Self-referral course draws stealth response from cardiologists

Wherever self-referral guru Dr. David Levin goes, controversy is sure to follow. Tuesday morning's refresher course on self-referral was no different.

People leaving the course were asked by a woman outside the door if they wanted to "hear" the other side of the story. She then handed them a single sheet of paper titled "Patients Belong in the Imaging Picture."

Christine Feheley of the American College of Cardiology said it was "odd" that the press statement was handed out at a refresher course. She also said that there is an alliance of people handing out these statements.

An RSNA spokesperson said the society does not allow solicitation or distribution of any material - pro or con - at any session. He called it a form of guerilla warfare.

Levin, the national medical director of HealthHelp, a utilization management company, addressed a full house of RSNA attendees. Dr. Alan Kaye, president of Advanced Radiology Consultants in Bridgeport, CT, spoke about self-referral issues as well.

"Self-referral leads to higher costs, more errors, and poor quality," Levin said. "And all this is evidence-based and medical policy should be evidence-based."

He presented a litany of studies documenting those effects.

The ACC's statement contends that Levin and his supporters are not telling the truth. The ACC and its supporters, including the American Academy of Neurology, American College of Surgeons, and American Urological Association, say that radiologists are more concerned with the loss of dollars than quality of care.

In August, the ACC formed the Physicians for Patient-Centered Imaging (PPCI), a coalition of 26 medical groups that aims to preserve physicians' right to perform imaging tests for their patients. The ACC issued a statement on its Web site:

"Working with the cardiovascular community and their PPCI partners, the ACC is planning an aggressive long-term campaign to educate key stakeholders about the role imaging has in appropriate, quality patient care. The College plans to defend the right of cardiovascular specialists to perform imaging services and will rely on its members to lend their expertise and experience to this fight."

The issue of inappropriate utilization is not new. Levin cited a 1965 study that found the utilization of plain x-ray exams by nonradiologists who self-refer was twice that of physicians who refer to radiologists.

He cited the seminal 1992 study by Hillman et al that found nonradiologists who self-refer had a two to eight times higher frequency of imaging exams per episode of illness. Hillman was attacked at the time of the study for being a biased radiologist. A U.S. General Accounting Office report published in 1994, however, vindicated Hillman's findings, Levin said.

Levin detailed a study that showed cardiologists had the largest percentage growth in imaging utilization rates between 1999 and 2001. Their rate rose 42% compared with 11.6% for radiologists.

"Self-referral raises healthcare costs with no increased benefit in clinical outcomes, relies on less sophisticated equipment with a loss of diagnostic quality, and has the potential to expose patients to unnecessary radiation," Kaye said.