Medicine
In the late 1990s, the urban public hospital where I trained as a medical student had a single CT scanner. To ensure that this precious resource was put to effective use, any physician ordering a non-emergent CT scan was required to personally present the patient's case to the on-call Radiology fellow and explain how the result of the scan would potentially change management. Since my attending surgeons were usually too busy to trudge down to the Radiology suite, they deputized their residents to do so, and most of the time my residents passed this thankless task down to the students. Thus, my classmates and I learned early on the difference between appropriate and inappropriate reasons for ordering CT scans.
Today, the widespread availability of CT scanners has made this sort of explicit rationing uncommon in the U.S. In fact, a 2011 editorial published in American Family Physician reviewed the accumulating evidence that CT scans are highly overused in medical practice, which puts patients at unnecessary risk of radiation-induced cancers and detection of incidental findings that can lead to overdiagnosis and overtreatment. Identifying overuse of CT scans often isn't easy, though. And some might argue that increasing use of CT scans may have the positive effect of improving diagnosis of common symptoms, allowing physicians to institute appropriate management of serious conditions more quickly.
Family physicians Andrew Coco and David O'Gurek investigated this possibility in a research study published in the Journal of the American Board of Family Medicine. They analyzed data on common chest symptom-related emergency department visits from the National Hospital Ambulatory Medical Care Survey from 1997 to 1999 and 2005 to 2007. Unsurprisingly, the proportion of these visits in which a CT scan was performed rose from 2.1% to 11.5% during this time period. However, the proportion of visits that resulted in a clinically significant diagnosis (pulmonary embolism, acute coronary syndrome or MI, heart failure, pneumonia, pleural effusion) actually fell slightly, challenging that notion that increased CT utilization leads to improved detection and treatment of serious health conditions.
In their editorial, Drs. Diana Miglioretti and Rebecca Smith-Bindman recommended that physicians and referring clinicians take several steps to reduce harms from CT scan overuse:
1. Use CT only when it is likely to enhance patient health or change clinical care.
2. When CT is necessary, apply the ALARA (as low as reasonably achievable) principle to radiation doses.
3. Inform patients of CT risks before imaging.
4. Monitor individual exposure over time and provide the information to patients.
These general points can and should be applied to many other medical interventions, including screening tests and treatments. To paraphrase: Never do anything to a patient unless you think it may help. When an intervention is necessary, intervene as little as possible. Always inform patients of the risks of any intervention, and monitor their exposure to its harmful effects over time so that they can choose to opt out later, if desired. Choose wisely!
**
This post first appeared on Common Sense Family Doctor on January 18, 2012.
- Should You Be Screened For Lung Cancer? Maybe Not, And Here's Why
If you are a lifelong heavy smoker age 55 years or older, the U.S. Preventive Services Task Force believes that screening for lung cancer with CT scans may save your life. Today the Task Force released provisional recommendations that assigned a...
- Making Wise Choices In Diagnostic Imaging
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- Dangers Of The Incidentaloma: How Ct Scans Can Hurt You
Mrs. Smith (not her real name) fidgeted in her chair in my examination room as I scanned the radiology report she had given me. She had visited the emergency room the previous evening with severe abdominal pain that had eventually been diagnosed as gastritis,...
- Incidentalomas: Reasons To Think Twice About Getting A Ct Scan
Mrs. Smith (not her real name) fidgeted in her chair in my examination room as I scanned the radiology report she had given me. She had visited the emergency room the previous evening with severe abdominal pain that had eventually been diagnosed as gastritis,...
- 4 Reasons To Not Be Screened For Lung Cancer
NOTE: A revised and updated version of this post, including my take on the July 29, 2013 U.S. Preventive Services Task Force draft recommendations for lung cancer screening, is available here. ** Lung cancer is the leading cause of cancer death in the...
Medicine
Curbing overuse is an important part of quality improvement
In the late 1990s, the urban public hospital where I trained as a medical student had a single CT scanner. To ensure that this precious resource was put to effective use, any physician ordering a non-emergent CT scan was required to personally present the patient's case to the on-call Radiology fellow and explain how the result of the scan would potentially change management. Since my attending surgeons were usually too busy to trudge down to the Radiology suite, they deputized their residents to do so, and most of the time my residents passed this thankless task down to the students. Thus, my classmates and I learned early on the difference between appropriate and inappropriate reasons for ordering CT scans.
Today, the widespread availability of CT scanners has made this sort of explicit rationing uncommon in the U.S. In fact, a 2011 editorial published in American Family Physician reviewed the accumulating evidence that CT scans are highly overused in medical practice, which puts patients at unnecessary risk of radiation-induced cancers and detection of incidental findings that can lead to overdiagnosis and overtreatment. Identifying overuse of CT scans often isn't easy, though. And some might argue that increasing use of CT scans may have the positive effect of improving diagnosis of common symptoms, allowing physicians to institute appropriate management of serious conditions more quickly.
Family physicians Andrew Coco and David O'Gurek investigated this possibility in a research study published in the Journal of the American Board of Family Medicine. They analyzed data on common chest symptom-related emergency department visits from the National Hospital Ambulatory Medical Care Survey from 1997 to 1999 and 2005 to 2007. Unsurprisingly, the proportion of these visits in which a CT scan was performed rose from 2.1% to 11.5% during this time period. However, the proportion of visits that resulted in a clinically significant diagnosis (pulmonary embolism, acute coronary syndrome or MI, heart failure, pneumonia, pleural effusion) actually fell slightly, challenging that notion that increased CT utilization leads to improved detection and treatment of serious health conditions.
In their editorial, Drs. Diana Miglioretti and Rebecca Smith-Bindman recommended that physicians and referring clinicians take several steps to reduce harms from CT scan overuse:
1. Use CT only when it is likely to enhance patient health or change clinical care.
2. When CT is necessary, apply the ALARA (as low as reasonably achievable) principle to radiation doses.
3. Inform patients of CT risks before imaging.
4. Monitor individual exposure over time and provide the information to patients.
These general points can and should be applied to many other medical interventions, including screening tests and treatments. To paraphrase: Never do anything to a patient unless you think it may help. When an intervention is necessary, intervene as little as possible. Always inform patients of the risks of any intervention, and monitor their exposure to its harmful effects over time so that they can choose to opt out later, if desired. Choose wisely!
**
This post first appeared on Common Sense Family Doctor on January 18, 2012.
- Should You Be Screened For Lung Cancer? Maybe Not, And Here's Why
If you are a lifelong heavy smoker age 55 years or older, the U.S. Preventive Services Task Force believes that screening for lung cancer with CT scans may save your life. Today the Task Force released provisional recommendations that assigned a...
- Making Wise Choices In Diagnostic Imaging
Many of the primary care-relevant recommendations in the Choosing Wisely campaign advise physicians to think twice before reflexively ordering diagnostic imaging tests in certain clinical situations. Inappropriate imaging increases radiation exposure,...
- Dangers Of The Incidentaloma: How Ct Scans Can Hurt You
Mrs. Smith (not her real name) fidgeted in her chair in my examination room as I scanned the radiology report she had given me. She had visited the emergency room the previous evening with severe abdominal pain that had eventually been diagnosed as gastritis,...
- Incidentalomas: Reasons To Think Twice About Getting A Ct Scan
Mrs. Smith (not her real name) fidgeted in her chair in my examination room as I scanned the radiology report she had given me. She had visited the emergency room the previous evening with severe abdominal pain that had eventually been diagnosed as gastritis,...
- 4 Reasons To Not Be Screened For Lung Cancer
NOTE: A revised and updated version of this post, including my take on the July 29, 2013 U.S. Preventive Services Task Force draft recommendations for lung cancer screening, is available here. ** Lung cancer is the leading cause of cancer death in the...