City University of New York



POLICY OPTIONS BRIEFTo:William T. Thorwarth, Jr., MD, Chief Executive Officer. The American College of RadiologyFrom: Alexander Kollar, Anna Chaykovskaya, and Adam SchwartzRe: CAT Scan Overuse Date: February 10th, 2015PROBLEM: CAT scan overuse CAT scan overuse in patients, especially in pediatric patients, is a dangerous problem in the healthcare sector. As a radiologic technologist, I have scanned children multiple times in one day in the emergency room setting. I have seen how there is little to no oversight when physicians make decisions to use this imaging modality on patients. “Performing two scans in succession is rarely necessary, radiologists say, yet some hospitals were doing that more than 80 percent of the time for their Medicare chest patients.” The use of medical imaging, especially high dose CT scans has soared in the last 20 years, “our resulting exposure to medical radiation has increased more than six fold between the 1980s and 2006, according to the National Council on Radiation Protection & Measurements.” There is a necessity for these exams, but their overuse is something that cannot be taken lightly. “Most researchers agree that there is no such thing as a dose of ionizing radiation that is so low that it will not have some effect on our body. Each exposure to radiation builds up in our body and the risk of cancer increases.? A single source of exposure to radiation is unlikely to cause cancer; the combined exposures increase our risk of cancer over time.” Until the late nineties, CAT scans were rare but are so routine now, that one in ten Americans will have one every year. That’s approximately a staggering 30 million CT scan a year. Since CT scanners cost millions of dollars, there is of course an incentive for their use. It is not easy to determine exactly how much an increase in cancer this can cause, but “a 2009 study from the National Cancer Institute estimates that CT scans conducted in 2007 will cause a projected 29,000 excess cancer cases and 14,500 excess deaths over the lifetime of those exposed.” CT scans are thus overused, but the frightening thing is that even when they are used for a legitimate medical need, they can be used incorrectly. The general guideline is that doses for medical imaging should be as low as possible, but there is no clear guideline to what that dose of radiation should be. Different private practices and hospitals use CT scanners differently nationwide. “The dose at one hospital can be as much as 50 times stronger than at another.”There is no specific rule or law when it comes to doctors ordering these exams. “Emergency room physicians routinely order multiple CT scans even before meeting a patient. Such practices, for which there is little or no evidence of benefit, should be eliminated.” A physician has guidelines and suggestions to follow, but it is ultimately up to him/her to decide how many CT scans to order. Perhaps a policy change where the ordering physician would have to consult with another fellow doctor, and document it before administering the exam would beneficial. This would be a legal incentive for future physicians to think twice before ordering an exam that is not only unnecessary but also dangerous to the patient. Many hospitals have already changed protocols. “What that means for us is when a physician orders a scan from a radiology department, the radiologist begins to engage in a conversation with those physicians, talking about what might be a more reasonable and acceptable approach.”This is great step that hospitals have taken, but they are the exception and not the rule. A broad policy change would make the above example a widespread practice.The long time rising cost of healthcare is another reason to implement change to CT scan practices. These exams are extremely expensive, ranging from hundreds of dollars to thousands each. The more that these exams are ordered, the more insurance companies will have to pay out. This will raise the cost of healthcare for every American. Not to forget the fact that “there will be 29,000 extra cancer cases a year.” The cost of treating these future patients will be a staggering addition to the already rising costs of healthcare. There are also other less expensive exams that doctors can order instead of CT scans. Ultrasound is significantly cheaper alternative which does not expos a patient to radiation. If a physician consults with other doctors in the hospital to determine that a CT is not warranted, then they will be saving insurance payer’s money and a significant radiation dose to the patient as well.Creating a policy where Hospitals and physicians are held accountable for their overuse of CT imaging is a must. This will save money, and reduce the cost of healthcare. It will more importantly, keep the patients in hospitals safer and healthier. After all, is that not the goal of the healthcare industry in the first place?POLICY SOLUTION: Substitute MRI for CT scan when possibleAny radiological imaging procedure procures costs to the individual. Most patients’ first question when going in for a test is how much will this test cost me? With any radiology exam an individual will acquire costs from the facility where the test is administered and from the doctors that will read the report and give the results. The national average cost of a CAT scan to a patient without insurance is $695 for a Brain CT, $785 for a chest CT and $900 for an abdominal CT, this is without the subsequent Doctor visit to obtain the results. When a patient is admitted to an emergency room or a hospital they do not get a choice of whether they want a CT scan. They also do not get a say so in how many scans are taken. If multiple scans are taken in one visit or one admission the patient will receive a bill for each scan separately. The average national cost of an MRI to a patient without insurance is $1,181 for a Brain MRI, $1,219, $1,219 for a Chest MRI and $1,166 for an abdomen MRI. Again this is without the professional component of the physician fee. A special contrast, a dye-like liquid that causes certain tissues or organs to be seen better on a scan can be used in both CT scans and MRI’s and can raise the price of both scans. However, an MRI that uses no radiation and can help dramatically lower the risk of cancer, on average, is only a couple of hundred dollars more expensive than a CT scan. POLICY SOLUTION: Better policy to send images with transfer patients Trauma patients transferred from one hospital to another often undergo repeat CT scans, some of which are clinically important (e.g., to assess progression of an intracranial hemorrhage) and some of which have no clear indication. After arriving at a trauma center, 60 percent of patients have repeat scans. Given the high dose of radiation, this is a disturbing statistic and adds to the increased cancer risks for patients, as well as, raising the costs to the patient upon discharge. This can easily be avoided by instituting a policy where the initial community hospital has to always provide the images with the patient when they are transferred to the trauma center. Repeat imaging also added up to 25 minutes of delay at the trauma center. While the patients in this study had no different outcomes, they did have substantially higher healthcare costs and were exposed to double the amount of radiation which exposes them to long term risks. Most hospitals and private practices store their records and imaging procedures digitally. There is no reason why in today’s modern computer interconnected world, hospitals shouldn’t all have the same capabilities to send images to one another in the same way that people can snap a picture on their phones and send it to someone almost instantaneously. POLICY SOLUTION: Better education for both patients and doctorsDoctors should be taught about the dangers of CT scans and should consult radiologists before using the advanced and complicated machines. There should be special training set for anyone considering using CT scans in their practice or hospital. A required continued education class should be mandated to physicians that have the authority to refer patients for CAT scans. This can better improve a physician’s choice of scan. Education can help to prevent over scanning patients and will help instill the dangers of CT scans in physicians. This education will help to inform physicians not to over prescribe CT scans but to explore options of Ultrasound and MRI technology to eliminate excess exposure to CT scans. Patients should also be informed about the dangers posed by overexposure caused by repetitive CT scans. Patients are asked to sign an agreement that informs them of the risks of the CT scan, but how many patients are actually told this by their physicians? Generally, physicians do not explain the risks of the CT scan when they refer a patient to be tested. If doctors told patients in detail the statistics of the dangers overexposure of CT scans, patients would be more inclined to ask Doctors for other types of scans. Doctors would be forced, in that scenario, to only expose a patient to the risks of a CT scan when absolutely necessary and where those benefits would out way the risk. If patients knew more about the risks of CT scans, they would be more inclined to do their due diligence and inform physicians if they have already had a recent scan done and to obtain those scans when possible to decrease their own exposures. POLICY SOLUTION: Strict regulationsRegulations should be enacted and enforced regarding the usage of CT scans. These regulations should transcend basic limitations of doctor usage, and also focus on how often a patient can receive scans. In fact, there are no regulations at all regarding how much radiation a person is allowed to be exposed to medically. Enacting laws and regulations to protect patients from improper or inappropriate use of CT scans can diminish the number of people diagnosed with cancer due to radiation exposure. A single CT scan emits as much radiation as 200 chest x-rays. Patients are often sent for recurring scans because there are no strict regulations upon the number of CT scans that can be performed upon a single patient in a day, week, year and so onxiv. Scans cannot simply be administered because a physician is fearful of a lawsuit, studies show 35% of imaging scans are simply ordered to protect the physician against lawsuit, not due to true medical needxiv. This calls for the need of regulations to be set in place for a standard of how many scans can be administered in a single person. Whether it’s the increase of other modalities of imaging, better procedures for transferring images with trauma patients, the increased education of patients and doctors, or stricter regulations, any one of the above policy changes would be a an improvement over the current system which is not optimal for patient safety and well-being. Thank you for your consideration. ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download