Volume of imaging procedures increasing

Radiologists contend self-referral within cardiology is to blame; cardiologists say growth has led to decline in morbidity, mortality.

Issue: February 2006

DALLAS — Cardiovascular imaging allows physicians to diagnose disease earlier, treat conditions faster and evaluate outcomes more efficiently. In a special session here on issues related to self-referral in cardiac imaging, Michael Wolk, MD, said that cardiologists “must be able to use the best technologies in our offices and the hospitals in which we work.”

Wolk, past president of the American College of Cardiology and professor of clinical medicine at Weill Medical College at Cornell University in New York, said that conversations about the growth in medical imaging “have become blurred with distortions, even evolving into debate about whether medical imaging performed by cardiologists is safe, of sufficient quality or even necessary.

“If cardiologists, oncologists, radiologists, urologists and orthopedists all realize that medical imaging has changed how we practice and deliver care by integrating diagnostic scans into the overall patient care plan, we can provide patients with a continuity of care that results in earlier diagnosis, prompter treatment and improved outcomes,” Wolk said.

Radiology’s perspective

The special session at the American Heart Association Scientific Sessions 2005 also included presentations by two radiologists who contended that the number of imaging procedures has climbed in recent years now that cardiologists have started doing more imaging in their offices.

David C. Levin, MD, said there was a 12% increase in utilization of noninvasive diagnostic imaging procedures by radiologists between 1993 and 2003. The utilization rate by cardiologists over the same time period increased 170%.

“History has shown that whenever cardiologists get involved in a type of imaging, use skyrockets,” said Levin, a professor in the department of radiology at Jefferson Medical College in Philadelphia. “You may not like that message, but nobody can dispute that.”

James P. Borgstede, MD, chair of the American College of Radiology Board of Chancellors, provided information regarding what both radiologists and cardiologists bring to MR and CT imaging. He said that even though the ACR and the ACC have developed comparable training standards, “only radiologists have to pass stringent physics board exams.”

Borgstede said that the opportunity for self-referral by cardiologists is troubling. Radiologists, “who are not in a position to self-refer, give an unbiased judgment and their judgment isn’t swayed by what they think the patient should have.”

Collaborative approach needed

Wolk agreed that the number of imaging procedures is growing, but said that the issue is more complex than outlined by the radiology community. The ACC knows that imaging services should be performed by an appropriate provider regardless of the provider’s specialty, he said. “We understand that a collaborative approach — including radiology — in education, training and research is essential to ensure appropriate and quality imaging.”

The radiology community’s strategy, he said, has been to “exaggerate the growth in imaging, allege poor quality of imaging by nonradiologists, cite safety concerns and claim cost savings with radiology. We need to tone down the rhetoric and get back to the patient,” he said.

Leslee J. Shaw, PhD, associate professor of medicine at UCLA, agreed that there has been significant growth in imaging procedures, along with revascularization and catheterization procedures. That growth, however, has coincided with a 35% to 50% decline in cardiovascular morbidity and mortality, she said.

“Imaging, when it is used in appropriately selected, stable chest pain patients at intermediate risk, can effect a 30% to 40% cost saving when it is used as a gatekeeper to angiography,” said Shaw, a member of Cardiology Today’s Editorial Board on the Health Policy, Patient and Practice Issues section.

Wolk said that the ACC’s efforts to ensure quality in imaging has included development of clinical competency statements on CT and MR, development of appropriateness criteria that will provide clarity about both the over-use and under-use of imaging, and revisions in training methodologies for educating fellows about a variety of imaging modalities. The ACC has passed a resolution for mandatory accreditation of labs and a Bethesda Conference report has addressed professionalism and ethics.

The ACC must continue to lead in this effort, he said, “or others will undoubtedly emphasize cost control and not quality improvement.” – by Kathy Holliman

For more information:

Shaw LJ, Levin DC, Wolk MJ, Borgstede J. Issues of self-referral in cardiac imaging. Special session presented at the American Heart Association Scientific Sessions 2005. Nov. 13-16, 2005. Dallas.