By Kelly Gooch, Becker’s Hospital Review, May 04, 2021.

Patients of physicians employed by hospitals are more likely to receive inappropriate referrals for diagnostic imaging, according to a study published May 3 in Health Affairs.

The study — led by researchers from Boston-based Northeastern University, Stonehill College in Easton, Mass., and Boston University — is based on commercial health insurance claims from the Massachusetts All Payer Claims Database, as well as Medicare claims data and data from health plans. Data was collected for MRI referrals for three conditions — uncomplicated lower back pain, nontraumatic knee pain without joint effusion, and nontraumatic shoulder pain without joint effusion — for 2009 through 2016.

For the study, researchers compared a study cohort of 583 primary care physicians who became employed by a hospital in Massachusetts from 2009 through 2016 with 3,102 Massachusetts physicians who were not employed by a hospital during the study period. 

The study found an association between hospital employment of physicians and patients’ likelihood of receiving MRI referrals generally. For the study cohort, researchers also found that patients’ likelihood of receiving inappropriate MRI referrals climbed by 26 percent related to hospital employment of physicians.

Additionally, researchers said physicians were more likely to refer patients for MRIs once they were employed by a hospital than before that employment began. 

“Our findings are in line with previous studies that have reported an association between hospital-physician integration and higher costs for patient care,” the study’s authors concluded. “However, our findings offer evidence that such higher costs are not largely a matter of better service access for patients. Rather, hospital-physician integration appears to be a potential driver of low-value care.”

Article link: https://www.beckershospitalreview.com/hospital-physician-relationships/hospital-employed-physicians-more-likely-to-order-unneeded-mris-study-finds.html

It’s such a common routine in a doctor’s office or clinic or hospital that patients tend to comply without thinking: Step on the scale, roll up your sleeve for the blood pressure cuff, urinate into a cup.

But that last request should prompt questions, at the least. The urine test is the first step into what’s sometimes called “the culture of culturing.”

In patients who have none of the typical symptoms of a urinary tract infection — no painful or frequent urination, no blood in the urine, no fever or lower abdominal tenderness — lab results detecting bacteria in the urine don’t indicate infection and thus shouldn’t trigger treatment.

Older people, and nursing home residents in particular, often have urinary systems colonized by bacteria; they will have a positive urine test almost every time, but they’re not sick.

Yet such test results, signifying what’s known in doctor-talk as asymptomatic bacteriuria, frequently lead to unnecessary treatment with antibiotics. Public health leaders and researchers have battled for years to persuade providers to stop reaching for their prescription pads every time a urine test comes back positive.

They have been only modestly successful. A recent study in 46 Michigan hospitals, for instance, found that of 2,733 patients with asymptomatic bacteriuria (average age: 77), almost 83 percent received a full course of antibiotics. The odds of this overtreatment rose 10 percent with each decade of age.

“We now recognize that there’s a strong cognitive bias,” said Dr. Christine Soong, head of hospital medicine at Sinai Health System in Toronto and co-author of a recent editorial on the subject in JAMA Internal Medicine. “Once a clinician sees bacteria in the urine, the reflex is, you can’t ignore it. You want to treat it.”

Now, the campaign has changed from trying to prevent needless treatment to trying to curtail the testing that prompts it. If concerned doctors can’t dissuade their colleagues from treating these non-infections, they’re trying to discourage them from ordering urine tests in the first place.

The very reserved headline on Dr. Soong’s editorial was: “De-adoption of Routine Urine Culture Testing — A Call to Action.” It probably should have been: “For Crying Out Loud, Stop With the Pee in the Cup.”

What’s raising this issue once more are the latest guidelines from the United States Preventive Services Task Force, the independent expert panel that reviews medical evidence and advises on prevention and screenings.

The task force concluded last month that for virtually everyone except pregnant women, screening for and treating asymptomatic bacteriuria provides no benefit and has potential harms. This didn’t come as news — the task force reached essentially the same determination in 1996, in 2004 and in 2008.

The Infectious Diseases Society of America, which updated its recommendations this spring, also cautioned against screening and treating, except for pregnant women and patients about to undergo invasive urologic procedures. The Choosing Wisely campaign has similarly weighed in against routine urine testing in older adults.

Why this strenuous effort? All of it is aimed at reducing the persistent overuse of antibiotics.

They’re lifesaving drugs, useful when patients actually have urinary or other bacterial (not viral) infections. But studies have shown that with asymptomatic bacteriuria, withholding antibiotics doesn’t endanger patients. Providing the drugs, however — especially to older people — definitely does pose risks.
“The public thinks it’s good to take an antibiotic,” said Dr. Heidi Wald, a geriatrician and chief quality and safety officer at SCL Health in Denver. “People don’t understand the risks of overuse.”

Antibiotics can cause side effects ranging from nausea and rashes to impaired kidney function and interactions with other commonly used drugs, like cardiac medications and antidepressants.

“The problem I worry about most in the frail elderly is C. difficile,” Dr. Wald said, referring to a virulent, hard-to-eradicate infection that has rampaged through the Medicare population.

Antibiotics affect the human microbiome, wiping out the protective microbes in the gastrointestinal tract and increasing people’s vulnerability to C. difficile, which the Centers for Disease Control and Prevention has called an “urgent threat.”

In the Michigan hospital study, patients treated for asymptomatic bacteriuria fared no better on a variety of measures than those who weren’t treated. “But they stayed in the hospital a day longer,” said Dr. Lindsay Petty, the study’s lead author and an infectious disease specialist at the University of Michigan.

She theorized that their doctors were awaiting urine culture results. The patients, meanwhile, faced additional risks of disrupted sleep, infections, physical deconditioning from time spent in bed and other hazards, while generating needlessly higher hospital bills.

Beyond its effect on individuals, “antibiotic resistance is one of the greatest public health crises of our time,” Dr. Petty said. When bacteria develop resistance to overused drugs, doctors are left with fewer and riskier weapons with which to fight infections.

Because U.T.I.s occur so commonly — 40 percent to 60 percent of women, in whom they’re far more common than in men, will experience at least one in their lifetimes — it’s easy for doctors and patients to engage in so-called scapegoating, blaming a supposed U.T.I. for problems that may have little to do with the urinary tract.

In older patients, particularly, confusion and hospital delirium can lead family members to urge doctors to order urine cultures, especially when dementia makes it difficult for patients to describe their symptoms.

But “the idea of attributing delirium to a U.T.I. is losing ground,” Dr. Wald said. When older patients grow confused, “maybe they’re dehydrated,” she said. “Maybe it’s a new medication.” Hospitalization itself might be to blame.

Doctors understand, after vigorous education efforts, that they need to prescribe fewer antibiotics; virtually every hospital has an antimicrobial stewardship program aimed at that goal. “This isn’t a knowledge gap,” Dr. Soong said.

But since many doctors can’t seem to overlook positive tests, even in asymptomatic patients — fearful, perhaps, of missing an infection — health care systems are working to curb their impulse to treat.

Some organizations have created pop-up alerts in electronic records when health care professionals attempt to order urine tests, reminding them of the proper criteria.

At Dr. Soong’s hospital, withholding the results of urine cultures, unless doctors actually called the microbiology lab to request them, reduced prescriptions for asymptomatic bacteriuria to 12 percent from 48 percent of non-catheterized patients, with no loss of safety.

“The extra step of having the clinician call eliminated a lot of frivolous testing,” Dr. Soong said.

Similarly, another Toronto emergency room reported success using containers with a preservative, allowing urine specimens to be held at room temperature for 48 hours, processed only at a doctor’s request. That two-step approach cut antibiotic prescriptions for emergency room patients in half.

There’s a role here for patients and families, as well. What if we asked why we were being asked to urinate into a cup?

“Asking further questions is always appropriate,” Dr. Petty said. “’Why do you think I need this test? What would you do with the results?’”

(Hint: “It’s just routine” is not a good answer. “The symptoms you’ve described could mean a urinary tract infection” is a better one.)

“Such questions should be welcome,” Dr. Petty said. “It’s a way for patients to protect themselves.”

Overly aggressive care can hurt patients, generating mistakes and injuries believed to cause 30,000 deaths each year.

From Kaiser Health News, May 24, 2017.

CT scan is short for computerized tomography scan. CT scans are a type of X-ray that provide highly detailed images. CT, or CAT scans, are special X-ray tests that produce cross-sectional images of the body x-rays and a computer. CT scans are also referred to as computerized axial tomography.

CT scan images allow the doctor to look at the inside of the body just as one would look at the inside of a loaf of bread by slicing it. This type of special X-ray, in a sense, takes “pictures” of slices of the body so doctors can look right at the area of interest. CT scans are frequently used to evaluate the brain, neck, spine, chest, abdomen, pelvis, and sinuses.

CT is a commonly performed procedure. Scanners are found not only in hospital X-ray departments, but also in outpatient offices.

Questions to ask your doctor before a CT scan

What do you expect to learn from the CT scan and will it change the plan? In “other words” is it truly necessary?

Is a CT scan the best way to learn more about the condition being evaluated? Is there a lower-risk or better option, such as an MRI, PET scan, or ultrasound?

Do CT scans cause cancer?

CT imaging exposes patients to higher levels of radiation than any other type of diagnostic radiology procedure. The ionizing radiation emitted from CT scans can harm DNA and cause tumors.

Children are particularly susceptible to the potential adverse effects of radiation however the diagnostic information obtained by CT is often essential for treatment planning – the risk associated with the CT is worth the benefit, in most cases.

In addition, children’s rapidly dividing cells are vulnerable to radiation from any kind of X-ray. To make CT scans safer, providers use X-ray shields to protect sensitive areas and adjust doses to minimize the risk for younger patients.

Radiation is more dangerous if it takes place on the same part of the body several times and with very high doses. So, radiation doesn’t tend to accumulate if you have multiple CT scans on five different parts of your body.

What is the evidence?

CT Imaging in Kids Raises Cancer Risk

According to one Dutch study published by Dr. Michael Hauptmann, MD, of the Netherlands Cancer Institute in Amsterdam, and colleagues in the Journal of the National Cancer Institute pediatric patients who had CT scans have a higher-than-expected risk of developing cancer later in life.

Researchers at British National Health Service hospitals also reported a link between CT scans of the head and the development of subsequent cancers. They found a clear relationship between increase in cumulative dose of radiation and increase in cancer risk.

Their results indicated that children and young adults who received a cumulative absorbed dose to the head of 50 to 60 mGy had triple the risk of brain tumors and those who received the same dose to the bone marrow had triple the risk of leukemia. As a point of reference—using current scan settings, two or three CT scans of the head would yield a dose of 50 to 60 mGy to the brain and five to ten CT scans of the head would yield that same dose to the bone marrow in children under age 15.

In the current report Dr. Hauptmann’s group analyzed data from the Dutch Pediatric CT Study, which focuses on brain cancer and leukemia but also tracks other cancers. The analysis comprised 168,394 patients who were <18 years when they had CT scans (unrelated to cancer) between 1979 and 2012

The risk for developing any type of cancer was 47% higher and ranged from 11% to more than three times higher for specific types of cancer.

The authors offered a cautious interpretation of the findings, noting that “CT scans for children represent a potentially life-saving and quality of life-improving technique for many patients. In addition, the tumors evaluated here are associated with small absolute excess risks.

The risk is quite small and the benefits of CT scans typically outweigh the risks. CT scans can be useful diagnostic tools; however, it’s important to justify their use and strive to keep radiation doses as low as possible.

Ed. – CT scan overdose and overuse causes cancer in 50,000 Americans a year. – Korley, Pham, Kirsch, 2009.

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By Catherine Guthrie, TIME, June 27, 2008.

Computed tomography (CT or CAT) scans help doctors detect everything from cancer to kidney stones. But some physicians are raising concerns about the safety of such procedures — most notably, an increase in cancer risk. A CT scan packs a mega-dose of radiation — as much as 500 times that of a conventional X-ray. If your doctor orders a CT scan for you or your child, should you think twice?

Absolutely, say researchers behind two recent studies that sound the alarm about the increased cancer risk associated with multiple CT scans. In the first study of its kind, physicians at hospitals in Florida and Washington, D.C., evaluated the medical-imaging records of 1,243 randomly selected patients to calculate just how much radiation each patient had sustained in the past five years. Although CT scans were the biggest source of radiation, other offenders included X-rays and mammograms. The results of the study, presented in May at the annual conference of the Society for Academic Emergency Medicine, were disturbing: the average patient had received 45 millisieverts (mSv) of radiation. (The typical chest X-ray dispatches 0.02 mSv of radiation.) And 12% of patients had gotten more than twice that amount — 100 mSv or more. “Our focus is to bring awareness to the fact that people are getting large doses of radiation and it’s not innocuous,” says Timothy Bullard, the study’s lead author and chief medical officer at Orlando Regional Medical Center. “We want people to use the technology appropriately.”

“Appropriate” is the key word — especially since a review study published last November in the New England Journal of Medicine determined that as many as one-third of all CT scans performed in the United States are unnecessary. The authors take issue with the “perhaps 20 million adults and, crucially, more than 1 million children per year in the United States [who] are being irradiated unnecessarily.” Part of the problem, the authors say, is that patients are being prescribed multiple, unneeded CT scans, a predicament that could be avoided with better communication between physicians. “Having the same CT scan twice is ridiculous,” says David Brenner, the review’s lead author and director of the Center for Radiological Research at Columbia University Medical Center. “There is no excuse.” In one of the review’s highlighted studies, among patients undergoing CT scans, 30% were on their third scan, 7% had five or more, and 4% had more than nine. Also to blame: doctors increasingly practicing defensive medicine. “There is an underlying philosophy that you’re at fault if you miss anything,” says Bullard. “The goal is to be perfect every time.” Plus, he notes, CT scans have no immediate negative side effects. “They are quick, painless, and send patients away with the sense of satisfaction that everything’s been done.”

Exactly how much radiation is too much? Because CT scans came into vogue in the 1980s and radiation-induced cancer takes roughly 20 years to develop, long-term studies of CT scans and cancer are still under way. But scientists are already anticipating future health implications. Indeed, researchers found a population of 25,000 Japanese post-atomic-bomb survivors who were exposed to roughly the same amount of radiation as two CT scans. Based in part on those studies, the Food and Drug Administration estimates that an adult’s lifetime risk of developing radiation-induced cancer from a CT scan is roughly 1 in 2,000. Worse, the risk for children is even higher.

Compared with adults, children are more sensitive to radiation because they have longer life expectancies and because their cells divide more rapidly, making their DNA more vulnerable to damage. A child’s risk of developing a fatal cancer from just one CT scan is as high as 1 in 500. Although newer machines can be adjusted to deliver up to 50% less radiation for children and small adults, a 2001 study published in the American Journal of Radiation showed that radiologic technologists (RT) rarely make those adjustments. “Changing technical factors is very easy. It just requires a little thought and a few extra seconds,” says Michele Scoglietti, a spokesperson for the American Society of Radiologic Technologists. “But I think there are many RTs who are either not trained to vary the technique, don’t know how, are in a hurry or are just lazy.”

When doctors first ordered a CT scan for Jen Houck’s six-month-old daughter in 2003, the new mom was more worried about the risks of anesthesia (used to keep children from squirming in the machine) than of radiation exposure. In 2006 and 2007, her daughter, now 5, had two additional CT scans, 6 months apart, for what doctors initially thought was a growth abnormality. They’ve since determined the child was perfectly healthy. “All that, just to find out her head is bigger than normal,” says the 27-year-old mother of two in Boone, North Carolina. In hindsight, Houck wishes she had done things a bit differently. “I would have asked more questions about the necessity for a third scan so soon after the second.” She also says no one mentioned the option of a low-dose scan, and she has no idea how much radiation her daughter received. “I wish I’d known to ask the question.”

So what should you ask, if a doctor recommends a CT scan for you or your child? Brenner suggests the following: is a CT scan really necessary? Might a test that doesn’t involve radiation, such as an ultrasound or MRI, do the job? In some cases, a CT scan is absolutely required — for example, for diagnosing severe head trauma or internal injuries, for acute abdominal pain, or to diagnose an existing cancer. If your doctor schedules you for a scan, call ahead to see if you can bring a flash drive. That way you can take an electronic copy of your CT scan to go, and may be able to avoid another scan later, should you move or change doctors. (A hard copy of the scan is bulkier, but may also be an option.) If your child needs a CT scan, ask the technologist to put the machine on pediatric-appropriate settings. For more information on kids and CT scan safety, visit the Alliance for Radiation Safety in Pediatric Imaging.

Gadolinium: The MRI Agent Linked to Brain Abnormalities.

Magnetic resonance imaging (MRI) is one of the better choices if you need a diagnostic imaging procedure performed. Unlike CT scans or X-rays, an MRI does not use ionizing radiation that may cause DNA damage or cancer. But there are risks involved when contrast agents are used, including potential brain abnormalities revealed by a new study, so it’s important to use extreme caution and only get an enhanced MRI if it is absolutely necessary.

Gadolinium-Based Contrast Agents Linked to Brain Hypersensitivity

Gadolinium is a paramagnetic metal ion that moves differently within a magnetic field. Because the gadolinium ion is known to be toxic, it is chemically bonded with non-metal ions when used during MRIs to allow it to be eliminated from your body before it is released in your tissues.

For the first time, a new study has shown that the gadolinium may not be immediately eliminated and may instead persist in your body.

Gadolinium-Based Contrast Agents Also Linked to Life-Threatening Skin Thickening

Among patients with severe kidney disease, the use of gadolinium-based contrast agents is linked to the development of Nephrogenic Systemic Fibrosis, or NSF. NSF can be fatal.

I recommend that everyone use caution with gadolinium-based contrast agents and only use them when absolutely essential. Even if you’re healthy, these contrast agents may cause side effects like life-threatening allergic reaction, blood clots, blood vessel irritation and skin reactions, including hives, itching, and facial swelling.

Other MRI Risks You May Not Know About

The effects of exposure to MRIs’ strong magnetic field are largely unknown.

Research has shown that there are biological effects in the human body, however, including to the retina, pineal gland, and some cells in the paranasal sinuses. Time-varying magnetic fields may also interfere with your nerve cell function and muscle fibers, while MRIs also produce acoustic noise that has been known to cause temporary (and, rarely, permanent) hearing loss.

The MUST-KNOW Rule if You Are Getting an MRI

But the KEY here is to avoid using MRI scans with contrast unless ABSOLUTELY necessary. Often the use of contrast agents is optional and an acceptable MRI can be conducted without the use of a contrast. Many times, physicians will order these tests just to be complete and cover their butts from a legal perspective. If that is your case, then simply refuse to have the test done with contrast. If necessary, consult with other physicians that can provide you with a different perspective.

If You Need an MRI, It Pays to Shop Around

Hospitals may charge exorbitant fees for high-tech diagnostics, like MRIs, to subsidize other poorly reimbursed services. And, hospitals are allowed to charge Medicare and other third-party insurers a “facility fee,” leading to even more price inflation.  With a few phone calls to diagnostic centers in your area, you could save up to 90 percent over what a hospital would charge for the same service.  

Jan. 9, 2014.

Editor: Although the publication date of an article may not be current the information is still valid.

From Harvard Women’s Health Watch. Updated: April 2, 2018   

There’s been a lot in the media about radiation exposure from medical imaging, and many of my patients are asking about it. They want to know if radiation from mammograms, bone density tests, computed tomography (CT) scans, and so forth will increase their risk of developing cancer. For most women, there’s very little risk from routine x-ray imaging such as mammography or dental x-rays. But many experts are concerned about an explosion in the use of higher radiation–dose tests, such as CT and nuclear imaging.

Over 80 million CT scans are performed in the United States each year, compared with just three million in 1980. There are good reasons for this trend. CT scanning and nuclear imaging have revolutionized diagnosis and treatment, almost eliminating the need for once-common exploratory surgeries and many other invasive and potentially risky procedures. The benefits of these tests, when they’re appropriate, far outweigh any radiation-associated cancer risks, and the risk from a single CT scan or nuclear imaging test is quite small. But are we courting future public health problems?

Higher radiation–dose imaging

Most of the increased exposure in the United States is due to CT scanning and nuclear imaging, which require larger radiation doses than traditional x-rays. A chest x-ray, for example, delivers 0.1 mSv, while a chest CT delivers 7 mSv (see the table) — 70 times as much. And that’s not counting the very common follow-up CT scans.

In a 2009 study from Brigham and Women’s Hospital in Boston, researchers estimated the potential risk of cancer from CT scans in 31,462 patients over 22 years. For the group as a whole, the increase in risk was slight — 0.7% above the overall lifetime risk of cancer in the United States, which is 42%. But for patients who had multiple CT scans, the increase in risk was higher, ranging from 2.7% to 12%. (In this group, 33% had received more than five CT scans; 5%, more than 22 scans; and 1%, more than 38.)

What to do

Unless you were exposed to high doses of radiation during cancer treatment in youth, any increase in your risk for cancer due to medical radiation appears to be slight. But we don’t really know for sure, since the effects of radiation damage typically take many years to appear, and the increase in high-dose imaging has occurred only since 1980.

So until we know more, you will want to keep your exposure to medical radiation as low as possible. You can do that in several ways, including these:

Discuss any high-dose diagnostic imaging with your clinician. If you need a CT or nuclear scan to treat or diagnose a medical condition, the benefits usually outweigh the risks. Still, if your clinician has ordered a CT, it’s reasonable to ask what difference the result will make in how your condition is managed; for example, will it save you an invasive procedure?

Keep track of your x-ray history. It won’t be completely accurate because different machines deliver different amounts of radiation, and because the dose you absorb depends on your size, your weight, and the part of the body targeted by the x-ray. But you and your clinician will get a ballpark estimate of your exposure.

Consider a lower-dose radiation test. If your clinician recommends a CT or nuclear medicine scan, ask if another technique would work, such as a lower-dose x-ray or a test that uses no radiation, such as ultrasound (which uses high-frequency sound waves) or MRI (which relies on magnetic energy). Neither ultrasound nor MRI appears to harm DNA or increase cancer risk.

Consider less-frequent testing. If you’re getting regular CT scans for a chronic condition, ask your clinician if it’s possible to increase the time between scans. And if you feel the CT scans aren’t helping, discuss whether you might take a different approach, such as lower-dose imaging or observation without imaging.

Don’t seek out scans. Don’t ask for a CT scan just because you want to feel assured that you’ve had a “thorough checkup.” CT scans rarely produce important findings in people without relevant symptoms. And there’s a chance the scan will find something incidental, spurring additional CT scans or x-rays that add to your radiation exposure.

October, 2010

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How Hospitals and Doctors Put Thousands of Patients At Increased Risk for Cancer.

​​​By Dr. Evan Levine, a member of APRA’s Medical Advisory Board.

In the 1990s a new type of stress test was developed that could be done in just half the time of the usual nuclear stress test, earning more profit for hospitals and doctors. The only problem was that it would result in an exposure of radiation equal to an additional 140 chest x-rays or a lifetime of mammograms, resulting in an increased risk of cancer over the next 20+ years. But the victims were never told.