Waste is what you get with rampant, uncritical use of MRI and health information technology, according to two papers out this week. The authors of a companion editorial to one of the papers even go so far as to suggest we should make waste a quality of care measure. I applaud them.
MRI Use Soaring for Stroke Care
James F. Burke, MD, department of neurology, and colleagues from the University of Michigan Medical School, Ann Arbor, MI, take a look at neuroimaging for the evaluation of acute stroke in a paper in the February Annals of Neurology. A companion editorial by S. Claiborne Johnston, MD, PhD, and Stephen L. Hauser, MD, neurologists at the University of California San Francisco, has the provocative title: “Modern Care for Neurological Problems Must Address Waste.” Tame, yet critical at the same time.
Burke and colleagues acknowledge that imaging is a fundamental part of acute stroke evaluation and that it is more accurate than computed tomography (CT) for stroke diagnosis. However, they also point out that no data has shown that stroke patients undergoing MRI do any better than those who do not. They also note that the most recent American Heart Association Scientific Statement advises the routine use of MRI or CT angiography for stroke (not both). The American Academy of Neurology guideline states that MRI use should be limited to the first 12 hours of stroke onset.
What they found, in a study of neuroimaging for stroke in 11 states between 1999 and 2008, is an astronomical increase in MRI use. In absolute terms, it is up 38%, relative utilization rose 235% (from use in 28% of strokes to two-thirds in 2008). At first glance, the numbers might seem like a reasonable jump, given the change in clinical practice guidelines.
Delving deeper, they show:
- 95% of patients getting MRIs also had a CT;
- there was striking geographic variation in MRI utilization.
- MRI utilization was highest in Arizona (79%), lowest in Oregon (55%).
- Diagnostic imaging was the second leading cost center in percentage increase, outpaced only by room and board.
- MRI costs rose faster (up 413%), from 1999 to 2007, than overall diagnostic imaging.
- In 2008, in this analysis, MRI costs contributed 10% and CT 8% of total hospital costs.
- In states with the highest use of MRI, use has leveled off so that just about all eligible patients are getting MRIs.
- Head CT use was stable over the same time period.
Doctors order these tests, yet they don’t know yet whether they improve outcomes, according to the paper. Do patients need both tests? Doubtful. Also, all that variation reflects the uncertainty in the standard of care.
“No question, it is very satisfying to see that infarction on the MRI, but does it matter in terms of patient care?,” write Johnston and Hauser, in a companion editorial. “More importantly,” they continue, “would the ca. $700 be better spent focusing on maintaining better secondary prevention, a major problem after stroke that could be addressed with more aggressive disease management.”
When Health Information Technology Jacks Up the Bill
In a separate paper in the March Health Affairs, Danny McCormick, MD, assistant professor of medicine at Harvard Medical School, and director of social and community medicine at Cambridge Health Alliance, and coauthors, challenge the contemporary mantra that health information technology will cure so many ills in our healthcare system.
Here, they demonstrate how the ease of access to electronic test results led to a 40% to 70% jump in ordering imaging studies. when doctors had access to computerized imaging. They argue electronic access to test results alone may offer enticements to additional ordering.
“What we’ve got are computer systems that are essentially built around the bill,” said David Himmelstein, MD, the paper’s senior author, and professor of CUNY School of Public Health at Hunter College, New York, NY, in an interview with Patient POV. “People are buying systems that jack up the bill. These systems, with rare exception, are not built by clinicians on the ground, and so they tend to overlook clinical information, improving care, and saving dollars.”
I loved this part of the study: even though women received more imaging studies than men, they didn’t get more advanced imaging. Hey girls, I guess these docs just don’t find visualization of us as that interesting or worthwhile. The authors didn’t pursue this, but I wonder whether this reflects that doctors take illness less seriously in women. It’s not as if I want access to the same waste that men get, but don’t you think it’s a finding worth looking at further? It’s got to be hypothesis generating.
Himmelstein was hard on the purchase and dissemination of many off-the-shelf systems. “We keep hearing that we are going to save dollars by computerizing,” he said.“Yet there is not an iota of evidence that this is true.” Importantly, the paper looked at electronic test ordering, not electronic health records. In the paper, they point out that predictions of cost savings as high as $8.3 billion with computerization were based on data from a few stellar systems: the VA, Latter Day Saints, Regenstrief, and Brigham and Women’s Hospital. These systems are not representative of what doctors are buying.
Together, these papers shine a light on how easy it is to order imaging tests and how imaging is the gee-whiz technology of our age. If we really ever get serious about waste and want to work on it equitably, we will have to invite patients to the table from the outset.
Bring the public in early and often in medical technology assessment discussions.
Don’t say you are committed to “patient-centered care” if you don’t bring patients to the table. Warning: If you leave patients out, the public sees it as smacking of benefits denied, arbitrariness, and cheapness.
But the other thing is that until we stop rewarding doctors based on volume, and instead, inspire outcomes, we are going to drown in the morass of waste.
Thanks for bringing your sharp focus to the costs and waste in the imaging world. Now, where do we look for oversight?
What good will it do to bring the public into medical technology assessment discussions?
The public spends $30 billion a year on alternative medicine. They spend $3 billion on vitamins. They demand antibiotics for colds. If you run TV commercials for a new drug — or a new imaging scan — they demand it from their doctor. If you run radio ads, they line up in free-standing radiology centers for full-body CAT scans.They refuse to have their children vaccinated.
Many of the so-called consumer organizations are subsidized by the drug and medical device industry. A major medical product launch today includes creating an astroturf consumer organization and hiring some nurses to run it. If you want to go over to the dark side, it’s a good way to make a lot of money.
If the public were capable of evaluating medical technology, the free market would work: they wouldn’t pay for these useless, dangerous technologies and we wouldn’t have this problem.
There was an editorial in the New England Journal of Medicine which said that you can’t control medical interventions on the patient level — you have to do it on the doctor level. This may not be possible without changing the financial incentives, since doctor education merely got the results you describe.
The only way I know to evaluate medical treatments is to have a panel of experts, in which the voting members have no financial stake in the outcome, like the UK NICE. It doesn’t always work but it’s the best we’ve got. That’s what Donald Berwick was trying to do in CMMS, but unfortunately the Democrats didn’t stand up for him (or anything else).
I agree with a bit of what you raise here, but I disagree with you lumping all patients together.There are examples of places where patients have been brought in, learn how to weigh the evidence of benefit, harm, and yield. Plenty of people are skeptical about running to the latest best thing or seeking unproven tests. IF ACA survives SCOTUS, I think that we will see more of this and I am looking forward to it. In a future post, I’d like to talk about good programs that bring patients in. That said, industry does have a hand in some. I agree that they could tilt the balance.
This is a great example of basic human behavior. When I was a kid and my mother gave me a choice, say between two flavors of ice cream, I almost always choose both. So, give a physician a choice of two imaging modalities, they too want both. Furthermore, now that seeking information is so much easier than the days I had to take myself to a library, I access a lot more information. If I need to make more effort to access information, then I am likely not going to bother unless I really want it. Likewise a physician will order more tests if it just takes a mouse click instead of filling out forms. In both cases there is no immediate cost to me having both flavors or finding more information. Similarly, these is no cost to the physician ordering more imaging studies or other tests.
Only when a means to modify behavior is introduced will any system start making intellegent choices, i.e., we need a cost element. The problem is, how to set a cost mechanism. Ancedotally, I have heard that increased co-pays has reduced the number of patients electingto have some high cost imaging studies. But what is a prohibitive cost to me will be a negigible cost to someone else and vice versa. Better healthcare is not like buying a more expensive car, it can be the difference between life and death.