MR Imaging, Electronic Test Ordering Creates Waste

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.

What’s the Patient Got to Do with It?

Here we are discussing the prostate cancer screening guidelines, but what bothers me is that the patient is brought in as a footnote at the end of the analysis. I find it really dispiriting that there is so much lip service to “patient-centered” medical homes, outcomes research, and more, yet the patients are on the periphery of the discussion. Heck, we are an industry now, except it is all from the outside looking in!

Maybe, before academics, policy wonks, and patient engagement companies hole up and review the evidence on important issues affecting you and me, they ought to open the general topic for public commenting and questioning that is out there for everyone to see.

I know what you are thinking –and of course, it has occurred to me too: I am talking chaos. Well, perhaps…but…maybe we must do better. What if we had more feedback loops where patients and the public enter into real-time discussions at the front end, when priorities are being set, where care is being given?

In some parts of the world, medical technology assessment discussions bring patients in from the start before decisions are made on whether or not to cover specific items. What about webcasts available on demand where the logic of evidence reviews is easy to find? What about more Q&As bringing patients in? Maybe the questions asked would shift if patients participated as real partners. Maybe the answers would be more understandable.

We need more of this in the US. Without it, we perpetuate distrust, anger, and a mockery of the science.