Tag Archives: mri

KevinMD: Media is key to curbing MRI overuse

On the MedPage Today outlet KevinMD.com, Dr. Kevin Pho himself writes that media coverage of the overuse of certain screening procedures is “long overdue,” and praises The New York Timesrecent coverage of a study showing that in some cases MRIs can lead to more harm than good.

In the Times, reporter Gina Kolata explained, when unleashed upon the throwing shoulders of 31 healthy professional baseball pitchers, “M.R.I.’s found abnormal shoulder cartilage in 90 percent of them and abnormal rotator cuff tendons in 87 percent.” It’s a result, Kolata wrote, that shows that MRIs are “easily misinterpreted and can result in misdiagnoses leading to unnecessary or even harmful treatments.”

Back at his web portal, Pho writes that there are two steps that need to be taken to curb the overuse of the MRI. The first is cracking down on physicians who own their own MRI machines or otherwise profit from the tests, and the second is what he calls “adjusting patient expectations.” That’s where, he says, the media comes in.

there are some, but not all, patients who expect a scan and equate an MRI with “being thorough.” In fact, when orthopedic fellows cited in the Times story suggest that patients may not need a scan, patients “look at them like, ‘You don’t know what you’re doing.’”

Doctors can help educate patients away from the mythical benefits of overtesting. But the most effective teacher is the media, which wields significantly more influence. That’s why a story like this in the Times should be applauded, and promoted.

A fun aside? The study was conducted by none other than Dr. James Andrews, whose name will be familiar to anyone with even a passing familiarity with the sports pages.

Frugal Minnesota splurges on lower backs

For physicians and patients, treating lower back pain is an exercise in restraint and patience. According to federal guidelines, such pain usually resolves itself within six weeks with minimum intervention, so it’s often a matter of resisting the temptation to order a $500 MRI within that time window. And in Minnesota, a state known for its health-care-related moderation, that temptation seems to be too much.

As the Christopher Snowbeck of the St. Paul Pioneer Press reports, Minnesota doctors are worse than the national average when it comes to giving lower back pain patients MRIs without exploring cheaper alternatives. And in the land of Lake Wobegon, being below average is a big deal. The conclusions come from Hospital Compare’s newly released 2008 outcomes data. To learn more about this data, check out AHCJ’s recent conference call on the subject.

For some help reading between the lines of Snowbeck’s story (and the Hospital Compare data), see Gary Schwizter’s recent blog post on the subject; he doesn’t mince words.

The story includes other excuses from local providers along the lines of “the data are outdated…we’ve changed…we’re better now…that can’t be right…it’s not us!” When have you ever seen a story on health care data that didn’t have these predictable reactions? It reminds me of The Tobacco Institute continually rejecting any new finding that showed new harms from smoking. When you don’t like the data, damn the data. For most of the history of medicine we had no outcomes data to show patterns of practice or what happens to people over time. Now that we’re starting to collect some such data, vested interests find that information is a menacing thing.

For more about treatment of back pain, particularly how much money is spent on it, see the just-released “Back Problems: Use and Expenditures for the U.S. Adult Population, 2007” (PDF) from the Agency for Healthcare Research and Quality.

CDC health overview: Diagnostic scans tripled

The CDC has released the 2009 version of Health, United States, their annual summary of health numbers and trends. It’s an epic heap of data; get the full PDF here.

For a 574-page, 10.22 MB government document, it’s surprisingly easy to navigate. There’s a table of contents, links and a nifty little feature which allows you to pull up a spreadsheet of the data from any chart or graph. In addition to the lead story on medical technology and scanning, the report includes 150 data tables. That’s a bit too much to summarize here, so we’ll settle for the CDC’s version of the highlights:

  • … the rate of magnetic resonance imaging, known as MRI, and computed and positron emission tomography or CT/PET scans, ordered or provided, tripled between 1996 and 2007.
  • The rate of adults aged 45 and over discharged from the hospital after receiving at least one knee replacement procedure increased 70 percent from 1996 to 2006 (26.5 per 10,000 population in 1996 to 45.2 per 10,000 in 2006).
  • From 1988-1994 to 2003-2006, use of antidiabetic drugs among adults aged 45 years and over increased about 50 percent, and the use of statin drugs to lower cholesterol among this age group increased almost tenfold.
  • The number of new organ transplantations per 1 million people increased 31 percent for kidney transplants (43.7 per 1 million in 1997 vs. 57.2 in 2006) and 42 percent for liver transplants between 1997 and 2006 (15.6 per 1 million in 1997 vs. 22.2 in 2006).
  • Life expectancy at birth increased more for the black than for the white population between 1990 and 2007, thereby narrowing the gap in life expectancy between these two racial groups. Overall U.S. life expectancy in 2007 was 77.9 years.
  • In 2007, 20 percent of U.S. adults were current cigarette smokers, a slight decrease from 21 percent in the previous three years. Men were more likely to be current cigarette smokers than women (22 percent vs. 17 percent).
  • In 2005-2006, 30 percent of adults often or almost always had trouble sleeping in the past month.
  • In 2007, 20 percent of adults 18 years and over had at least one emergency department visit in the past year, and 7 percent had two or more visits.
  • The percentage of the population taking at least one prescription drug during the previous month increased from 38 percent in 1988-1994 to 47 percent in 2003-2006, and the percentage taking three or more prescription drugs increased from 11 percent to 21 percent.

Panel recommends FDA restrict MRI scan drugs

An advisory panel has “recommended Tuesday that the Food and Drug Administration effectively ban, for patients with severe kidney disease, the use of two drugs used to create high-contrast images on magnetic resonance imaging (MRI) scans.” ProPublica’s Jeff Gerth has been reporting on the issue for some time and offers some valuable background on the topic.

The drugs in question are GE’s Omniscan and Covidien’s Optimark. Bayer’s Magnevist, the category’s market leader, escaped the most serious censure, but all three agents have been linked to nephrogenic systemic fibrosis, a rare but very serious disease.

Dr. Haig: Patients often demand excessive tests

Doctors are in such a position legally, economically and socially that it is difficult to fight patients’ demands for excessive, well-advertised tests and treatments, Dr. Scott Haig writes in Newsweek. This insatiable, ill-informed demand is a key reason why the consumer, too, is a guilty party when it comes to soaring health care costs.

Haig writes about how, despite the fact that their condition could be easily and accurately diagnosed with no technology at all, two of his patients demanded MRIs for their ruptured Achilles tendons. Their insurance would cover the procedure, and one of them had even seen an advertisement trumpeting the hospital’s fancy new MRI machine. Convincing a pushy patient that the fanciest, most expensive treatment or diagnostic technique isn’t the best one is an often insurmountable challenge, Haig writes, a challenge that becomes ever more significant as pressure to cut health care costs mounts.

Blocking a patient who wants something they saw in an advertisement is time-consuming. Teaching the complex truth one on one is a lot harder than convincing large numbers through eye-catching, sound-biting market psychology. It’s a money loser too. Most of the time, a patient who has been sold on something you don’t want to use will just leave and go to another doctor.

We face this issue every day: the pill they saw on TV or in the magazine, the new scan, the diet supplement, even the specific brand of hip or knee prosthesis are difficult, occasionally impossible, to deny to the folks who ask for them. In the American doctors’ precarious medico-legal (and fiscal-social) position, career success is increasingly built on cooperation with the corporate and government powers that touch us. Playing along with that sketchy (but expensive) new treatment or being a champion of the wacky new state initiative is more likely to help your career than giving an educated but honest appraisal of actual patients’ well being.