Greg Freiherr, Industry Consultant

Greg Freiherr has reported on developments in radiology since 1983. He runs the consulting service, The Freiherr Group.

Blog | Greg Freiherr, Industry Consultant | June 18, 2012

JAMA, can we please move on?

The lag between news and peer-review last week dragged radiology back into the quagmire of concern about patient exposure to diagnostic radiation, thanks to an ill-considered publication that illustrates the shortcomings of peer-reviewed journals as it does the failure of opinion leaders to lead.

A paper published in the June 13 Journal of the American Medical Association (JAMA) entitled, “Use of Diagnostic Imaging Studies and Associated Radiation Exposure for Patients Enrolled in Large Integrated Health Care Systems, 1996-2010” http://jama.jamanetwork.com/article.aspx?articleid=1182858, described growth in the use of advanced diagnostic imaging, as if the data were some new revelation, concluding that the use of such imaging should be balanced against benefit and cost, as if this trend were continuing unabated.

Results published in JAMA detail the number of exams during the 15-year period from 1996 to 2010 – the average number per person; the percentage comprised by advanced imaging (i.e., computed tomography [CT], magnetic resonance imaging [MRI], nuclear medicine and ultrasound); the rates of imaging examinations per 1,000 enrollees in 2008 by modality, site and anatomic area; and the total rate of imaging per 1,000 enrollees per year with the most common ranked from one to five (radiography, ultrasound, CT, MRI, angiography/fluoroscopy and nuclear medicine). Ultrasound doubled, CT tripled and MRI quadrupled. If the findings were put to lyrics, Arlo Guthrie would have been the one to sing them.

JAMA would have been Officer Obie. Alice’s Restaurant would have been the medical community. And the truth would have been laid bare about advanced imaging from 1996 to 2010, just as it was in the days after that fateful Thanksgiving, when a good deed by Arlo and his friends went awry and their guilt was established by plaster tire tracks, footprints and dog smelling prints; 27 eight-by-ten color glossy photographs with circles and arrows and a paragraph on the back explaining each; pictures of the approach, the getaway, the northwest corner of the southwest corner and, of course, aerial photography.

Just as the hard facts were irrelevant for Arlo, so are they for the imaging community. What happened in 2010 is not what is happening in 2012. The years leading immediately to the present and the ones to come in the future are not the 14 years from 1996 to 2010, an atypical era of growth for high-tech medical imaging that is no longer underway. Myriad studies have noted the increased cumulative patient exposure coming from imaging, a fact underscored by the release of several generations of dose reduction technologies by industry.

What we want to know – what we need to know – is whether the technological advances and heightened awareness of patient exposure have led to less patient dose; whether the declining sale of high-tech imaging system due to cutbacks in reimbursement and a global recession has reduced the growth rate in medical imaging; whether guidelines from medical societies are making a difference?

Instead, we’re getting conclusions like the one published last week: “Given the high costs of imaging – estimated at $100 billion annually — and the potential risks of cancer and other harms, these (imaging) benefits should be quantified, and evidence-based guidelines for using imaging should be developed that clearly balance benefits against financial costs and health risk.”

Especially telling is this reference to the need for guidelines, a reference made despite the publication two months ago of such guidelines by just about every major medical discipline ("'Choosing Wisely' Campaign Validates Use of Imaging Tests," http://www.itnonline.com/content/choosing-wisely-campaign-validates-use-imaging-tests).

The irrelevance of the JAMA article is as much an indictment of the peer review system as it is of the publication of this study.

Officer Obie, can we please move on?

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