To scan or not to scan

August 30, 2010

There is an increasing consensus that many high tech radiology procedures are overused but no agreement on what to do about it.

An important review study reported in the Archive of Internal Medicine concluded that exposure to even one CT scan can produce cancer later in life. The editorial in the Archive notes that every day more than 19,500 CT scans are done in the U.S. and that almost 70 percent of non-elderly adults received a CT scan within a three year period. That amount is stunning, especially when there are no clear data to support the value of these scans in improving outcomes or quality of care. The studies reported in the Archive concluded that the sheer volume of CT scanning being done, combined with the variability in radiation exposure between machines and providers, has led to thousands of excess cancers and deaths.

So, given that we have known this for some time, why isn’t the picture changing? Steve Hillman and Jeff Goldsmith provided an important perspective on this issue in a recent New England Journal of Medicine.

Among both patients and providers in the U.S. there is an assumption that more is better. More treatment and more diagnostic tests are presumed by both patients and physicians to produce better outcomes. Whenever there is a recommendation to stop or refrain from doing things — e.g., watchful waiting vs. surgical intervention for men with prostate disease, allowing a virus to run its course rather than prescribing an unneeded antibiotic, recommending palliative vs. therapeutic care in the terminally ill, or not doing testing at all for those with low back pain, there is an outcry that someone, somewhere is withholding needed care.

Witness the outcry about recent recommendations related to mammograms, or the charges of rationing when policy makers encourage the use of care based on evidence. In particular, when recommendations like these come from health insurers or the government there is a belief that the recommendations are just ploys to reduce spending so that someone else (greedy health plans?) can benefit. It is interesting to note that device makers, practitioners, and others who have a clear and direct economic interest in doing more don’t come under the same kind of public scrutiny as academics and others who argue – based on evidence – for doing less.

In fact, years of research tell us that in many cases conservative approaches to medical care actually result in better patient outcomes than do aggressive interventions. A backlash against these evidence-based recommendations can put both the short and long term health/well being of patients at risk.

Why do so many in the U.S. equate good medical care with more medical care? Much of this belief is founded and grounded in deep-seated American values. America: land of opportunity and endless possibilities. America: home of entrepreneurs and inventors of new things. America: where we prize individual achievement pulling ourselves up by our boot straps, Horatio Alger style. Our natural optimism and belief in all things possible combined with baby boomers’ “live forever or die trying” ethic lead some to believe – deep in their hearts – that death is optional.

Indeed, many of the things that make this country great also conspire to lead us down a path of greater and greater consumption in the search for ways to avoid the inevitable. There are many who hope the Affordable Care Act will change this picture. But if health policy makers are going to change the trajectory of health care spending, they must also understand the values and beliefs that underlie it.

Policy wonks beware: change will be more difficult than you think.