Medical Imaging Rates Continue to Rise: That Might Be OK

The JAMA study found that medical imaging rates continue to rise across multiple US sites and even in Canada.

This week, we’re talking about scans. CT scans, MRIs, ultrasounds, all those imaging modalities that tell us what’s going on inside our patients. According to a new study appearing in the Journal of the American Medical Association, those scans are on the rise… but whether that is a bad thing is a bit of an open question.

We’ll get there. But let’s start with the study itself.

Rates of scans by age group over time. The kids are all right.

Researchers from UCSF collated data from 7 US health care systems and from Ontario, Canada – a unified health system – to determine how often various types of imaging studies were performed over time.  The data was pretty stark, across all sites there has been, in general, an increase in the use of CT scan, MRI and Ultrasound from 2000 to 2016. These increases were seen across the US and even in Canada, ye panacea of universal health care.

Less radiation for kids. It’s a good thing.

Digging a bit deeper, there were a few interesting quirks in the data.

The rate of CT scans in children actually decreased over time.

I’m speculating here but this may be due to increased awareness of the potential consequences of ionizing radiation exposure. Nuclear medicine scans decreased as well for reasons that, I’ll admit, are not entirely clear to me, but I’m hopeful you all can enlighten me.

Nuclear medicine scans decreasing… but I have honestly no idea why. If you know, leave a comment - I feel like I must be missing something obvious.

But still, overall what we have is a study showing a pretty dramatic increase in the rate we order imaging for patients, crossing multiple health systems, two countries, and a few different payment models. This despite efforts like the choosing wisely campaign designed to curb utilization of procedures like this.

And my reflex here is to shake my head and lament the state of a health care system where we no longer really think and just reflexively order imaging tests.

But then I thought about Star Trek.

Yup. Star Trek.  See, in Star Trek – 100% of the patients get advanced imaging.

Wait - I don’t have a prior auth for this tricorder scan.

Sure, it’s with a tricorder, but they get it as soon as they walk into sick bay. And Dr. Crusher never wrings her hands about the slow death of the physical exam.

What’s the harm of imaging? Basically, there are three things.  First, exposure to ionizing radiation – in the case of CT scans at least. Second, cost. And third, the discovery of incidental findings that lead to further workup and stress.  These are real harms and things we should worry about, but we should also realize that these harms may be changing over time.

New CT protocols reduce radiation exposure. Costs are somewhat more contained under current payment models. We’re likely still too defensive regarding incidentalomas, but the point is that as risks decrease, we’d expect utilization to increase.

Why? Because imaging tests are really useful. Not for everyone, and not always, but it’s hard to deny that you don’t get useful information from these tests.

The most successful way to avoid the radiation, cost, and anxiety of imaging exams, in my opinion, is to give doctors enough time to actually talk about the risks and benefits with their patients. Time with patients is more valuable than the highest Tesla MRI, but try to convince insurance companies to see that.

This commentary first appeared on medscape.com