A clinically meaningful approach to evaluating repeat medical imaging

Without a clinically-based common lexicon of why MRI or CT scans, for example, are “repeated,” policy makers and insurance companies are making decisions based on a body of research using vague, ill-defined ideas that seem to be based on the premise that anything repeated is, by definition, wasteful. Where they should be focusing their attention, instead, is on which diagnostic tests have higher value, and will lead to better patient outcomes. Those are tests worth doing! The others are often not. Operating solely on analyses of insurance claims data, without considering the circumstances of individual patients, serves neither patients nor the health care system well. Our focus needs to be on patients, and not just on numbers.

This week, the Harvey L. Neiman Health Policy Institute seeks to fill this void with a new report that provides guidelines to researchers and policy makers on the effectiveness and appropriateness of repeat medical imaging tests. The decision-making framework established by the Neiman report could also be applied to multiple types of other diagnostic tests as well.

Optimally, this report will dispel the notion that repeat testing is automatically synonymous with excessive spending and health system abuse. It categorizes different types of repeat testing and explains how a repeat imaging exam can be essential to protecting patient health and preventing even greater downstream health spending. It also provides categories to help researchers and policy makers identify those imaging examinations which provide less value—setting the stage for the use of clinical decision support and electronic imaging record integration as the nexus for system improvement.

Take the patient who undergoes a pre-operative chest x-ray. A vague shadow raises the question of an early lung cancer—but this could just as easily be a scar. If you were the patient, wouldn’t you want an answer? If you’re a physician, and this was your patient, wouldn’t you want a definitive answer, if at all possible? That’s where supplementary imaging comes into play. Nominally, some researcher could say that a chest CT scan was a “repeat test” but in a circumstance like this, it’s the best test to determine whether this is a benign nothing or an early cancer that needs to be treated accordingly.

How about the woman with breast cancer who just completed chemotherapy? Her CT scan shows her free of disease, but she’s sadly involved in a car wreck the next day and flown to a trauma center. She undergoes a “repeat” CT scan of the abdomen—for entirely different circumstances. When she’s treated as a just a number in some big research data file, some would argue that she got two CT scans in two days and that must be wrong. When she’s treated as a human being, however, she got darned good care.

I'm not suggesting that there aren't tests that don't meet standards of effectiveness and necessity. That happens much more than we’d like. And that’s why many of us see real time clinical decision support as being part of the solution—just like better electronic imaging and health record integration—in moving the imaging value proposition forward. But, as the Neiman report makes clear, we’ll never have meaningful and productive discussions about improving our system if we paint repeat imaging with broad brush strokes.

Ideally, current health care reform initiatives will allow us to achieve better individual patient care and improved population health, all at less cost. Repeat medical imaging needs to be part of the discussion—but that discussion needs to be a thoughtful one.

Richard Duszak, MD, FACR is the Chief Executive Officer and Senior Research Fellow of the Harvey L. Neiman Health Policy Institute.