Double take: Repeat imaging defined & in context

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A classification system that categorizes repeat medical imaging into four types could better help researchers and policy makers discriminate between necessary repeat diagnostic imaging and questionable repeat exams. The American College of Radiology’s Harvey L. Neiman Health Policy Institute released a proposed repeat imaging classification grid Feb. 19 in a policy brief.

Repeat testing has come under fire as a source of billions of dollars in wasted healthcare spending. However, the lack of clarity related to the amount spent on repeat imaging, the potential savings and the actual definition of repeat testing pose challenges.

“When investigating the appropriateness of a repeat test, investigators must precisely define their methodology, specifically as it pertains to the clinical context in which such services are performed. Without precision and uniformity, further investigation may result in health care policy which could unintentionally impede the quality of individual patient care and overall societal health,” wrote Pam Kassing, MHA, and Richard Duszak, MD, from the Neiman Institute.

Duszak characterized the issue as “the core of healthcare reform,” and explained that the model could help differentiate useful testing from unnecessary testing to answer questions about efficient and effective resource use that provides optimal care, accurate diagnosis and appropriate treatment while containing costs.

The system divides repeat imaging into four categories: supplementary, duplicative, follow-up and unrelated, and includes subcategories to provide additional clinical context.

Supplementary imaging, which comprises use of a different modality in the same or overlapping encounter, according to the scheme, may be high value-added if it confirms or refutes a questionable finding from the initial imaging exam, or low value-added in the case of overlapping exams that ignore appropriate use criteria.

Duplicative imaging, the same modality used in the same or overlapping encounter, may be intentional or unintentional. Both subcategories may provide opportunities for reducing repeat imaging. However, strategies for reducing repeat exams depend on the reasons for the repeat exam. Take, for example, defensive imaging. Substantive tort reform may be required to curb such orders. Integrated health information exchange or EHRs may help reduce orders based on unknown or unavailable prior imaging.

Follow-up imaging is comprised of recommended screening, standard follow up or surveillance, non-standard follow up or surveillance and inaccessible prior information, with the former two typically necessary. Real-time decision support in information and ordering systems could reduce non-standard follow up exams, while integrated health records and health information exchanges could minimize studies performed in the absence of a complete imaging history.

Unrelated imaging consists of imaging performed during an unrelated encounter, and is typically necessary in the cases of a cancer patient who undergoes staging CT and  then another trauma CT after an unrelated motor vehicle accident.