Whether or Not to Image:
Who Decides?
William R. Hendee, PhD
Distinguished Professor
Radiology, Radiation Oncology, Biophysics,
Population Health
Medical College of Wisconsin
Professorship Appointments:
University of Wisconsin-Milwaukee
Marquette University
University of New Mexico
University of Colorado
Rand Definition of Appropriateness
The indication to perform a medical procedure is
appropriate when the expected health benefit
(i.e., increased life-expectancy, relief of pain,
reduction in anxiety, improved functional
capacity) exceeds the expected negative
consequences (i.e., mortality, morbidity, anxiety
of anticipating the procedure, pain produced by
the procedure) by a sufficiently wide margin that
the procedure is worth doing.
Appropriateness of a specific test in a
specific clinical situation for a specific
patient
Epidemiological appropriateness of a typical
imaging test for the typical patient with a
typical clinical situation
Appropriateness of imaging from a
comparative effectiveness perspective or a
cost effectiveness perspective
– E.G. Medicare Coverage Advisory
Committee does not include cost or costeffectiveness when formulating a
recommendation for or against
reimbursement
1. Justification
• Necessity
• Appropriateness
Integrated components of
an imaging examination
4. Consultation
2. Optimization
• Equipment
• Personnel
3. Implementation
• Performance
• Interpretation
Drivers for Appropriate Imaging
Cost
Quality
Dose
Driver for Appropriate
Imaging
The cost of healthcare is growing
faster than other sectors of our
economy and imaging is growing
faster that other sectors of healthcare.
BCBS Medical Cost Reference
Guide 2008
Healthcare is the largest sector of the economy
Medicare alone is
currently 3.2% of GDP
and increasing rapidly!
Medicare Spending per Capita in the United States, by
Hospital Referral Region, 2003
No Difference in Outcome
Source: Dartmouth Atlas Project, The Dartmouth Atlas of Health Care.
BCBS Medical Cost Reference Guide 2006
Driver for Appropriate
Imaging
Quality
“The American health care delivery system is
in need of fundamental change. The current
care systems cannot do the job. Trying harder will
not work. Changing systems of care will.”
“The Institute of Medicine’s
Committee on Quality Health Care in America”
www.iom.edu
Driver for Appropriate
Imaging
Radiation Dose
Reduction
Preliminary estimate of changes in
U.S. medical radiation exposure
U.S. 1980
U.S. 2006
Interventional 0.4 mSv
All other ?? mSv
Radiography 0.3 mSv
Natural 2.8 mSv
Medical 0.54 mSv
Nuclear medicine 0.8 mSv
Natural 2.4
(UNSCEAR)
CT scanning 1.5 mSv
Total 3.6 mSv per capita
Medical 3.0 mSv
Total ~ 5.4
Drivers for Inappropriate Imaging
1. Unaware of proper imaging use
2. Liability concern
3. Financial incentives
a. Self-referral
4. Psychosocial issues
a. No oversight from colleagues
b. Public expectations
c. Stubborn quest for diagnostic certainty
ACR Intersociety Conference
July 30 – August 1, 2004
Why No Solution to Inappropriate
Imaging?
Need better data-ACR AC are a good start
but hard to develop metrics for every
combination of clinical scenarios
Resistance from those with financial
incentives to image
– Threaten access issues
– Politically volatile
Patient demands and expectations
Solutions To Ensure Appropriate
Imaging
Governmental & payer
Physician
– Utilization of appropriateness criteria in
selection of imaging examinations.
The Future
– Radiology Order Entry Systems (ROEs)
– Radiology decision support systems
– Radiology Business (Benefit) Managers
Governmental and Payer Solutions To
Ensure Appropriateness In Imaging
Quality assurance-Medical Improvement for
Patients and Physicians Act of 2008 (MIPPA)
– Pay for performance criteria extended thru
2010
– Accreditation of imaging facilities 2012
Precertification: For cost savings. The
promised savings of precertification is ~10%
and this represents the profit margin of the
insurance companies and radiology benefit
management firms (RBMs).
Physician Solutions For
Appropriate Imaging
Objectivity in image selection
Quality exam, correct exam, least expensive
exam to answer the clinical question at hand.
Expected health benefit > negative
consequences by a sufficiently wide margin
such that the procedure is worth doing.
Appropriateness Criteria
Radiology order entry (ROE) might allow
replacement of precertification and improve
primary care efficiency with decreased costs
– Concept endorsed by the Leapfrog Group
– Massachusetts General Hospital order entry and
decision support projects are already in use and
commercially available
ROE is an objective data driven system for
appropriateness and removes radiologist
and clinician subjectivity
Requests
imaging
examination
High Utility
Educational Reference
Material
Decision
Support Tools
To Access Utility
result
Pre
Certification
Low Utility
Choose to
Proceed
Comparative Effectiveness
Research
A type of health care research that
compares the results of one approach
for managing a disease, types of
surgery, or other kinds of medical
procedures and tests to the results of
other approaches. The results often
are summarized in a systematic
review.
The Decision to Image
Appropriateness in imaging is only one
piece of the medical puzzle
Our goal must be improvement in patient
outcome