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Unnecessary image ordering a financial drag on healthcare system

But targeting each clinical scenario individually might not address some of the underlying drivers of this trend.

Jeff Lagasse, Associate Editor

Though a doctor may order an MRI, that doesn't necessarily mean the patient needs it. A new study conducted by researchers at IT Southwestern's Center for Patient-Centered Outcomes Research, and published in JAMA Internal Medicine, shows that a physician's prior image ordering habits, as well as ownership of the equipment, were strong indicators of unnecessary imaging orders.

Such orders are problematic because they result in what the authors call "low-value care," which is financially burdensome for both the patient and the physician or institution ordering the image.

[Also: IBM Watson aligns with health systems, imaging firms to fight cancer, diabetes, heart disease]

Uncomplicated back pain and uncomplicated headaches are two of the most common reasons patients with health insurance received low-value, or unnecessary, imaging such as X-rays, computed tomography or magnetic resonance imaging, according to the study. Previous research has shown that this kind of waste may account for up to one-third of all medical expenditures.

Additionally, low-value services can trigger downstream cascades of unnecessary care and clinical harm.

[Also: Cardiac stress imaging fraught with unneeded risks]

Whether or not this excessive imaging happens is partly explained by how much unnecessary imaging the clinician orders in general, and whether or not the clinician owns the medical equipment; if they do, they're more likely to order a test.

For patients who got an MRI but didn't need one, which doctor they went to mattered more than the injury or symptom they had. Essentially, some clinicians simply offer financially irresponsible care, albeit unknowingly in most cases, the authors said.

The study examined the records and characteristics of 100,977 primary care physicians, specialty physicians and chiropractors in search of predictors for unnecessary back pain and headache imaging ordering. It found that chiropractors and specialists were more frequent back pain imagers, and that primary care physicians who ordered more back pain imaging also ordered more headache imaging.

Some approaches to change clinician behavior have shown promise -- particularly audit-feedback mechanisms, where clinicians receive regular feedback on specific performance metrics in comparison to peers. But targeting each clinical scenario individually might not address some of the underlying drivers of this trend, such as varying levels of discomfort with clinical uncertainty, overestimating the benefits of testing or group practice trends. It also doesn't directly address the pervasive fear of malpractice.

When it comes to ownership, previous legislation has limited imaging equipment ownership and clinician self-referral. But exceptions have been made for patient convenience and evolving practice models, so the laws may be less effective than they should be. Although there are payment programs that hold healthcare provider groups responsible for the cost of care, early evidence shows that their effectiveness at reducing low-value care has been modest, even among self-selected provider groups.

The next steps for researchers, according to the study, should include examining other nonclinical factors that might influence clinician practice habits, and ultimately exploring how to help patients and clinicians make better clinical decisions together.

Twitter: @JELagasse
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