Imaging utilization, defensive medicine, and decision support

A massive cultural revolution, incentivizing a move away from blind defensive medicine, is needed to address a number of cascading key trigger points in support of appropriate imaging.

It is not just the swell of patients’ demands for more imaging, triggered by consumer directed marketing promoting the availability and benefits of procedures such as full body scans. Nor is it just the disturbing and proven relationship between physician self-referrals and higher imaging utilization,1 perhaps to feed costs associated with acquiring expensive imaging equipment.  Many physicians choose to and are taught to practice ‘rule-out medicine’ as opposed to actual ‘diagnostic medicine’ in fear of liability and expensive litigations from possible missed findings. According to a recent survey,2 the cost of defensive medicine is estimated to be in the $650-$850 billion range, or between 26% and 34% of annual healthcare costs in the U.S.

A thought provoking NEJM paper titled “The Uncritical Use of High-Tech Medical Imaging”3 makes an interesting observation: imaging tests are most valuable when the probability of disease is neither very high nor very low but in the moderate range. 

 Various imaging utilization management systems have been enforced in various forms by insurance companies and radiology benefit management (RBM) companies. Prior authorization, prenotification, and various forms of network strategies that focus on examination costs, total quality and practice guidelines have also had varying levels of success.

Beyond more tailored tort reform, and an evolution in medical education and training, perhaps the most effective antidote to this trend is data – intelligent personalized data based on solid evidence-based medicine, presented tightly integrated into the decision support and physician order entry workflow.

Ordering physicians want to do what is best for their patients, and presenting them with intelligent personalized data around image order entry appropriateness, alongside easy access to relevant priors will work wonders. This is difficult, but not impossible – and is a critical step towards meaningful value-based imaging.



1. Stensland, Ariel Winter and Jeff. Impact of physician self-referral on use of imaging services within an episode. Medicare Payment Advisory Commission . [Online] April 8, 2009. [Cited: February 2, 2013.]

2. A Costly Defense: Physicians Sound Off on the High Price of Defensive Medicine. Jackson Healthcare. [Online] May 27, 2011. [Cited: February 14, 2013.]

3. The Uncritical Use of High-Tech Medical Imaging. Bruce J Hillman MD, Jeff C Goldsmith PhD. 1, s.l. : N Engl J Med, July 1, 2010, Vol. 363.

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