Overuse of CT scans is dangerous and expensive

I read two articles yesterday that complemented each other:

In Kaiser Health News (KHN) Heavy Use Of CT Scans Raises Concerns About Patients’ Exposure To Radiation

And on KevinMD two radiologists posted The financial costs of treating CT-induced cancer

Each underscores the fact that CT scans are significantly overused in American healthcare.

Although CT scans are an essential diagnostic tool, the Food and Drug Administration reports that an estimated 30 to 50 percent of imaging tests are believed to be medically unnecessary.

Considering we spend tens of billions of dollars every year on diagnostic imaging, that’s a lot of wasted money.

But direct costs aside, the risk of radiation-induced cancers and the cost of treating those is also huge.

Like X-rays, CT scans represent a potentially significant health problem, one that experts say may not show up for years: cancer caused by radiation. In most cases, it is impossible to definitively attribute cancer to radiation exposure that occurred years or even decades earlier.

A JAMA article looking at the overuse of diagnostic imaging, including CT scans, determined:

Computed tomography and nuclear medicine examinations deliver much higher doses of ionizing radiation than conventional radiographs, and extensive epidemiological evidence has linked exposure to radiation levels in this range with the development of radiation-induced cancers.  It is estimated that 2% of future cancers will result from current imaging use, if imaging continues at current rates. [my emphasis]

The radiologists from the KevinMD post wrote:

A criticism may be that CT-induced cancer costs may occur decades from now but are non-existent at present because cancer requires several years to decades to develop after radiation exposure.  We disagree.  For years, the problem of radiation-induced cancer from medical imaging has been framed as a future event.  Hundreds of millions of CT scans have been performed in the U.S. since the 1990s, thus, we have already been paying for those excess cancers.

They calculated that CT-induced cancers cost around $260 million every year.

Why is this happening? There are a lot of reasons.

Physicians often blame the patients for demanding certain services, such as CT scans. That may be true. Don’t insist on a CT scan if the physician doesn’t recommend it. (And question it if s/he does.)

Related post: What parents should know: Protecting children from unnecessary CT radiation exposure

Newer CT equipment uses less radiation, but it’s expensive. Until now, hospitals and imaging centers have been paid the same whether the machine is new or old, so there is little incentive to invest hundreds of thousands of dollars in new equipment. A new Medicare rule this year will reduce payment if CT machines fail to meet certain safety standards.

And physicians order more CT scans and other diagnostic tests because it works to protect them from medical malpractice suits. I posted about this sad fact recently: Cover your a** health care.

What was most frightening to me in the KHN article was the apparent lack of radiation dosing standards in the industry.

Smith-Bindman [Rebecca, MD] said that excessively high radiation dosage is a problem requiring urgent attention. A 2009 study she led found that the actual radiation doses from CT scans varied as much as 13-fold for the same test performed at the same hospital, and these doses were much higher than those required to make a diagnosis. Except for mammography, there are no federal regulations governing radiation doses.

There are several reasons for the variation, Smith-Bindman said, including the failure to adjust the radiation dose based on body size and a desire to achieve more finely detailed images, which can be achieved by ramping up the dose. Nor are there national standards for technologists who administer CT scans, which involve increasingly sophisticated equipment. Some states don’t even require that they be licensed, allowing virtually anyone to operate the equipment.

“There’s no standardization of how these exams get conducted,” Smith-Bindman said. “There’s no oversight and no one’s responsible for this.”

Yikes.

What’s a person to do? Ask questions. Ask about alternatives. Ask about risks and benefits. CT scans are a useful tool, but only when used appropriately.

To learn more about when CT scans may or may not be useful, read my posts on the Choosing Wisely campaign and the Number Needed to Treat.

KHN also suggests two websites that are dedicated to promoting safer, more informed use of imaging studies.

  1. Image Wisely: Radiation Safety in Adult Medical Imaging
  2. Image Gently: The Alliance for Radiation in Pediatric Imaging

Am I the only one who thinks our health care system is a wild west where a sign should warn”Venture at your own risk”??

Sláinte,

Frugal Nurse

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Comments

Overuse of CT scans is dangerous and expensive — 4 Comments

  1. You know the problem with these scans exists not only in the US…I live in Russia and when I had some breething problems, I came to a special clinic and asked a radiologist if I should have a chest scan despite the fact that the doctor didn’t say that I need it. She said “you really need it” and quickly done the test… after that a doctor asked if I want to pay less giving 50% of money directly to the doctor…In Russia it is rather an expensive test as in Europe…When several days after that I came to that place again and enquired why didn’t she tell me about the risks she was laughing at me….also noone told me about the dose I’ve had…the radiologist just said that many people undergo ct scans today and noone cares about it especially about the dose… 2 or 10 msv it doesnt’t matter and it is funny for her to hear that I care about it…she also said that there are patients in their clinic who undergo about 5 CT scans in four days….The key is that they don’t care for absolutely anything but money…It is very sad…very irresponsible people, and I feel very upset that I went there and didn’t follow my acute doctor’s advice…In Russia medicine and service are on a very low level because most people live poor lives…

    • Hi Tatiana, thanks for sharing your experience. I know health care spending and over treatment are problems in other countries, as well as ours. Radiation comes from many sources and each of us should be mindful of our exposure. I had a run-in with a mammogram tech who insisted I should use the clinic’s brand new 3D mammogram machine, even though the radiation is so much higher I would have to sign a consent form to have it done. I refused. She couldn’t believe I wouldn’t want “the best” mammogram (which is highly debatable). Perhaps her job was to “sell” the 3D mammograms; I don’t know. She was actually very rude to me, and I have not gone back to that clinic. Thanks again for the comment. Cheers, FN

  2. The decision on whether or not to scan someone should not be taken lightly, I agree. In the emergency room we have several validated tools to decide when to CT a patient. For instance…if a patient comes in with trauma and arrives in a c-spine collar there is the NEXUS criteria and Canadian C Spine Rules to decide whether or not exposing someone to the radiation of a CT scan outweighs the risks. I have found these to be really helpful in decision-making around this topic. Also, ultrasound is being used more and more in medicine…hopefully this can decrease our use of CT scans!

    • Hi Sarah, thanks for your comment and some perspective from a health provider’s point of view. I’m glad to hear decision-making tools are being utilized and CT scans, at least in your ER, are not being ordered without cause. Do you know how well your CT machines are calibrated or maintained? I’ve known for some time that CT scanners can vary widely in the amount of radiation delivered, even when considered “low dose”. Interesting that only mammographic radiation is regulated. Because the new 3D mammograms use a higher dose of radiation, the FDA requires patients to sign a consent form. I hope this lack of oversight for CT scans is a problem that will be addressed soon. Cheers, FN