Several years ago, Dr. James Jelinek began slowly turning down the dial on radiation used in the CT scanners at MedStar Washington Hospital Center.
The chairman of the radiology department didn’t announce the change to the department. Instead, after consulting with several CT experts, he said he wanted to see for himself: How far could he reduce the dose of radiation delivered to patients before colleagues noticed the difference in the image produced?
Almost 50 percent less, it turned out.
“We’d been trying to get the best image,” Jelinek said. “But we really didn’t always need to.”
It was the start of the MedStar hospital's radiation reduction program, which encourages radiologists to more carefully consider patient radiation exposure and prods physicians to rethink imaging, Jelinek said. MedStar’s program is among a growing number of efforts to prove less can be more in health care.
The hospital is one of a number of institutions around the region to embrace an American Board of Internal Medicine Foundation initiative, "Choosing Wisely," which has pushed for doctors and patients alike to question certain tests and procedures, and potentially take a bite out of the estimated $765 billion in annual health care waste. As part of the initiative, medical specialty associations created lists of services most likely to be overused. For example, the American Academy of Pediatrics advised physicians against routine CT scanning of children with minor head injuries or abdominal pain.
At the same time, the New York Times reported Friday some of the most influential medical groups have begun asking doctors to consider cost, not just effectiveness, when weighing treatment decisions. An article published earlier this month in the Journal of the American Medical Association called on professional specialty associations to highlight when services were only a little bit better for a much bigger cost. (Last week, Kaiser Health News pointed out some specialty associations appeared to avoid mentioning the most costly procedures in their field even when studies showed they were often wasteful.)
The Institute of Medicine estimates 30 percent of health care is unnecessary, a point the ABIM Foundation is trying to drive home.
“We’re trying to spark the conversation between physicians and patients about what care is really needed,” said Dr. Daniel Wolfson, executive vice president and chief operating officer of the ABIM Foundation.
Regional hospitals — particularly those in Maryland, in the wake of changes to the way hospitals are reimbursed for care — say they’ve been trying to use the initiative to change the culture in their institutions. The goal is to reduce unnecessary medicine that could cause patient harm and drive up costs.
"Doctors in training are almost always in fear that they’ll be criticized for not ordering enough tests. We’re trying to change that,” said Dr. David Hellmann, chairman of the Department of Medicine at Johns Hopkins Bayview.
The hospital decided to focus on patients with heart attack symptoms where redundant tests were often ordered. Now doctors who try to order duplicative ones receive an automatic alert, Hellmann said. That move reduced the double testing by 60 percent and reduced charges to patients by $1 million in a year, Hellman said.
Making decisions to reduce testing or procedures is not always an easy sell, said Dr. Barry Meisenberg, chairman for quality improvement and health care systems research at Anne Arundel Medical Center in Annapolis.
“It’s extremely uncommon for a hospital to say, ‘Hey, you don’t need all that testing.’ That’s not what we normally do,” Meisenberg said. “Physicians are worried about disappointing their patients. We tell doctors, 'You should find comfort under the umbrella of your professional society’s recommendations.'”
About a decade ago, there was a push for patients to get full body CT scans to look for potential problems, Jelinek said. But the medical community found the testing created too many wild goose chases that could actually harm patients because of unnecessary procedures and stress.
Jelinek said the radiology department has begun following different strategies to make sure imaging is appropriate. They take a hard look at other options for young patients, such as using MRI of the abdomen and pelvis in young patients with inflammatory bowel disease. While some patients might need much sharper imaging for an accurate diagnosis, a 30-year-old woman with appendicitis wouldn't, Jelinek said. Technicians can use software to help reduce some of the grainy appearance in an X-ray image or CT scan done with lower amounts of radiation, Jelinek said.
Still, the message can get muddied. Jelinek said he’s seen worried patients refuse scans when they really needed them. Some patients worry their care is being rationed.
“There are some patients who don’t like this message,” Meisenberg said. “You can show the guidelines and they don’t care. They want it when they want it. So it becomes a negotiation.”
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