Renee Lee

Doctors with Financial Interest in Self-Referring MRI Scans Yield More Negative Results 
By Renee Lee

CHICAGO - Nonradiologists with a financial interest in imaging equipment tend to self-refer imaging to patients who are more likely to turn up negative results, according to a study presented Wednesday at RSNA.

Study authors Ben E. Paxton, MD, radiology resident at Duke University Medical Center, and Ramsey Kilani, MD, said imaging has been a significant driver of healthcare costs in the country.
Paxton called the study “exciting,” because unlike similar ones done in the past, this study actually looked at whether imaging results were positive or negative, instead of relying on billing and ordering patterns.

Of 500 consecutive lumbar spine MRI exams ordered by two physicians, one with financial interest and one without, 86 percent more negative results were found in doctors with financial incentive. This indicates some procedures may have been ordered unnecessarily.

“Most people are not surprised that there are more negatives with those with financial interest,” Paxton said, “but what is surprising is the degree of difference. With 86 percent extrapolated across the country, that’s a lot of money.”

The imaging order data of those with financial interest versus no financial interest reviewed by Paxton and Kilani came from doctors with similar variables. The doctors had similar experience levels and similar training backgrounds.

The results showed 42 percent of imaging orders from those with financial interest were negative, compared to 23 percent for non-interest. The mean age for imaging also bore significant differences. The mean age for financial interest was 49.6, significantly younger than non-financial with 56.9 years of age.

Kilani emphasized they were not saying the results meant particular image orders were actually unnecessary.

“We aren’t saying this is a particularly sinister act,” Kilani said. “We need to get a handle on the magnitude of the problem because we can’t afford to waste money on healthcare these days.”

In fact, there were an estimated 662 million Medicare imaging studies done in 2007. Forecasted estimates for 2017 include $4.3 trillion in total healthcare costs and $884 billion in Medicare expenditures.

When asked what this means for patients dealing with doctors ordering scans, Kilani stressed his belief that the results of the study should have more of an impact on the government more so than specifically at the patient-doctor level. Paxton added that increased imaging utilization may place the patient at risk for potential adverse consequences.

“It is important for patients to be aware of the problem of self-referral and to understand the conflict of interest involved when their doctor orders an imaging exam and then collects money on that imaging exam,” he said.

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Doctors with Financial Interest in Self-Referring MRI Scans Yield More Negative Results

CHICAGO - The review of coronary angiography results have showed significant differences between men and women in risk factors for coronary artery disease as well as major adverse cardiac events, according to a study presented Wednesday at RSNA.

Coronary artery disease (CAD) involves a narrowing of the blood vessels that supply blood and oxygen to the heart. It is typically caused by a build-up of fat and other plaque forming on vessel walls. The Centers for Disease Control and Prevention has pinpointed heart disease as the leading cause of death for both men and women.

John W. Nance Jr., MD, a radiology resident at John Hopkins Hospital and a coauthor of the study, U. Joseph Schoepf, outlined the study on Wednesday. Researchers at the Medical University of South Carolina analyzed the results of coronary angiographies of 480 patients with a mean age of 55 that had acute chest pain. About 65 percent of the patients were female, 35 percent male.

The CT results are able to show the number of vessel segments with plaque, the severity of blockage and the composition of the plaque. Results were compared to data collected spanning a 12.8 month follow-up period. From this, researchers gathered information regarding the extent, severity and type of plaque build-up to correlate with occurrences of major adverse cardiac events, such as heart attack or bypass surgery.

The results were significantly different for men versus women, Nance said. In the total study period, 87 of the patients experienced major adverse cardiac events. The correlated results showed that women with a large amount of plaque build-up and extensive hardening of the arteries are at significantly greater cardiovascular risk than men.

Major adverse cardiac events risks were higher specifically in women than men when there was extensive build-up of plaque of any kind. Women with four or more vessel segments narrowed were also nearly twice as likely as men to have a greater extent of CAD.

When searching for risk factors associated with different types of plaque, however, men were at higher risk than women for major adverse cardiac events when their artery segments contained non-calcified plaque. 
Nance said he believes the results of the study should serve as a hint to doctors when evaluating patients. “Doctors should consider these findings when seeing patients,” he said. “They should also have more optimized reporting.”

Nance also believes this should be yet another push for doctors to strive for providing more individualized care for their patients.

Risk Factors for Coronary Heart Disease Differ For Men Versus Women

CHICAGO - Ninety-seven percent of U.S. teens play games either on the computer, Web or console. Of adolescent boys, 50 percent admit to playing video games rated Mature. These statistics are perhaps far more startling after a study presented Wednesday at RSNA that showed violent video games alter brain function in young men.

While some studies have alluded to the fact that violent video games cause more aggressive behavior, there have been very few neuroimaging studies regarding violent games conducted, said study coauthor Vincent P. Mathews.

The controversy on whether violent video games should be on the shelf has been at the center of several court cases, most notably being a 2010 case making it to the Supreme Court. There has, however, been little scientific evidence to support the claim of prolonged neurological effect from violent gaming.

The study followed 28 adult males from the ages of 18 to 29, all with low exposure to video gaming. One group played a first-person shooter game at home for 10 hours the first week, then refrained from play the next week. The other group of men did not play any games during the two-week period.

Each of the men underwent functional magnetic resonance imaging (fMRI) at the beginning of the study and had follow-ups after the first and second week. Participants also completed an emotional interference task as well as a cognitive inhibition counting task.

Compared to baseline results, after one week of violent game play the men showed less activation in the inferior frontal lobe during the emotional task and less activation in the anterior cingulate cortex during the counting task. After the second week with no game play the changes in activation to the sites diminished.

These areas of the brain are responsible for inhibition, monitoring of emotions and attention. 
Because there were no demographic differences in the men studied, Mathews said, it is assumed that the altered brain functions were due to the playing of violent games.

“This is the first study of its kind to look at longitudinal effects,” Mathew said. “Although people usually play these games for a lot longer, the point is even with this amount of time there are changes in brain function.”

A previous short-term study, where adolescents were asked to play violent games for 30 minutes, yielded similar results for the researchers. In that study, the boys were split into a group playing a violent shooter game and a group playing an “exciting” but not violent racing game.

Matthews said, “People need to be aware there are changes in the brain when parents allow their children, or adults themselves, choose to spend their leisure time playing violent games.”

Video Game Violence Alters Brain Function in Young Men

In an ironic twist for radiology, effective imaging of skin cancers has just been accomplished by none other than the imaging modality in closest contact with the skin: ultrasound. 

  “We in radiology have scanned basically the entire body, but not the skin, which seems like it should be superficial and accessible to imaging,” said lead investigator Dr. Eliot L. Siegel, vice chairman of radiology at the University of Maryland School of Medicine in Baltimore. 

  Tuesday at the 2009 RSNA meeting Siegel unveiled results of a study that, for the first time, looked at the utility of ultrasound elastography for identifying skin cancers. 

  Findings suggest that high-frequency ultrasound with elastography has the potential to measure the extent and depth of skin lesions as well as reduce the number of unnecessary skin biopsies. 

  Siegel and colleagues used high-frequency ultrasound with elastography to evaluate 40 patients with either benign or malignant skin lesions. They found malignant lesions are dramatically less elastic than nonmalignant skin. The elasticity ratios recorded by the investigators ranged from 0.04 to 0.3 for benign lesions to 10 and higher for malignant lesions.

According to Siegel, skin cancer will develop in one in five people in the U.S. The American Cancer Society finds that more than one million cases are diagnosed each year. Melanoma is the most deadly, but it is highly curable if detected early. Ultrasound with elastography could provide clear details of the skin without biopsy, Siegel said. 

  “Melanoma has increased precipitously from 1935 to 2010,” Dr. Siegel said. “This makes it even more important to differentiate melanoma from other skin cancers.” 

  According to coauthor Dr. Bahar Dasgeb, a dermatologist at Wayne State University in Detroit, current dermatology assessment of lesions is purely visual. That could change thanks to elastography. 

  “If lesions have anything that catches the eye of the dermatologist, it’s biopsied,” she said. “Elastography can help determine the nature of the lesion before a potentially unnecessary biopsy is ordered.” 

  Ultrasound hardware with a frequency between 14 and 16 MHz is relatively common and currently available clinically. To streamline and better perfect ultrasound with elastography, technology with the ability to image at a higher frequency and the capability to compute elasticity ratios must be developed, Siegel said. 

  “We believe ultrasound seems to better and more accurately detect skin cancer. It has tremendous potential,” Siegel said.

In an ironic twist for radiology, effective imaging of skin cancers has just been accomplished by none other than the imaging modality in closest contact with the skin: ultrasound.

Author | Renee Lee

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