Friday, June 27, 2008

ICES completes CT/MRI Usage Study - Suggests tests may be overused

In the understatement of the year, a study by ICES concluded that some CT and MRI tests are being over-ordered, resulting in longer diagnostic imaging wait times.

"The focus of the Ontario Wait Times Strategy has been to spend nearly $100 million in the province to increase the supply of CT and MRI, yet despite this, wait times for MRI are still way above target. An obvious question is whether the scans are being ordered for the right and appropriate reasons," citing a 12-fold increase in use between 1994 and 2006.

The author then goes on to list the usual culprits including head, knee and back pain.

"One group of physicians will tend to point fingers at another as the source of the problem. But in reality, the onus doesn't fall on one single group, and all of us - physicians, patients, researchers and government - must each play a role in improving the system."

What do they recommend to improve the system? e-health solutions to better incorporate practice guidelines, better tracking of orders and improved educatation of patients and physicians.

My take on this is that the 12-fold increase between 1994 and 2006 is alarmist. In 1994 we only used CTs and MRIs for cancer and trauma for the most part. The technology was severely rationed. As a patient (and on behalf of my own) if the choice is either a CT or surgery to differentiate myofascial pain from true arthritis versus , I'll opt for the CT.

The 'over-use' they are describing is not the typical culprits seen in the US media such as head, chest and full body scans for screening. What the report is trying to demonstrate, is the group of patients where follow-up could be used to diagnose a problem when the chances of finding anything on CT or MRI is remote. When the doctor could say, "I can't find anything. It's probably nothing so come back and see me in a month and we'll reassesses it. Call me if anything changes."

But rather than doing longitudinal studies of physicians and their decision to investigate the authors pulled data from CT scanners and looked at orders. It is a much quicker and cleaner study but I think they have overstretched with their conclusions. The line between rationing care and reasonable use becomes thin when there is a chance (however remote) of a space occupying lesion or the ability to avoid surgery. Left out of the report is the Ontario governments' policy of limiting and shutting down private CT clinics over the past 5 years and recent shortages of technicians and radiologists which would also impact on wait times. It's a good study on an important study but I question to what degree political grandstanding is overshadowing scientific thought.

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