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Imaging More Wisely.

The right imaging tests performed at the right time can lead to earlier and more accurate diagnoses, better treatment decisions, and improved patient outcomes. Unnecessary and inappropriately performed tests harm patients by causing them discomfort and anxiety, by leading to a large number of irrelevant incidental findings, and by exposing them to ionizing radiation that can have harmful effects on their health. We waste approximately $30 billion annually on unnecessary imaging tests in the United States.1 In 2012, the American Board of Internal Medicine Foundation launched the Choosing Wisely initiative to advance a national dialogue on avoiding wasteful or unnecessary medical tests, treatments, and procedures.2,3 The American College of Radiology followed suit by launching the Image Wisely campaign, which calls for eliminating unnecessary imaging and using the minimum amount of radiation needed to perform an indicated test.4 Three studies in this issue of JAMA Internal Medicine underscore the need for additional strategies to achieve these goals. In one study, Drescher and Sirovich5 found that the rates of computed tomographic (CT) scanning for patients visiting an emergency department with respiratory symptoms quadrupled between 2001 and 2010. Imaging increased in every severity group but rose most steeply among patients with lowacuity symptoms (such as those with nasal congestion), who are the least likely to benefit from such testing. The authors found no measurable health benefits of greater CT scan use and concluded that a great deal of the increase in the use of CT scanning in the emergency department is unnecessary. Two other research letters in this issue, both by Mercuri et al,6,7 suggest that our problems in the use of imaging studies are not just the increasing rate of unnecessary tests but also the marked variation in how safely the tests are performed. The focus of their investigation is myocardial perfusion imaging (MPI), which is the most common imaging test used in the United States for diagnosing coronary artery disease and accounts for approximately 20% of the total annual medical radiation to which patients are exposed.8 In one study, Mercuri et al6 showed that the use of radiation varied markedly across the United States and that only 14% of US facilities were within the quality benchmark compared with 32.6% of facilities in 64 other countries. A typical US patient received a radiation dose for an MPI test that was on average 20% higher for the same test performed in the 64 other countries. There is no obvious benefit of using higher radiation doses to perform this test. In addition, the harm of the higher radiation dose per MPI test in the United States is compounded by our markedly greater use of this imaging test compared with other countries. In a related analysis, Mercuri et al7 also found that the rates of stress-first imaging, which uses a lower radiation dose, are far lower in the United States than in other countries (7.7% in North America vs 84.4% in Europe). Adopting a practice of stress-first imaging among patients undergoing MPI in the United States could result in a dramatic decrease in the average radiation dose without loss of clinical information. The variation in radiation dose in the performance of MPI is consistent with what data have previously been reported for CT scans.9 There are many reasons why the use of imaging has grown over time and why there is variation in the amount of radiation delivered when these tests are performed. Clinical management has increasingly come to rely on CT scans and other imaging tests as the technical quality and speed of imaging have improved. There has been an annual growth of around 8% in the use of CT scans in the past decade,10 but the growth in the availability of CT scans has not been matched with a system of accountability. Physicians independently decide when to order tests and determinehowtheyareperformed.Thereis littleoversightofthequality of their decisions or penalties for their overuse or misuse of imaging studies. The lack of explicit and enforceable radiation standards for most imaging studies and the lack of transparency on how much radiation a patient receives when undergoing a diagnostic test undermines accountability. Overuse and misuse of imaging tests are also predictable symptoms of a fee-for-service payment system that incentivizes volume over value. Adding a CT scan to an emergency department visit can double Medicare’s reimbursement for that visit.11 The multistudy MPI approach most frequently used in the United States is associated with a 30% higher rate of Medicare reimbursement than the lower-dose stress-only imaging. To change the rate of use and the radiation doses associated with imaging tests, we must realign the incentives in our fee-for-service system to reward quality rather than quantity. Congress has recognized the shortcoming of the fee-forservice payment model and earlier this year created the Medicare Incentive Payment System, which will soon place Medicare physicians at financial risk for their practice style. Physicians will be able to choose to either have their Medicare payment affected by how their performance compares with that of other Medicare physicians or to join organizations, such as accountable care organizations (ACOs), which accept financial risk for a defined population of patients. When physicians choose to have their performance judged against that of other Medicare physicians, they will have 4% of their reimbursement at risk based on their performance beginning in 2019; this percentage will increase to 9% by 2022. Physicians participating in ACOs Related articles Opinion