Toward Evidence-based Decisions in Diagnostic Radiology

The use of diagnostic imaging tests and the development of evidence-based guidelines, reviews, and other materials have both undergone substantial growth in recent years. However, the proliferation of evidence-based information has not translated into the universal deployment of medical and coverage policy for diagnostic imaging that is similarly evidence-based. One possible reason is the failure of those institutions generating evidence-based information to format findings in an accessible manner for all relevant stakeholders. The Institute for Clinical and Economic Review has developed a simple and transparent method for rating evidence that is accessible to clinicians, patients, payers, and other policy makers. The authors describe this process in relation to three imaging-based examples (computed tomographic colonography, coronary computed tomographic angiography, and positron emission tomography for dementia neuropathology). The issues raised, controversies considered, and use of the ratings in setting policy are discussed in relation to each example.

The past decade has featured remarkable growth in the use of the common tools and outputs of evidence-based medicine, defined as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients” . The publication of systematic reviews and meta-analyses, the preferred methodologic approach for synthesizing published evidence on the effects of medical interventions, grew by >60% between 2005 and 2009 . Similarly, medical societies and other purveyors of clinical practice guidelines, including the American College of Radiology, are increasingly describing their products as evidence-based .

During this same time period, there has also been an unprecedented increase in the use of diagnostic imaging. Annual increases in the use of computed tomography, magnetic resonance imaging, and other advanced imaging services are estimated to range from 8% to 10% in the Medicare population alone ; Medicare expenditures for these services more than doubled between 2000 and 2006 . Multiple factors have been associated with this growth, including financial incentives for physician ownership of imaging devices, increased patient and clinician self-referral, and increased imaging capacity , none of which is well correlated with acceptance of evidence-based information to guide clinical practice.

Indeed, the submission of and payment for imaging claims appear to be largely independent of any concept of suitability for patients, despite the presence of well-accepted guidelines on appropriate imaging practice. A cross-sectional study of the American College of Radiology (ACR) Appropriateness Criteria and Medicare Part B payments for neurologic imaging found that although the most appropriate tests were twice as likely to be reimbursed as the least appropriate tests, nearly two thirds of claims for tests with “low” appropriateness for a given condition were nevertheless paid .

So why has the explosion in evidence-based research not resulted in widespread acceptance by decision makers to modulate imaging utilization? It is certainly possible that the variability in what is described as “evidence” is simply too broad to engender the universal trust of clinicians. A cross-sectional analysis of >300 treatment recommendations in cardiovascular management guidelines indicated that fewer than half of these recommendations were based on “high-quality” evidence . In addition, and in a reflection of what is found in the medical literature, many imaging guidelines focus on choices between diagnostic modalities, rather than addressing whether such testing should be performed at all. For example, the widely disseminated ACR Appropriateness Criteria provide detailed guidance on choice of imaging modality but are inconsistent on the question of whether imaging is even appropriate for a given circumstance. Finally, there is some indication that the study of gaps between evidence and practice has remained relatively constant over time, with relatively little attention paid to developing interventions to address these gaps .

However, it may also be the case that evidence-based data on appropriate imaging use are not universally accessible to all relevant stakeholders. For example, clinical guideline documents are rarely presented in a fashion that is digestible by patients. In addition, public and private payers may use very different approaches to estimating the potential benefit of diagnostic imaging, preferring to focus on efficiencies in clinical practice gained and improvement in long-term outcomes over the test performance statistics and other intermediate outcomes produced by most trials of imaging technologies.

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The institute for clinical and economic review approach

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Rating Comparative Clinical Effectiveness

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Rating Comparative Value

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Table 1

Measures of Economic Impact Considered in Appraisals Conducted by the Institute for Clinical and Economic Review

Measure Of Primary Interest to Resource use (eg, test frequency, need for hospitalization) Patients, clinicians Cost to achieve treatment success Clinicians Cost to prevent adverse outcome Clinicians Cost per life-year gained Policy makers, payers Cost per quality-adjusted life-year gained Policy makers, payers Budgetary impact Payers, health systems Manpower trade-offs Health systems

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Integrated Evidence Rating

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Case studies using the institute for clinical and economic review rating approach

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Computed Tomographic Colonography (CTC)

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Impact of appraisal

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Coronary Computed Tomographic Angiography (CCTA)

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Impact of appraisal

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Positron Emission Tomography for Dementia Neuropathology

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Conclusions

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References

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Toward Evidence-based Decisions in Diagnostic Radiology

The institute for clinical and economic review approach

Rating Comparative Clinical Effectiveness

Rating Comparative Value

Integrated Evidence Rating

Case studies using the institute for clinical and economic review rating approach

Computed Tomographic Colonography (CTC)

Impact of appraisal

Coronary Computed Tomographic Angiography (CCTA)

Impact of appraisal

Positron Emission Tomography for Dementia Neuropathology

Conclusions

References

Further Reading

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