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Basic tenets of operational research suggest that adopting MedPAC’s recommended 90% utilization factor would have significant negative consequences for patients.

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66 Percent of Voters Urge Obama to Tell Congress to Reject Proposed Cuts to Medical Imaging, Poll Finds

Summary:

A public opinion survey released on the eve of President Obama’s Joint Address to Congress on health care shows that Americans recognize the value of medical imaging as a critical component of high-quality health care. Specifically, 71 percent of voters oppose making further Medicare cuts to advanced imaging tests and screenings, such as MRIs and CT scans, as a means to pay for health care reform, the Access to Medical Imaging Coalition (AMIC), a coalition of physician, patient and imaging manufacturer groups, said today.

In an online survey of 4,426 likely voters conducted September 4–8 by Zogby Interactive, 78 percent of respondents said that Congress’s proposed cuts to medical imaging services, including MRIs, CTs and PET scans, will have a significant impact on physicians’ ability to detect diseases – such as heart disease and cancer – at their earliest stages. Moreover, 66 percent said that President Obama should urge Congress to reject these additional medical imaging cuts when he addresses lawmakers tomorrow.

Zogby International was commissioned by Powell Tate to conduct an online survey of 4,426 voters. A sampling of Zogby International’s online panel, which is representative of the adult population of the US, was invited to participate. Slight weights were added to region, party, age, race, gender, education to more accurately reflect the population. The margin of error is +/- 1.6 percentage points. Margins of error are higher in sub-groups.

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Imaging Equipment Utilization Rates Lower Than Assumed

Authors:

Radiology Business Management Association (RBMA)

Summary:

The Radiology Business Management Association (RBMA) conducted a survey of its members with freestanding/outpatient imaging centers to collect imaging equipment specific information in anticipation of possible actions to be taken by the United States Congress and the Centers for Medicare & Medicaid Services (CMS). Based on the information obtained from this survey – the most recent and comprehensive data collection of its kind to-date – RBMA calculated equipment utilization rates using two different methodologies for diagnostic imaging services, advanced diagnostic imaging services, and centers located in rural and non-rural settings.

RBMA found diagnostic imaging utilization rates that are far below those that have been proposed in Congress (75 percent in the CHAMP Act1 and in the recently released U.S. House of Representatives “Tri Committee” healthcare reform bill2), the “normative” 90 percent standard recommended by the Medicare Payment Advisory Commission (MedPAC) for equipment costing $1 million or more3, or the Administration’s proposal of a 95 percent utilization rate4. Moreover, RBMA’s results suggest a significant difference in equipment utilization between rural vs. non-rural providers. It follows then that any increase in the utilization rate could greatly harm rural imaging centers’ continued ability to provide imaging care to patients within their communities.

RBMA recommends that Medicare’s utilization rate for medical equipment be based on actual and timely equipment utilization data collection, ensuring the provision of accurate and robust information for decision makers in formulating evidence-based policy rather than projections of efficiency.

RBMA further warns that an excessive utilization rate may hamper freestanding/outpatient facilities’ ability to introduce new and emerging diagnostic services that may help further prevent and detect disease.

In conclusion, RBMA’s survey findings are more consistent with CMS’ current equipment utilization assumption of 50 percent rather than the higher rates proposed by either Congress or the White House.
RBMA cautions that imaging care would experience multiple adverse impacts from any increase in equipment utilization rate that does not reflect actual use in practice. Rural imaging centers’ provision of services and all freestanding/outpatient centers’ ability to adopt new imaging services to further advance disease detection and prevention would particularly be affected.

These findings also reinforce the need for CMS and diagnostic imaging community stakeholders to work together to develop a more comprehensive and timely equipment utilization data survey for a more factual read on how diagnostic imaging services are currently used in actual practice.

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Improved Selection of Patients for Hepatic Surgery of Colorectal Liver Metastases with 18F-FDG PET: A Randomized Study

Author:

Theo J.M. Ruers, Bastiaan Wiering, Joost R.M. van der Sijp, Rudi M. Roumen, Koert P. de Jong, Emile F.I. Comans, Jan Pruim, Helena M. Dekker, Paul F.M. Krabbe, and Wim J.G. Oyen

Publication:

Journal of Nuclear Medicine, Vol. 50, No. 7, July 2009

Summary

In a randomized multi-center study of 150 patients with colorectal liver metastases recommended for surgery, Ruers et al evaluated the benefits of F-FDG PET by comparing the utilization of F-FDG PET combined with CT to the utilization of CT alone for staging and developing surgical recommendations, with the primary metric for determining success being the overall percentage of futile laparotomies (abdominal incisions to resect the tumor growth) resulting from each diagnostic strategy.

F-FDG PET proved highly successful when combined with CT, ultimately reducing the percentage of futile laparotomies – defined as either any laparotomy that did not result in complete tumor treatment, revealed benign disease, or did not result in a disease-free survival period longer than 6 months – by a net 17 percent (45 percent for CT alone versus 28 percent for F-FDG PET/CT), or a relative reduction of 38 percent.

The authors also noted that because this data was collected between 2002 and 2006, they were forced to use separate PET and CT equipment in making their determinations. With the recent innovative breakthrough and ability to utilize joint PET/CT technology, Ruers et al wrote that in the future “the actual reduction of futile laparotomies will be larger than 38%.”

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David W. Lee, Ph.D. and David A. Foster, Ph.D.

PRESENTATION:

Academy Health 2009 Annual Research Meeting, June 29, 2009

BACKGROUND:

Diagnostic imaging, such as computed tomography (CT), magnetic radiology (MR), ultrasound and x-ray, uses advanced radiation technology to view the inside of a patient’s body for signs of stroke, cancer and other serious diseases. Though the significant medical benefits of such technologies have been well documented and established, there continues to be debate over how often to use diagnostic imaging as total U.S. healthcare system costs continue to soar.

In order to test whether the “more is better” hypothesis holds for diagnostic imaging, researchers examined the association between the use of inpatient diagnostic imaging services (CT, MR, ultrasound and x-ray) and three risk-adjusted hospital outcome measures: mortality, length of stay and total inpatient hospital costs. Researchers used patient-level data to determine whether the patient received imaging services, and the mean number of services received. The study examined 2007 data from the Thomson Reuters Hospital Drug Database for 1.1 million patients treated at 102 hospitals, ranging from hospitals with fewer than 200 beds to those with more than 500 beds, and with the majority of hospitals surveyed located in the Southern region of the U.S.

RESULTS:

The study findings suggest that the increased use of imaging services is associated with lower patient mortality while at the same time having little or no impact on length of stay or costs. The risk-adjusted probability of receiving an imaging service had an inverse and statistically significant correlation with risk-adjusted mortality for all four imaging modalities, ranging from -0.20 (MR) to -0.24 (ultrasound). This means that as use of imaging increased, patient mortality decreased.

While utilization of imaging services was positively correlated with costs and length of stay, none of the correlations between imaging and costs achieved statistical significance. Associations between imaging utilization and length of stay were statistically significant only for the likelihood of receiving any ultrasound, the number of ultrasounds received and the number of x-ray services received.

IMPLICATIONS:

Because providers are only reimbursed for the professional component of inpatient diagnostic services, use of these services likely reflects a confidence in their clinical value. This study highlights the need for further assessment of how diagnostic imaging shapes key clinical, operational and economic outcomes in the inpatient setting, particularly as discussions about its appropriate utilization continue.

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The Quality of Medical Care, Behavioral Risk Factors, and Longevity Growth

Authors:

Dr. Frank Lichtenberg, PhD, Columbia University

Publication:

Released through the National Bureau of Economic Research.

Summary

In his evaluation, Dr. Lichtenberg sought to determine the reach and effect of certain variables on life expectancy: the effect of the quality of medical care, behavioral risk factors (obesity, smoking, AIDS incidence), and other variables (education, income, and health insurance coverage) on life expectancy. In determining the quality of medical care, Dr. Lichtenberg evaluated average quality of diagnostic imaging procedures, average quality of practicing physicians and the mean vintage (FDA approval year) of outpatient and inpatient prescription drugs.

Across the board, Dr. Lichtenberg found that life expectancy increased more rapidly in states that experienced larger increases in utilization of advanced medical imaging, but that those same states did not have larger increases in per capita medical expenditure.

Based on this finding, Dr. Lichtenberg concluded that “this may be the case because, while newer diagnostic procedures and drugs are more expensive than their older counterparts, they may reduce the need for costly additional medical treatment. The absence of a correlation across states between medical innovation and expenditure growth is inconsistent with the view that advances in medical technology have contributed to rising overall U.S. health care spending.”

Interestingly, advanced medical imaging techniques were attributed with increasing life expectancy by 0.62 to 0.71 years (out of a total 2.37 year increase) over the 14-year period in question, which is comparable to the 0.58 to 0.68 year decrease in life expectancy due to increased prevalence of obesity.

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Diagnostic accuracy of computed tomographic colonography for the detection of advanced neoplasia in individuals at increased risk of colorectal cancer

Authors:

Regge D, Laudi C, Galatola G, et al.

Publication:

Journal of American Medical Association, 2009;301(23):2453-2461.

Summary:

In a multi-center study, Dr. Daniele Regge and her team examined a cohort of 937 patients, each of whom had one or more of the following three determining factors that may increase a patient’s susceptibility to colorectal cancer: the existence of advanced neoplasia in a first-degree relative, a personal history of colorectal adenoma, or a positive result from a fecal occult blood test (FOBT). In measuring the sensitivity and accuracy of CT colonography, researchers recruited at-risk patients to undergo CT colonography in the morning, followed by a standard colonoscopy later in the day.

Compared with unblinded colonoscopy as “the gold standard,” Regge and her team found that CT colonography exhibited 85% sensitivity and 88% specificity in detecting advanced colorectal neoplasia. As a result of their findings, the researchers decided “that CT colonography may be an acceptable alternative to colonoscopy in patients with a history of adenoma and those with a family history of colorectal neoplasm.”

According to the University of Michigan’s Emily Finlayson, MD, MS, CT colonography is not only beneficial due to its noninvasive nature – it also greatly reduces the risk of adverse events, half of which occur due to sedation (which CT colonography does not require).

“While the use of CT colonography as a screening and surveillance modality is still a matter of debate,” said Finlayson, “the study by Regge et al suggests that CT colonography may be an acceptable alternative to colonoscopy in patients with a history of adenoma and those with a family history of colorectal neoplasm.”

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Long-term study results validate efficacy of CT scans for chest pain diagnosis

Authors:

Dr. Judd Hollander et al, University of Pennsylvania

Presentation:

Presented May 15, 2009, at Society for Academic Emergency Medicine’s annual conference

Summary:

In the first long-term study to follow a large number of patients who have undergone emergency room computed tomography angiography (CTA), Dr. Judd Hollander and his team at the University of Pennsylvania tracked 481 patients for one year after receiving a negative scan (i.e., a scan that showed no serious coronary blockages or damage to the heart). While numerous studies have evaluated and demonstrated the cost-effectiveness of CTA – with previous research by Hollander et al showing that CTA saves up to $2500 per patient – this is the most definitive study to date evaluating the diagnostic and long-term efficacy of CT scans for excluding cardiovascular disease in patients presenting to the emergency room with chest pain.

Of the 481 patients tracked, 10% of the patients required re-hospitalization at some point over the course of the year during which they were followed, while another 11% received additional cardiac testing. However, not a single patient suffered a heart attack or required revascularization procedures to open blocked arteries. This shows CTA to be a highly successful, efficient means of screening individuals for cardiovascular disease.

With these positive results, Hollander et al concluded that, “The evidence now clearly shows that when used in appropriate patients in the ED [emergency department], we can safely and rapidly reduce hospital admission and save money…It seems time to make a national coverage decision that will facilitate coronary CTA in the emergency department.”

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