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DI payment should be linked to guidelines

Barry RubinOTTAWA – The best way to reduce the volume of inappropriate diagnostic imaging in Canada is to start linking payment for exams to the use of DI guidelines, according to an August 25 article in the Canadian Medical Association Journal. By doing so, the system could save millions of dollars, speed up wait times, and eliminate unnecessary radiation exposure in patients.

According to the authors of the article, titled “Appropriate, quality imaging tests through linkage of payment to guidelines,” an estimated 10%–30% of imaging tests are done for inappropriate indications; the numbers vary by jurisdiction, modality and referring group.

As well, Barry B. Rubin MD PhD (pictured), Bernita Drenth, and Rob S.B. Beanlands MD, say that doctors and technologists working in DI facilities should require minimum training to conduct and interpret tests, and the facilities themselves should be properly accredited.

“Linking mandatory use of guidelines, independent accreditation of imaging facilities and minimum training requirements for healthcare professionals who perform and interpret imaging tests to payment should promote appropriate use and increase the quality of imaging tests,” the authors say. “Reducing the number of imaging tests for inappropriate indications will decrease wait times for tests ordered for appropriate indications and will improve the efficiency of healthcare systems.”

Dr. Rubin and his co-authors, who are all members of the Ontario Expert Panel on Appropriate Utilization of Diagnostic and Imaging Studies, say that some physicians are ordering and interpreting tests without DI training; these doctors may be ordering DI exams without regard to established guidelines.

“In many jurisdictions, all that is needed for physicians to perform and be compensated for the majority of imaging studies is licensure as a medical doctor and the equipment necessary to do the test. There are few requirements that imaging studies be done for approved indications, or that physicians billing for diagnostic tests have the training or expertise necessary to perform a safe, accurate diagnostic examination.

Moreover, some DI labs may not meet current standards: “Many laboratories perform imaging tests for approved indications, meet the accreditation standards and have technologists and physicians who are trained to provide quality care. However, not all imaging facilities meet these standards, and in many areas there is no requirement that they do so.”

Spending on diagnostic imaging in Canada now exceeds $2.2 billion annually; the authors say that reducing the number of unnecessary imaging tests by 10% would save $220 million per year. Furthermore, “It seems unlikely that the cost of monitoring the use of guidelines and mandating accreditation and minimum training requirements would approach the cost of these potential savings.”

To develop a comprehensive approach for the use of imaging resources, the Ontario Ministry of Health and Long-Term Care formed the Expert Panel on Appropriate Utilization of Diagnostic and Imaging Studies in 2012. The panel includes physicians in academic and community practice, within urban and rural settings.

It concluded that appropriate use of imaging tests would be optimized if the use of accepted indications for imaging tests, based on guidelines developed by national or international specialty societies, was linked to payment for these tests.

To ensure quality, the panel recommended that mandatory independent accreditation of imaging facilities and minimum training requirements for technologists and physicians performing and interpreting the imaging tests be linked to payment for these tests.

According to the authors, the volume of imaging tests has risen more rapidly than most other drivers of healthcare costs, with the number of magnetic resonance imaging (MRI) and computed tomography (CT) tests increasing threefold between 1995 and 2010.

Inappropriate imaging tests increase costs and wait times and result in unnecessary radiation exposure during CT scans. Conversely, failing to do imaging tests for appropriate indications may lead to underuse and missed diagnosis, with deleterious clinical consequences.

Dr. Rubin and his colleagues write that other strategies have been implemented to increase the appropriate use of imaging tests.

For example, the Royal College of Radiologists in the United Kingdom developed the iRefer program to guide physicians regarding the most appropriate investigations for various indications and to inform decisions about commissioning of imaging services.

As well, the guidelines for diagnostic imaging referral issued by the Canadian Association of Radiologists help physicians to choose the most appropriate tests. However, there is no link between the use of the iRefer Program or the referral guidelines and payment to physicians for imaging services.

In the United States and in Canada, the Choosing Wisely campaigns (www.choosingwisely.org, www.choosingwiselycanada.org) encourage physicians, patients and other healthcare stakeholders to discuss tests and procedures, including imaging tests, that may not be medically indicated and may cause harm.

This is a positive step; however, the campaign’s overall impact on the use of imaging tests will be limited, because specialty societies have targeted only a small number of imaging services and participation in the Choosing Wisely initiative is optional.

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1 Comment responses

  1. Avatar
    September 20, 2014

    The family physicians are regarded as the gatekeepers to the health care system, including diagnostic imaging services. The increase in the overall use of advanced diagnostic imaging has been attributed to the growth in referrals from family physicians. As now in some province they can order such tests which previously, only specialists were allowed to do (giving example of MRI).
    The traditional role of radiologists is to supervise medical imaging and there interpretation for the diagnoses and treatment of patients. They also play a role in determining the appropriate use of imaging services and playing a greater role in the decision-making process for safe imaging.
    The evolving responsibility of radiologists other than the traditional role has been expanded to play a role as economic gatekeepers. However, the clinical productivity pressures can discourage radiologists from embracing these roles
    Who is the referral base for the imaging. It is the family physicians, specialist and in small number nurse practioner and chiropractor. In the article as described the case may be true for those province where they have private imaging centres where the non radiologist will be involved in reporting some imaging studies and also self referring. But in some provinces most of the radiologist are in a hospital based practice getting the referral from GPs and specialist. One can raise the issue of self referral from radiologist regarding the follow-up studies in some circumstances like example of followup of lung nodules for which there is guideline available.
    The issue of what is the standard of care. Whether seeing the patient before imaging is done or after. For example a surgeon wants to exclude acute appendicitis for right lower quadrant pain and doing imaging rather than using clinical judgement. Taking example of chest films done in ICU or CCU daily for the same indication with no change. Opening gate of MRI have skyrocketed the waiting time. Delay in providing the clinical service due to limited resources ( joint surgeries and endoscopy) the patient will be imaged again and again. There may be a medico-legal aspect into it in which I donot want to go in detail.
    Judging by the clinical information available on the requisition, it is very difficult for the radiologist that how appropriate or necessary the study is as they do not have clinical background knowledge of the patient presentation. Refusing a study for being inappropriate at that time might have some implication in future if something turn wrong. Who will to be blamed, the radiologist or the referring physician. No one want to take a chance as there can be litigation issue. It has been implied that inappropriate use might be reduced if communication between radiologists and ordering physicians occurs more frequently and effectively. But sometimes it is difficult to open lines of communication due to busy schedules, relocation and administrative changes. It appears that both radiologists and ordering physicians blamed inappropriate use on each other.
    Medical imaging involves lot of technology and new advance are going on and new high tech scanners are coming in market. It is safe to say that medical imaging is technology driven industry. As new technology keeps up coming the cost will certainly rise. As disease donot follow books, the guidelines not always follows the signs and symptomatology. In physiology we have read about positive feedback cycle which causes system instability. It opposite is negative feedback cycle. DI payments linked to guideline or to imaging referrals will be a short lived solution. Everything is linked to each other, the system has to be changed.

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