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The use of advanced imaging methods such as computed tomography (CT), magnetic resonance imaging (MRI), and positron-emission tomography (PET) has made diagnosis more accurate and less invasive for nearly all organ systems. Unfortunately, as the use of imaging has rapidly increased, imaging costs have grown as well. Indeed, until recently, these costs were the fastest-growing physician-directed expenditures in the Medicare program, far outstripping general medical inflation.1 ,2
Such dramatic growth has placed imaging in the policy spotlight. There is broad agreement that an unknown but substantial fraction of imaging examinations are unnecessary and do not positively contribute to patient care. Unnecessary use has indiscriminately tarred technologies that provide great value to patients and the health care system when used appropriately. Failure to reduce unnecessary use risks inviting policies that could stifle important future innovation.
Several interrelated factors have promoted the nonbeneficial use of imaging. For one, the evidence basis for using imaging is incomplete; much imaging practice is driven by habit or anecdote. Although new imaging technologies are exhaustively evaluated for regulatory purposes, they enter clinical practice with limited testing of their contribution to improving health.3 Nonetheless, information on the Web, in the lay press, and in direct-to-consumer advertising has promoted the benefits of diagnostic imaging while underplaying the risks and costs. As a result, despite well-publicized concern over the possible long-term effects of accumulated diagnostic radiation, patients pressure their physicians to refer them for imaging studies even when imaging is unlikely to provide any value.
Patients' desire for more imaging aligns with compelling financial interests of physicians who have acquired imaging equipment and, thanks to a loophole in Medicare antiabuse legislation, can "self-refer" their patients for imaging studies in their offices. There is an extensive literature validating the relationship between self-referral and significantly higher imaging utilization.4
Physicians often request imaging exams out of concern over liability risk. Legal actions over failure to diagnose serious abnormalities are common, whereas lawsuits arising from the overuse of testing are exceedingly rare. Like most people, physicians tend to overweight small risks, especially when the consequences may be severe. A recent survey of Massachusetts physicians showed that 28% of diagnostic...