Overuse of neuroimaging: Is decision support the answer?

Research published this past week in JAMA Internal Medicine found that in the case of headaches and migraines--for all age groups--neuroimaging procedures are significantly overused at a cost to the healthcare system of about $1 billion a year.

According to the researchers, out of the University of Michigan Health System, over a four-year period, MRI and CT scans were ordered for about 12 percent of outpatient headache visits, despite the fact that headaches are virtually always caused by fairly benign conditions.

The results were so striking that the researchers called for a "national strategy" to guide and support the optimization of headache neuroimaging practices.

This isn't the first time that concerns about the overuse of neuroimaging for headaches and migraines have been raised. As a response to those concerns, the American Headache Society--as part of the Choosing Wisely Initiative--last November released a list of headache interventions that should be discouraged, including neuroimaging studies on patients with stable headaches that meet the criteria for migraine, and CT scans for headache when MRI is available, except in emergency settings.

There are many problems associated with unnecessary neuroimaging. For example, the tests are expensive and there's always the risk they can show something that is potentially problematic when it actually isn't, leading to follow-up tests, expensive consultations, unneeded treatments and unnecessary anxiety for patients. There's also the radiation dose associated with CT scans to consider.

Physicians are aware of these risks, as well as the likelihood that the headache symptoms they are dealing with are unlikely to be associated with any kind of serious underlying issue. Yet they persist in ordering these tests. Why?

More than likely, they are practicing defensive medicine and responding to the natural concerns of patients who want to make sure they're not suffering from some kind of brain tumor or other serious condition. We do, after all, live in a litigious society, in which providers can be sued for missing a such a diagnosis.

To that end, healthcare organizations should look more to add or increase use of clinical decision support tools. Studies have shown that the use of CDS systems can improve patient outcomes while reducing imaging utilization. And the ability of physicians to point to the fact that they are using evidence-based decision support to make appropriate decisions on whether or not to order imaging tests should help protect against litigation.

Following imaging appropriateness guidelines and utilizing CDS also should help deal with the problem of patients pushing for more imaging tests. But, so should improved communication between radiologists, referring physicians and their patients, as well as initiatives like Choosing Wisely, which are specifically geared toward educating patients about medical tests that may not actually need.

Perhaps that can be the start of the national strategy that the researchers believe is so badly needed. - Mike (@FierceHealthIT)

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