Better Tracking Needed for Unsafe, Costly Multiple CT Scan Practices

I was recently interviewed for an article, published in The New York Times, about the tendency for some hospitals and imaging centers to perform multiple CT scans on a single patient in one day. Not only is this extra radiation exposure an extremely unsafe practice, but it is also a very costly one for the Medicare system and other insurance companies.

There is a very strong and growing movement within the Centers for Medicare and Medicaid Services (CMS) to assess the appropriateness of the more than 800 billion dollars in direct medical care they will pay for in 2011. This is the direct result of federal legislation developed and implemented over the last decade that has significantly expanded the role of CMS to include physician quality reporting. This has largely been driven by cost concerns but also has been driven by concerns focused on patient safety and the desire to reduce medical errors. CMS has adopted numerous performance measures and developed varied programs to assess, and in many cases, pay for performance.

There exist relatively few quality or performance measures that are specifically focused on radiology, although given the rapid growth in spending on imaging over the last two decades, there is growing interest in developing such measure. For example, organizations such as the National Quality Forum (NQF), tasked with developing and endorsing quality and reportable measures, has convened several committees to try to encourage the endorsement of quality measures specifically focused on imaging. I had the honor of participating in the last committee focused on endorsing Imaging Efficiency Measures.

Current measures that were endorsed by NQF and have been adopted by CMS include measures to assess the appropriateness of CT imaging of the chest, specifically imaging that utilizes repeat scans. The purpose of this, as other measures, is not to double-guess what would be best for an individual patient, but rather, on average, is to asses whether a facility doing a good job of minimizing unnecessary repeat imaging. In this case, while most facilities are doing a good job keeping repeat chest CT exams to a minimum (fewer than 5 percent of all CTs of the chest across all facilities involved both with and without contrast studies) some facilities are using repeat chest imaging in the vast majority (nearly 90 percent of patients). As mentioned earlier, this has both cost implications as well as safety implications, as double scanning nearly doubles the cost and doubles the radiation dose to which a patient is exposed, while in most cases, adds little or nothing to the diagnosis. Again – this is not to say what is best for an individual patient, but rather to assess performance at the institutional or physician level.

Within radiology, on a national level, we have not done a very good job of developing quality measures, or assessing compliance with measures that do exist. This needs to change. We need to rapidly begin to standardize what we do and than assess how well each physician and institution complies with those standards. It is long past time where each physician and each facility develops their own unique standards of how studies are done, attributing the variation to the "special needs" of their patients. I am not surprised at how far some facilities deviated from the standard on repeat double imaging for chest CT, as we have not standardized, or tracked performance very much at all. This is a great place to start, but we need many more measures focused on the appropriateness of imaging and the way those exams are conducted.

On the positive side, we have incredible informatics tools within radiology to begin to standardize what we do. For example, within the area of setting and minimizing radiation doses for CT, we should begin to immediately assess the doses that are used at each facility that conducts CT, and collect and use these data to assess performance. And we have the data to do this at our finger tips. I have submitted a quality metric to the National Quality Forum called the UCSF CT radiation dose measure. The focus of this measure is to improve the safety and consistency of medical imaging with CT by improving the appropriateness of CT radiation exposures. This measure can be assessed easily by every U.S. facility that conducts CT. The measure is well on its way to endorsement and if endorsed, I believe it could have a real impact on lowering doses to which patients are exposed.