Are We Scanning Too Much?

So let’s talk about redundant imaging. As radiologists and technologists, we see this all the time. Just some easy examples that pop in to my head are patients that have recently had a chest CT and then the primary care doc or some other practitioner orders x-rays of the thoracic spine without any change in the patient’s condition. No trauma or other worrisome clinical finding since the chest CT. Are you kidding me? CT is vastly superior to x-ray when it comes to imaging the bony spine. Why would you order x-rays when a CT was just performed a week earlier? If the patient didn’t have a fall, and doesn’t have any new back pain symptoms from when the CT was performed, then why get an inferior study when the more comprehensive exam was recently performed. We see this all the time. Is this sheer laziness or perhaps a misunderstanding of the information you get with a CT scan? Hard to know, but something isn’t right here. A simple phone call to the radiologist ahead of time could avoid extra imaging that the patient doesn’t need. Not to beat a dead horse, but the same thing happens with abdominal CT‘s and lumbar x-rays. Abdominal CT‘s can show you everything you need to know about the bony structures of the lumbar spine and in much more detail then you would get with lumbar x-rays. And just to round out the discussion, I am not including MRI here in this scenario. MRIs are a whole separate discussion and can add loads of value when imaging the spine. For the moment, I’m just comparing x-ray and CT.

Anyway, where else do we see redundant imaging? Well how about cases where patient’s get a CT scan of the abdomen and we see a dilated gallbladder, gallbladder wall thickening, gallstones and haziness in the adjacent fat. These findings are definitive for cholecystitis. However, not infrequently, an hour later the patient is sent for an ultrasound of the right upper quadrant. Why bother doing this? Some people might make the argument that it’s better for assessing the gallbladder wall and looking for pericholecystic fluid and measuring the size of a common duct. Yeah, ultrasound is a great option by itself or when you don’t have all these classic CT findings already present. But to do an additional exam in this scenario just doesn’t make sense. I have never seen an ultrasound refute a CT diagnosis of cholecystitis. When all the signs on CT are present and pointing towards cholecystitis, ultrasound rarely changes the diagnosis. It certainly can confirm it, but in this situation you’re not getting any extra pertinent information.

OK, how about another example. And I’m sure you guys probably see this all the time as well. Let’s talk about the work-up for a transient ischemic attack or one of those partial or intermittent strokes. In most institutions, if you come into the hospital with something that resembles a stroke, whether the symptoms are still present or not, 99.9% of emergency rooms are going to order a non-con head CT, most likely followed by a CT angiogram of the head and neck. This all sounds reasonable so far. But then, why do you need to follow up the CT angiogram with a carotid ultrasound and an MRA of the head and neck. I would say an MRI of the brain with diffusion imaging is helpful for looking for a small strokes which can be invisible on CT, however I see no benefit for the ultrasound and MRA once the CTA is already performed, unless the radiologist recommended it for some reason and perhaps wanted another exam for clarification. To bolster my point of view, I can across a recent article in the American Journal of Radiology specifically addressing the work-up of TIA’s. (Click here for the article) The authors concluded that the redundant imaging was likely secondary to a lack of provider familiarity with guidelines. Well if you are unsure of what to order as a medical provider, the simple solution here is to call the radiologist and ask them. Although I do get calls from practitioners from time to time on what exam to order, or what exam would be the best choice to look for a certain condition, I rarely get a call before many of these redundant imaging studies. Many times, the MRA and ultrasound are ordered before we’ve even had a chance to sign off on the CT angiogram. Ridiculous! All this extra imaging contributes to the ever-increasing medical costs every year and just ends up padding the budgets of hospitals that bill ridiculously high prices for these exams.

So what’s to be done? Well I would say there’s no harm in questioning the ordering provider. If you are in a position to and perhaps along with your radiologist colleagues, if you already know a CT of lets say the abdomen and pelvis was just performed on patient Jones and then the ER wants to send the patient back for lumbar x-rays, give them a call and find out why? If you’re uncomfortable with this, talk to the radiologist on duty and let them know that it seems like there is some redundant imaging going on here. Any radiologist worth his/her body weight, will take some time out of the day to speak with the ordering provider if it’s feasible to do so. Now, I can’t promise you that your local radiologist will be as diligent as I am, however if you want to remain a patient advocate, it’s at least worth having a discussion with the ordering provider or radiologist to see if you can spare the patient some extra radiation and medical expenses.

Anyway, that’s how I feel about all this redundant imaging. We see it all the time and there are cases where we can make a difference and avoid some imaging over-utilization. I’m sure many of you feel the same way and also feel powerless to stop it, but maybe raising a concern here and there can make a difference in some patients’ lives. Now if you want to find out some of my other opinions on the types of things you should be doing as a CT technologist at your institution, which will help you become one of the most desirable Techs to work with, check out my free course at www.CTSuperTech.com. Yes, it’s 100% free and spending 30 minutes of your time watching this informative course will give you a significant chance to elevate your status at your workplace. Doesn’t that sound worth it?