Significant Increase Seen in Rate of Diagnostic Imaging, with Accompanying Radiation Exposure Hazards

Among six large, integrated healthcare systems in the United States between 1996 and 2010 there was a substantial increase in the use of sophisticated diagnostic imaging, including approximately a tripling of the use of computed tomography (CT) and almost a quadrupling of the use of magnetic resonance imaging (MRI), as well as a marked increase in estimated radiation exposure.

The study’s findings were published in the June 13, 2012, issue of the Journal of the American Medical Association (JAMA). “The use of diagnostic imaging in the Medicare population has increased significantly over the last two decades, particularly using expensive new technologies such as CT, MRI, and positron emission tomography [PET]. The development and improvement in these advanced diagnostic imaging technologies is widely credited with leading to earlier and more accurate diagnoses of disease using noninvasive techniques,” according to the authors. They noted that CT and nuclear medicine scans deliver much higher doses of ionizing radiation than traditional radiographs, and evidence has tied exposure to radiation levels in this range with the development of radiation-induced cancers.

“Most studies that have evaluated patterns of diagnostic imaging have assessed insurance claims for fee-for-service insured populations where financial incentives encourage imaging. No large, multisite studies have assessed imaging trends in integrated healthcare delivery systems that are clinically and fiscally accountable for the outcomes and health status of the population served. Understanding imaging utilization and associated radiation exposure in these settings could help us determine how much of the increase in imaging may be independent of direct financial incentives,” the researchers wrote.

Rebecca Smith-Bindman, MD, of the University of California, San Francisco (UCSF; USA), and colleagues conducted a study to estimate trends in imaging utilization and associated radiation exposure among members of integrated health care systems. The study consisted of an analysis of electronic records of members of six large integrated health systems from different regions of the United States. Review of medical records allowed estimation of radiation exposure from selected tests. Between one million and two million member-patients were included each year from 1996 to 2010. Enrollees underwent a total of 30.9 million imaging examinations during the study period, reflecting an average of 1.18 tests per person per year, of which 35% involved advanced diagnostic imaging (i.e., CT, MRI, nuclear medicine, and ultrasound).

The researchers found that use of radiography and angiography/fluoroscopy rates were relatively stable over time: radiography increased 1.2% per year, and angiography/fluoroscopy decreased 1.3% per year. The authors stated that in comparison, the utilization of sophisticated diagnostic imaging changed markedly. CT scans tripled (52/1000 enrollees in 1996 to 149/1000 in 2010, 7.8% annual growth); MRI scans quadrupled (17/1000 to 65/1000, 10% annual growth); ultrasound scans approximately doubled over the same period (134/1000 to 230/1000, 3.9% annual growth). Nuclear medicine rates decreased (32/1000 to 21/1000, 3% annual decline), although after 2004, PET imaging rates increased from 0.24 per 1,000 enrollees to 3.6 per 1,000 enrollees, with a 57% annual growth rate.”

The authors also found that the increase in the utilization of CT was associated with an increase in estimated exposure to radiation, with the average per capita effective dose increasing from 1.2 mSv in 1996 to 2.3 mSv in 2010. The percent of enrollees who received high (> 20-30 mSv) or very high (> 50 mSv) radiation exposure during a given year also approximately doubled across study years. The researchers also estimated that by 2010, 2.5% of enrollees received a high annual dose of greater than 20-50 mSv, and 1.4% received a very high annual dose of greater than 50 mSv. By 2010, 6.8% of patients who underwent imaging received a high dose of more than 20 to 50 mSv and 3.9% of patients received a very high dose above 50 mSv during this single year.

The researchers noted that the “increase in imaging use over this period was likely driven by many factors, including improvements in the technology that have led to expansion of clinical applications, patient- and physician-generated demand, defensive medical practices, and medical uncertainly--all factors that would be expected to influence utilization across all systems of medical care. The increase in use of advanced diagnostic imaging has almost certainly contributed to both improved patient care processes and outcomes, but there are remarkably few data to quantify the benefits of imaging. Given the high costs of imaging--estimated at USD 100 billion annually--and the potential risks of cancer and other harms, these benefits should be quantified and evidence-based guidelines for using imaging should be developed that clearly balance benefits against financial costs and health risk.”

George T. O'Connor, MD, MS, of the Boston University School of Medicine (Boston, MA, USA), and contributing editor, JAMA, and Hiroto Hatabu, MD, PhD, of Brigham and Women’s Hospital and Harvard Medical School (Boston), wrote in an accompanying editorial that while the information from this study and another recent report indicate that a nontrivial number of patients in the United States receive a high or very high annual exposure to ionizing radiation from imaging studies in a given year, “these data are not linked to clinical outcomes and do not reveal whether the radiation risks from these imaging studies are outweighed by the health benefits provided by the diagnostic information obtained. The data also cannot address how much of this testing is driven by defensive practice styles due to concerns about malpractice. They do suggest however, that clinicians need to consider--and discuss with their patients--radiation risks when ordering diagnostic tests, possibly taking into account the cumulative radiation exposure a patient has received in recent months or years. Furthermore, the radiation risks and financial costs of advanced diagnostic imaging clearly warrant more research, including studies using informatics infrastructures such as that used by Smith-Bindman et al, to enhance decision support to guide the use of these technologies.”

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