Diagnostic imaging has been on the rise in urology and other specialties, and while government agencies assert that the increase is due to the inappropriate and unnecessary ordering of imaging studies, an increase in utilization alone is not necessarily synonymous with inefficient or inappropriate ordering.

Researchers believe that this problem is complex and merits more intensive study because an accurate understanding of all of the factors that contribute to increased imaging is important for policy making.

“Here’s the critical problem,” said Beth Kosiak, PhD, Associate Executive Director for Health Policy at the American Urological Association (AUA). “Until you have the clinical assessment of what appropriate imaging is and what the appropriate modalities are for the diagnosis and treatment of specific urologic conditions, you don’t really know what amount of imaging is appropriate or inappropriate for each and every individual clinical condition.”

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Everyone understands that some percentage of imaging overutilization occurs, “but what percentage of the total imaging out there is due to duplicative, unnecessary, or inappropriate imaging? I can tell you for sure that no one knows. And that’s really an important percentage for us to try and get our hands around,” she said.

Although patient demand, evolving standards of care, and the need to practice defensive medicine could well account for the change in utilization rates, often the government “likes to assert—sometimes to the exclusion of other things—that the increase is financially driven,” Dr. Kosiak said.

Analyzing rates of utilization

“We would like to find out what the actual relationship is between ownership and higher rates of utilization, if any. The AUA is trying to get some data that will help us disaggregate what is going on.”

One part of the AUA’s approach is to gather and analyze Medicare claims data from urology practices.

A few specific events have propelled the AUA into high gear in its quest to determine the most efficient and clinically appropriate imaging for specific urologic conditions. One was the Appropriateness Criteria panels convened by the American College of Radiology (ACR). The ACR Appropriateness Criteria are evidence-based guidelines aimed to help physicians in various specialties use radiologic services appropriately and efficaciously (www.acr.org/secondarymainmenucategories/quality_safety/app_criteria.aspx).

Given the many other urologic problems in which imaging is a key part of the diagnostic process—such as kidney and ureteral stones, bladder cancer, and kidney cancer—the AUA followed the ACR’s lead and is beginning to work guidance for clinically appropriate imaging into its guidelines process. Such guidance will not only be useful to urologists, but non-urologist physicians who encounter these conditions.

“Another major impetus for the AUA to focus on imaging issues occurred when several insurance companies decided they would not reimburse urologists for in-office ultrasound unless they had a dedicated sonographer or radiologist on hand,” Dr. Kosiak said. AUA, with the help of the board and Pat Fox Fulgham, MD, was able to convince the insurers to change their policy, she noted.

Is there widespread overutilization?

Dr. Fulgham, Chair of the AUA’s Urologic Diagnostic and Therapeutic Imaging Committee and Clinical Professor of Urology at University of Texas Southwestern Medical School in Dallas, has a view similar to that of Dr. Kosiak. “If you take the non-pejorative approach to this and ask, is there some ill-advised utilization of imaging, the answer to that has to be, ‘Of course there is.’ Our understanding of how to use it is imperfect,” Dr. Fulgham said. “But I don’t think you can make the statement that there is widespread overutilization of imaging in urology or any other specialty unless you define your terms and say, ‘What do I mean by overutilization?’”

Dr. Fulgham is a key figure in urologic imaging discussions. In fact, he will be speaking on imaging overutilization at the AUA 2010 Annual Meeting in San Francisco in late May. One topic on his agenda will involve what, exactly, is meant by overutilization.

“The cost of providing medical care has gone so high over the last couple of decades that the government is looking for some answers,” Dr. Fulgham said. “An obvious target is imaging, which accounts for 15% to 16% of the total costs of paying providers. Imaging accounts for a large proportion of spending on physician reimbursement, and that’s why it has received so much attention in the recent past. The advance in technology, and particularly in CT scanning, fits so well with urologic diagnoses—especially kidney stones and urologic cancers—that it was an absolutely perfect opportunity to diagnose early and then monitor the effects of treatment.”

Although the federal government harbors skepticism about physician self-referral, Dr. Fulgham and colleagues may have helped to ease concerns by showing that groups of urologists who have come together to purchase equipment are not ordering any more tests after ownership than they were before. “Trends in imaging have indeed been up, but that’s independent of physician ownership of equipment,” he said. “Yes, the utilization of imaging is rising, but it was rising even before urologists began to own CT scanners [or other imaging equipment].”