RSNA 2016: Reasons for wasteful imaging—and how to fix them

The costs of imaging services have risen at twice the rate of other health technology sectors such as pharmaceuticals, and they are rapidly approaching 10 percent of total healthcare costs. While imaging has changed medicine for the better, some of the growth can be attributed to inappropriate imaging—costing between $3 billion and $10 billion annually.

Bruce E. Lehnert, MD, assistant professor of radiology at the University of Washington School of Medicine, elucidated catalysts and mitigation strategies for wasteful imaging at a presentation during RSNA 2016 in Chicago.

Lehnert pointed to medical legal concerns, unfamiliarity with clinical evidence, repeat imaging and communication barriers as the main drivers of inappropriate imaging.

Defensive medicine accounts for 5 to 25 percent of all imaging costs, according to Lehnert. Half of legal claims against physicians are diagnosis related—whether it’s delayed or incorrect—setting the stage for radiologists who need to protect themselves from getting burned.

“In Massachusetts—which I understand has a particularly toxic medical legal environment—it’s estimated that approximately a quarter and perhaps almost up to a third of cross sectional and ultrasound imaging is performed for defensive purposes,” said Lehnert.

Another reason for wasteful imaging is a radiologist’s lack of familiarity with clinical evidence. Keeping up with the amount of published literature would overwhelm any specialist, according to Lehnert.

“If a person read five papers an hour during normal work hours, it would take 11 years to read all the currently published literature,” said Lehnert. “At this pace, it would take about 40 years to read all papers related to, echocardiography, for example—clearly an impossible task.“

Communication barriers in medicine are linked to a variety of negative outcomes: access to care, patient satisfaction, diagnostic certainty and, yes, wasteful imaging. Studies show an overutilization of CT in non-English speaking patients, especially with psychiatric admissions, who receive head CTs at twice the rate of English speakers.

The final driver of inappropriate imaging goes right to the source: radiologist recommendations. Radiologist self-referrals are responsible for about $226 million in scans every year, and a study found that around 5 percent of these are wasteful.

There are several viable strategies for mitigating the financial impact of inappropriate imaging, according to Lehnert.

Image storage and sharing technologies may provide the most benefit, he said.

“An analysis found that health information exchanges were associated with decreased odds of repeat neuroimaging and increased adherence to evidenced based guidelines,” said Lehner. “While some health information exchanges suffer from poor integration with workflows, we created a VPN for hospitals to refer to our emergency department, resulting in a repeat imaging rate of 17 percent—quite low compared to other reports.”

Campaigning to control overutilization and overtreatment is another method of reducing wasteful imaging, best exemplified by the Choosing Wisely campaign. However, Lehner tempers expectations, pointing out that the campaign has seen relatively little success in reducing waste imaging.

“It doesn’t seem to be having a profound effect, at least in respect to their test cases [of neuroimaging and lower back imaging],” he said.

On the other hand, clinical decisions support (CDS) systems are a demonstrably viable option for reducing inappropriate imaging, citing the success of Virginia Mason University.

“They developed a homegrown, focused CDS for high use imaging like lumbar spine or head MRI,” said Lehner. “They ended up with decrease utilization between 23 and 27 percent—and this was sustained over a decent period of time.”

A crucial pillar to the success of the CDS was how it was embraced by clinical staff, something that can be tricky, as Lehner found out firsthand when they implemented a CDS in his emergency department.  

It still provided benefits, but Lehner feels that it was slightly hamstrung by the poor way it integrated with the workflows and how the clinic staff were reluctant to accept the changes. Nevertheless, it increased adherence to guidelines for head CT from 49 to 77 percent and reduction in utilization of angiograms, from 26 to 21 percent.