ACR, providers react to media reports on chest CT scans
While applauding the intent of Medicare’s Hospital Compare quality measurement program, radiology stakeholders questioned the media’s interpretation of the data and the relevance of 2008 statistics.

Last week, articles in the New York Times and Washington Post suggested hospitals were overusing "double" chest CT scans based on 2008 data. The accusation is problematic on several levels.

For starters, 200 of the 5,795 registered hospitals fell into the 30 to 90 percent range for administering chest CT scans without and with contrast in succession, Bibb Allen Jr., MD, of Trinity Medical Center in Birmingham, Ala. and chair of the American College of Radiology (ACR) commission on economics, said in an interview. The corresponding national U.S. average is 5.4 percent. “The vast majority of patients are going to be at low levels. This is not a patient safety issue.”

Indeed, the quality measure program was developed to provide hospitals with a benchmark. “When a hospital [determines that they are an outlier] they will take steps to fix the situation. That’s the point of the measure--not to imply that the public is being over-radiated,” continued Allen.

Other issues relate to the timing of the data. The data addressed 2008 utilization. However, more recent Medicare data indicate that CT scans of the thorax without and with contrast dropped from almost 6 percent in 2006 to 4.9 percent in 2010, a 22 percent drop, Allen said.

That decline is likely due to educational efforts of various medical societies, including the Image Gently and Image Wisely programs, Allen noted.

In addition, providers need more than one year’s worth of data to implement meaningful changes in CT protocols. That is, the 2009 data will be released this summer; however, hospitals have not had a chance to respond to the 2008 data. “The 2009 data may look as bad as 2008 because hospitals need lead time to adjust,” explained Allen, who added that outlier hospitals may not show improvement until 2012 or 2013 because they have not been aware of their status.

Some outliers, however, have made tremendous improvements. Take Ashland Community Hospital in Oregon, which appeared on the list of 2008 outliers. The Centers for Medicare & Medicaid Services (CMS) data showed 40 percent of its Medicare patients received chest CT exams without and with contrast.

The current rate for the Ashland hospital stands at less than 3 percent for the entire population, confirmed Rob Hibner, director of radiology. In an interview, Hibner credited the hospital quality director and its radiology group with its turnaround. “In mid-2009, our quality director made me aware that this data would be made public.”

The timing of the quality measurement initiative coincided with the radiology department’s planned revision of its protocols. The hospital partnered with Medford Radiological Group to implement new protocols across the board, including CT chest, CT angiography and CT abdomen.

“It worked well and in tandem with what Medicare was finding out about disparities in CT chest protocols across the nation,” confirmed Hibner.

Similarly, as reported in the New York Times, Memorial Medical Center of West Michigan in Ludington cut its rate from 89 percent in 2008 to 3 percent in 2011.

The ideal may be a comprehensive, collaborative effort among CMS and professional societies to inform continuous improvement and patient safety. “We applaud the quality measure program. Hopefully, the Medicare Compare program will complement the ACR’s efforts to educate providers by identifying and alerting the small percentage of providers that are ordering these scans,” summed Allen.