on whatever they are most interested in working on, especially when they can get funding for it. The other component is projects that come to us: Someone will have an idea and need help with the methods or some aspect of the methods, or someone will want to collaborate, and we will tend to say yes, particularly if the project seems to have a likelihood of funding or a high public-health relevance. ImagingBiz: In your opinion, where has ITA had its greatest impact to date? Gazelle: Rather than pointing to a specific paper or discovery, I would say we have had our greatest impact in a couple of areas. One has been bringing this kind of research to a higher level, particularly as it relates to radiology, but also to technology assessment in general. Modeling approaches to evaluating imaging technologies and nonimaging technologies; developing techniques and approaches to making very complex, accurate models; and using them are things I think we do as well as, or better than, just about anybody. By our many publications in that area, we have contributed to the literature on a variety of different topics for which we’ve provided data. More important, I think we pushed the field forward. The other thing that we have done very well is that we have advanced people’s careers in this area. We train people well—we have a formal fellowship—but all junior faculty members who have come here have been successful in getting their own funding and launching careers allowing them to become independent investigators. Most of them have stayed, which is wonderful. That has been a big focus of mine: mentoring people and creating an environment where careers can flourish—where people are happy and can work successfully, advance the field, and contribute to the literature. From my standpoint, those are the two areas where we’ve made our biggest contribution. ImagingBiz: Have there been any low points or disappointments? Gazelle: I don’t know if I’ve had any. There’s always a low point when you submit a grant, and you thought it was a good one, and it doesn’t get funded, but I think we’ve been fortunate. We’ve been on a steady upward pathway: The program keeps growing; there is increasing attention to, and awareness of, the work we are doing; and we have great people here. I am one of those lucky people who, almost as soon as the alarm goes off, looks forward to coming to work. ImagingBiz: As both a radiologist and the director of an institute that can both negatively and positively affect radiology coverage decisions, how do you stay focused on the mission and avoid the pitfalls of partisanship? Gazelle: My view is that, first of all, at the end of this equation are the patient and the health care system. We will do the best thing for our field, radiology, and for our hospital, if we are always thinking of what is in the best interest of the patients—what is best for them and how best to spend our money. Take a specific example: Let’s say we did an analysis of some imaging technology and found that even though proponents in the field were saying it should be covered, it really shouldn’t be covered. We’re better off, as a field, with that result. If I’m the advocate for that technology, I may not be better off, but we are better off as a field. If we are guided by rigorous science, and if we’re asking questions about what’s best for our patients or what’s best for our health system, I don’t think there’s any conflict whatsoever. ImagingBiz: In this current environment, in which radiology appears to have a big target painted on its back, why is your work important to the specialty? Gazelle: I don’t think our work is any more important to radiology than to health care in general, but if it is, it’s because radiology has some expensive technologies, and it is going to become an increasingly visible target for efforts to reduce spending as part of health care reform. I chaired the ACR’s Commission on Research and Technology Assessment. At my first meeting in that role, I stood up and said that the biggest challenge facing us, as a field, is to conduct research that demonstrates where we bring value to the care of patients and where we’re not bringing value. This, in essence, demonstrates the value of imaging. Our research is critically important because when we are spending hundreds of millions on imaging, if we can’t show that it improves outcomes, we’ve got a big problem.