CT or not CT?

An image ordering system for physicians has surfaced at Brigham and Women's Hospital in Boston in an attempt to stem the growing number of unnecessary imaging exams ordered.

While prescription drugs may be the single biggest driver of rising healthcare costs, at Brigham and Women's, as elsewhere, questionable imaging studies run second, and closing.

Partners HealthCare found that it spends about twice as much on drugs as on high-end imaging, but at 18% per year, the imaging budget is growing faster than the drug budget. Partners' system includes Brigham and Women's, Massachusetts General Hospital, and a number of community hospitals and private physician practices.

The number of CT scans performed in the Partners system rose 76% between 1999 and 2002. MRI exams rose 90%.

Under the exam ordering system developed by Dr. Ramin Khorasani, vice chair of radiology at Brigham and Women's, physicians enter the patient's symptoms along with imaging exams being considered into the computer.

In obvious cases, the system approves the exam, but in situations in which a scan is not usually performed, the system will offer the physician other options. Although the doctor makes the final decision about whether to order a test, the system could refer physicians to past scans in similar situations that have turned up nothing or recommend that the doctor check with a specialist before the test.

"The system has the capability of letting physicians know whether an exam is likely to be helpful," Khorasani said. "The goal is help physicians make the best decision."

Khorasani said some unnecessary tests have already been reduced, such as abdominal CTs that are unlikely to yield useful information, although data here are still being collected. The program uses information from medical literature and the hospital's database for its recommendations.

Imaging has become increasingly popular due to improving technologies. As modalities get faster and more powerful, parts of the anatomy that once could be explored only by invasive procedures can now be scanned in seconds.

Just last month, a report in the New England Journal of Medicine (2003;348:2491-2499) found that MRI used in conjunction with a dye can detect the spread of prostate cancer, a breakthrough believed to eliminate the need for some surgeries.