Practice guidelines

Dr. Cooperberg calls for more clinically established guidelines from professional associations or national regulatory bodies to illustrate when testing really is not indicated. “In a sense, I think there’s already pretty good awareness of what the criteria should be,” he said.

“However, if the financial or legal incentives are such that they’re still going to favor overtesting, we’re still going to see overtesting no matter what the guidelines state. And this is a failing of the way our health-care system works. Defensive medicine is extremely expensive, and I think this is a prime example of defensive medicine.”


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With no movement toward medicolegal reform and no movement toward reducing payment for diagnostic tests, opportunities to resolve overutilization of imaging are being missed, Dr. Cooperberg said.

This is not a matter of fraud, he said. “Physicians are not doing anything wrong per se in ordering these tests. But if a urologist or a radiation oncologist or even a radiologist has financial incentives to do tests, they’re going to do tests. The issue is the financial incentive to do the test, no matter which physician is incentivized.”

He added: “People are focused on physician salaries and on pharmaceutical costs, but why do we pay what we pay for a CT scan? Medicare payments for interpretation of a CT scan and a bone scan are about half the payment for performing a robot-assisted prostatectomy. Is reading the scans really half as hard? Does it take half as long? Are the risks half as high? You can ask the same questions about the facility fees.”

Eight years ago, a study published in Urology (2002;59:400-404) looked at whether practice patterns changed in response to AUA’s evidence-based guidelines on when CT and bone scans are useful in staging prostate cancer. The study showed that the use of imaging modalities for prostate cancer patients varied by specialty and region. Here are some of the findings:

  • In all regions, patients undergoing radiotherapy (RT) patients were more likely than radical prostatectomy (RP) patients to undergo CT scans.
  • In the South, RT patients were more likely than RP patients to have MRI and bone scans.
  • In the West, RT patients were more likely than RP patients to have bone scans.

One of the study’s investigators, Christopher Saigal, MD, MPH, Associate Professor of Urology at the University of California-Los Angeles, said the findings suggested that, at the time, physicians did not widely embrace AUA’s evidence-based guidelines on when CT and bones are useful in staging prostate cancer.

The study relied on Medicare data from the 1990s, which Dr. Saigal said had an important limitation. “The Medicare data we used gave us a broad picture of what was happening in the country, but the major disadvantage of Medicare information is that it contains no cancer clinical information, so you can’t see what a person’s Gleason score was at diagnosis, for example,” he said. “Such clinical information in important in assessing how often this imaging was used appropriately.”

Educating patients

Dr Saigal pointed out that proper utilization of imaging tests does not depend solely on educating physicians. “We also need to educate patients on the risks of overexposure to radiation; the risks of false-positives when they get an x-ray,” he said. “What’s needed is a concerted effort to tell patients about the risks and benefits of imaging, and at the same time promoting guideline use among physicians. I think with that two-pronged approach we’ll make some progress [in correcting imaging utilization rates].”

Dr. Saigal is the principal investigator on the Urologic Diseases in America (UDA) project, which also involves Dr. Cooperberg. “UDA is an effort to describe the burden of urologic conditions around the country and evaluate quality of care, access to care, practice patterns, and other policy-relevant topics,” Dr. Saigal said.

Physician ownership

An update of the Urology study from 2002 will be written in the next few months, but probably will not be available for another year as it goes through peer review. The results may provide insight into the hot-button issue of just how much physician ownership is driving up utilization rates.

“There has been a shift in who owns imaging equipment, and there has been a lot of concern about physician self-referral,” Dr. Saigal said. Many more practitioners have begun buying their own imaging equipment, “causing MEDPAC some concern that practitioners are overutilizing their own imaging equipment for financial reasons.”