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Doctors Need Decision Support in Ordering Imaging Diagnostics

Cheryl Clark, for HealthLeaders Media, July 28, 2010

It is almost certainly money well spent.

No one knows exactly how many increased cases of cancer are caused by diagnostic imaging. But the Medicare Payment Advisory Commission's June report, "Aligning Incentives in Medicare," provided this citation:

"Although an individual's risk of developing cancer from a single test is small, these risks are applied to a growing number of patients. A recent study  (from the December issue of the Archives of Internal Medicine projected that approximately 29,000 future cancers could be related to CT scans performed in the United States in 2007."

In the New England Journal of Medicine  last August, Emory University School of Medicine researchers and others noted that in a sample of 655,613 non-elderly adults who underwent at least one imaging procedure associated with radiation exposure, CT and nuclear imaging accounted for 75.4% of the cumulative effective dose, and 81.8% of the total dose administered in outpatient settings.

In the same study, the authors noted that far too many physicians seem unaware that these doses of radiation carry an increased risk of cancer.  "In one study of U.S. health care providers using CT in patients with abdominal and flank pain, less than 50% of radiologists and only 9% of emergency department physicians reported even being aware that CT was associated with an increased risk of cancer.

"An improved understanding of the risks of radiation is clearly needed, and raising such awareness among providers has been the focus of recent efforts," the researchers wrote.

The issue of CT radiation became even more of public concern since last August, when Cedars Sinai Medical Center in Los Angeles realized that incorrect settings on its 64-slice CT machines caused 260 patients who underwent brain scans to be exposed to ionizing radiation eight times the normal doses. About 40% developed hair loss and rashes as a result over an 18-month period, and all have been alerted they are at increased risk of developing cataracts, hospital officials said.

A number of these decision support systems already exist and work well, according to an editorial in the March 11 New England Journal of Medicine David J. Brenner of the Center for Radiological Research at Columbia University Medical Center in New York, wrote about success with the American College of Radiology's (ACR) "appropriateness criteria" DSS, a system the ACR offers to physicians at no cost.

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