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Economic motivation may affect how
often some physicians order imaging studies
Those referring patients to
themselves or members of their own specialty more likely to order
studies
BOSTON - October 30, 2007 - Diagnostic imaging has been one
of the fastest growing areas of health care in recent years. Some
of that increase can be attributed to the availability of improved
imaging studies, but whether some imaging utilization may be inappropriate
has been an issue of concern. Now a study from the Institute
for Technology Assessment in the Massachusetts General Hospital
(MGH) Department of Radiology finds that physicians who consistently
refer patients to themselves or members of their own specialty for
imaging studies, rather than to radiologists, are more likely to
order such studies for a variety of medical conditions. The results
suggest that economic motivation could underlie some of the excess
referrals.
"It's looking like a significant part of the increase in imaging
utilization is due to self- and same specialty referral," says
G. Scott Gazelle, MD, MPH, PhD, director of the Institute for Technology
Assessment, who led the study being published in the November issue
of Radiology. "We need to have some mechanism in place
to control this sort of inappropriate utilization of imaging."
Potential conflicts of interest in imaging studies have been of
concern for several decades, leading to the passage in the 1990s
of laws restricting some forms of self-referral - physicians' ordering
tests that they will be reimbursed for interpreting. Some earlier
studies found that self-referral was associated with higher utilization
of imaging studies. Other studies that documented a greater number
of imaging studies being performed by non-radiologists were not
able to distinguish whether that increase was due to differences
in referral patterns or to increased numbers of non-radiologists
offering such procedures.
The current study was designed to retrospectively examine how frequently
physicians ordered imaging studies for outpatients treated for specific
medical conditions and if that varied depending on whether the studies
were performed by radiologists or by members of the referring physician's
own specialty, who could be colleagues in the same practice. The
researchers analyzed data from a nationwide, employer-based health
plan with around 4 million members: employees at all levels, their
dependents and retirees. They identified pairings of six common
medical conditions - cardiopulmonary disease, heart disease, arm
or leg fracture, knee pain or injury, abdominal malignancy, or stroke
- with a diagnostic imaging procedure, and compiled information
on each physician who had seen at least six patients in one or more
of those condition/imaging pairings in the years 1999 to 2003.
The investigators analyzed every imaging referral and categorized
the physicians according to their referral patterns. For purposes
of this study, they compared only those physicians who referred
all patients to themselves or members of their own specialty for
imaging studies with those physicians who always referred to radiologists.
The results showed that, depending on the condition/imaging pairings,
those making self- or same-specialty referrals were from 12 percent
to more than 200 percent more likely to order an imaging procedure
than were physicians referring to radiologists.
"Some of those who self-refer will say that their patients
are sicker, but we found that controlling for the effect of patients'
age and additional health conditions made the likelihood of imaging
among self- or same-specialty referrers even stronger - more than
300 percent in some conditions. Others may claim to be offering
greater convenience for patients, but when we looked specifically
at CT and MR studies, less than 20 percent were carried out on the
same day as the referring physician visit, which means the procedures
should not be considered part of an office visit but rather separate
visits specifically for the purpose of imaging," says Gazelle.
Gazelle notes that the range of variation in imaging utilization
among same-specialty referrers was much greater than among radiologist
referrers. "It's not that everyone is overutilizing imaging;
but some appear to be, and we need to take a look at those with
the highest rates of utilization. We also need to consider whether
the self-referral laws, which currently exempt most procedures offered
in physicians' own offices, need to be toughened," he says.
Gazelle is a professor of Radiology at Harvard Medical School and
a professor in the Department of Health Policy and Management at
Harvard School of Public Health. The study's co-authors are Elkan
Halpern, PhD, Heather Ryan, MSc, and Angela Tramontano, MPH, all
of the MGH Institute for Technology Assessment and Department of
Radiology. The study was funded, in part, by the American College
of Radiology.
Massachusetts General Hospital, established in 1811, is the original
and largest teaching hospital of Harvard Medical School. The MGH
conducts the largest hospital-based research program in the United
States, with an annual research budget of more than $500 million
and major research centers in AIDS, cardiovascular research, cancer,
computational and integrative biology, cutaneous biology, human
genetics, medical imaging, neurodegenerative disorders, regenerative
medicine, systems biology, transplantation biology and photomedicine.
Media Contacts: Sue
McGreevey, MGH Public Affairs
Physician Referral Service: 1-800-388-4644
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