CMS’ Hospital Compare Adds to Dose Scrutiny

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In early July, the Centers for Medicare and Medicaid Services (CMS) expanded the Hospital Compare website to include new measures related to outpatient care—including four measures related to the use or overuse of imaging services. These measures include "outpatients with low back pain who had an MRI without trying recommended treatments first, such as physical therapy”; “outpatients who had a follow-up mammogram or ultrasound within 45 days after a screening mammogram”; “outpatient CT scans of the chest that were ‘combination’ (double) scans”; and “outpatient CT scans of the abdomen that were ‘combination’ (double) scans.”

The information is already generating results. A July 11 article in the Chicago Tribune reports that Edward Hospital, Naperville, Ill, launched an investigation after learning from the website that its doctors were ordering double CTs for patients at far higher rates than other local hospitals. The data, which dates back to 2008, indicated that 70% of outpatients at Edward received double chest scans that year, compared with a national average of 5%.

Leonard Berlin, MD, vice chair of radiology at Northshore University HealthSystem’s Skokie Hospital in Skokie, Ill, says that these so-called “double-scans”—CT exams performed without contrast, then repeated with contrast if necessary—are in some ways a relic of an earlier era in imaging. (According to Hospital Compare, Skokie Hospital’s 2008 rates for double CTs of the chest and abdomen were 59% and 46%, respectively, also well above the national average.) “Historically, it was the standard of care to do a scan without dye first,” he says. “Now—rightfully—there’s a movement asking whether we really need the non-contrast scan. That’s a justifiable question, and people have been moving in that direction.” Berlin adds that while the double scan increases the patient’s radiation exposure, it can minimize the use of contrast material, which is the reason it became a common practice in the first place. “There can be complications with contrast,” he says. “It was a safety thing.”

Berlin notes that since 2008, the year the data was collected, Skokie has put its own measures in place to reduce the use of double scans. “I can tell you that today, non-infusions followed by an infusion are done infrequently,” he says. “There’s an awareness now. We’ve had conferences about this. It probably was overdone in the past, and it’s good that we’ve minimized it.” He adds that he is unsure where the data presented on the website originated. "I don't recall that data, and I can't find the original data on the website," he says. "So I don't know where the data comes from, or how accurate it is."

As far as the data’s impact goes, Berlin says that he and his colleagues around the country have observed a marked decrease in the number of CT scans ordered since dose became a hot topic in the media. “CT volume is way down,” he says. “There’s no question about that. Maybe that even shows how much unnecessary CT there’s been.” However, he adds that even as CT volumes have declined, MRI volumes have risen. “People are now opting for MRIs, which can cost two or three times as much as a CT,” Berlin says. “So people might be doing unnecessary MRs instead of unnecessary CTs, and the irony is that the cost will eventually be passed along to patients.”

Berlin predicts that with so much attention paid to CT radiation exposure in recent years, soon the onus will be on radiologists to present patients with dose information for every medical imaging exam they receive, enabling them to track lifetime cumulative radiation levels. Noting that patients may not know how to accurately interpret this data—after all, most US residents are exposed to three mSv of background radiation annually, and a chest CT is typically seven mSv—Berlin says it will be important for radiologists and referring physicians to educate their patients on imaging's risks and benefits. “We all have to use common sense,” he says. “The message for the patient is that you should always discuss with your doctor whether you really need an imaging exam. Patients shouldn’t be intimated to ask, and referring physicians shouldn’t be angry to answer.”