DI payment should be linked to guidelines

OTTAWA – 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.