Can radiologists lead the fight against unnecessary imaging?

It may be time for diagnostic radiologists to begin thinking differently. That is according to a viewpoint article published Jan. 7 in the Journal of the American Medical Association, which argued the specialty must act as gatekeepers to combat wasted imaging. 

Despite small gains made by initiatives such as the Choosing Wisely campaign, unnecessary imaging remains high in the U.S. Radiographic incidentalomas—findings that were not the reason for initial testing— further complicate the problem, contributing to greater healthcare spending and potential health risks for patients, wrote first author Ohad Oren, MD, of the Mayo Clinic in Rochester, Minnesota, and colleagues.

“The specialty of diagnostic radiology may thus need to change focus: instead of training radiologists primarily to read images, they may need to be trained as gatekeepers who mostly regulate or are consulted about what tests should be ordered and, even more so, which ones should not be ordered,” Oren et al. added.

The group analyzed a few strategies already employed to reduce over-imaging, including utilizing appropriate use criteria and educating medical students on waste-saving strategies. But many of these techniques haven’t been tested in randomized clinical trials, and the few that have produced discouraging results, the authors wrote.

Instead, they suggested the most effective interventions may be those that target both the physician and patient, and also address outcomes that reflect patient safety and harms.

For instance, adjusting the quality and focus to the level of clinical suspicion can result in “more target-site focus” and reduce the chance of an incidental finding. A chest CT ordered for pulmonary embolism could use medium resolution for skeletal tissues and high resolution for pulmonary vessels to reduce the likelihood of detecting pulmonary nodules and related incidental findings.

Additionally, the authors suggested changes to the structure of ordering, distributing and reimbursing imaging which would marry the cost of low-value studies to higher out-of-pocket costs. A brain MRI in patients with stable chronic migraine could be prohibited all together.

Overall, advances in automated methods for reading images will require radiologists to spend less time reading and potentially more time consulting on which tests should, and should not be ordered, the authors wrote. They warned employing radiologists as gatekeepers must be done with caution to strike the balance between “ the need for accessible imaging with the harms mediated by the overuse of tests.”