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Does ‘Low-Value’ Imaging Equal ‘Wasteful’ Imaging?

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Imaging gets prominent mention in the much-talked-about article “Measuring Low-Value Care in Medicine,” published online Monday in JAMA Internal Medicine.

The article concludes that 26 “low-value” procedures cost Medicare anywhere from $1.9 billion (using its most specific measures, minimizing false positives) to $8.5 billion (using its most sensitive measures, minimizing false negatives) in 2009. It summed up its contentions thus:

In this national study of selected low-value services, Medicare beneficiaries commonly received care that was likely to provide minimal to no benefit on average. … These findings are consistent with the notion that wasteful practices are pervasive in the U.S. health care system.

Well, few would argue with the notion that wasteful practices are pervasive in the U.S. health care system, perhaps least of all those working in that system. But when it comes to individual cases—individual patients—it’s not so simple to define what’s “wasteful.” Or, sometimes, to talk patients out of demanding care they may not need.

A couple of reader responses to a Kaiser Health News blog post about the study illustrate some of the complexities. One mentions a problem that the study authors acknowledge: a lack of detailed patient information in the Medicare claims data that the authors mined. “I have seen plenty of doctors who inadequately document an adequate history and physical, simply due to time constraints, but still treat appropriately,” the reader says.

Another reader who says he has had a blocked right coronary artery for 17 years expresses frustration that his cardiologist is being pressured to stop ordering an annual nuclear stress test and echocardiogram. “I do not care about controlling costs in the system of medical financing,” the reader says. “I care only about my outcome. I have a right to the best care and that right is being denied.”

Providers face often-conflicting pressures from patients, insurance companies, government entities, practice managers, peers, schedules, and their own sense of what’s right, among other things—not to mention fear of lawsuits. The study does focus attention on legitimate problems. But we’re still trying to figure out the solutions.

For the record, here are the imaging procedures that the study flags as wasteful, based on characterizations from a variety of bodies as well as peer-reviewed medical literature:

  • CT of the sinuses for uncomplicated acute rhinosinusitis
  • Head imaging in the evaluation of syncope
  • Head imaging for uncomplicated headache
  • EEG for headache
  • Back imaging for patients with nonspecific low back pain
  • Screening for carotid artery disease in asymptomatic adults
  • Screening for carotid artery disease for syncope

Several other procedures the study questions also involve or sometimes involve imaging, including cancer screening for patients with chronic kidney disease receiving dialysis, bone mineral density testing at frequent intervals, preoperative chest radiography, preoperative stress testing, stress testing for stable coronary disease, use of inferior vena cava filters to prevent pulmonary embolism, and vertebroplasty or kyphoplasty for osteoporotic vertebral fractures.

Related CME seminar (up to 35.25 AMA PRA Category 1 credits™): UW Radiology Review Course “Not Just for Residents”

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