New Web site on imaging safety draws criticism

A firm hired by health plans to limit imaging is issuing radiation-exposure estimates for CT scans. Some worry patients will avoid the tests.

By — Posted March 24, 2008

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A health plan-owned company says it wants to promote discussion about the risks of radiation exposure from some imaging tests. To that end, it is bringing a cyber woman named Aimee into conversations with patients and physicians.

But some aren't sure Aimee's intentions are completely motivated by safety and want her to butt out.

Aimee is a model patient on a new Web site hosted by American Imaging Management, a subsidiary of WellPoint. Health plans rely on AIM or similar companies to control their imaging costs.

AIM says its new site is motivated by recent studies assessing the risks of radiation exposure. The patient chooses a procedure. A part of Aimee's body lights up, depending on what part is being scanned. Then the site tells the user how much radiation exposure a patient would get from various computed tomography scans, positron emission tomography scans and nuclear medicine tests. It compares the relative radiation exposure to the estimated annual radiation from sunlight and from a chest x-ray and lists alternative diagnostic tests.

"We're here to provide information patients can use in their conversations with their physicians," said Paul Danao, AIM's vice president for business development.

Some doctors said they suspect AIM could be trying to create doubt in patients' minds about the safety of tests to save money for its health plan clients, and they aren't comfortable with what they see as interference with the doctor-patient relationship.

Aimee isn't giving accurate and complete data, the doctors said, because the Web site doesn't allow for variance in equipment, or patient gender, age or weight. It doesn't give users a full risk-benefit analysis of a diagnostic test.

"This is not a service to anyone," said Richard L. Morin, PhD, professor in the Radiology Dept. at the Mayo Clinic in Jacksonville, Fla. and chair of the American College of Radiology Safety Committee. (See correction)

"The population that looks at this, whether it be physicians or patients, should realize these are estimates and no one can give them an absolute answer," Dr. Morin said.

A rapid increase in the use of imaging has sparked research into the risks of such procedures and development of solutions to minimize them.

An ACR blue-ribbon panel found that the number of annual CT scans from 1980 to 2005 increased from 3 million to 60 million and the number of nuclear medicine procedures went from 7 million to 20 million. The group, which included Dr. Morin, a medical physicist, said the benefits of diagnostic imaging are "immense" but that data suggest future increases in radiation-related cancers.

The ACR panel, in the May 2007 Journal of the American College of Radiology, recommended efforts to educate doctors and other stakeholders about the risks and steps to minimize them, including radiation safety education for physicians, standardization of radiation dosing and alerting physicians when their patients have reached certain radiation thresholds.

Then, a study in the Nov. 29, 2007, New England Journal of Medicine estimated that CT scans could account for 1.5% to 2% of all cancers. The ACR disputed that figure because the research was based on cancer cases among survivors of the 1945 Hiroshima and Nagasaki atomic bombs. But its blue-ribbon report cited a 2004 Lancet article that suggested nuclear medicine and CT scans could be behind 1% of U.S. cancer cases.

Health plans have taken those studies to heart. A February report by the Center for Studying Health System Change found that health insurers were ramping up oversight of imaging, given both the cost of high-tech imaging and safety concerns.

Another imaging management company, National Imaging Associates, has for more than two years notified some of its physicians when patients have high levels of radiation exposure. AIM plans to do the same later this year, Danao said.

"I think it's a good idea if it's done correctly," said Don Frush, MD, professor of radiology at Duke University School of Medicine and chief of pediatric radiology at Duke University Hospital in Durham, N.C.

Financial pressure

Health plans acknowledge they have financial reasons to limit imaging.

During a March conference call, WellPoint CEO Angela Braly mentioned radiology management programs as one way to address medical costs more aggressively. Her statement came soon after WellPoint announced it was adjusting its earnings projections down for 2008 due to higher-than-expected medical costs, sending its stock tumbling by 28% on March 11. Stock prices of all health insurers sustained losses under WellPoint's weight, with the four largest -- WellPoint, UnitedHealth Group, Aetna and Humana -- losing $24 billion in market value in one day.

Given that pressure, some doctors say imaging management companies should not be the ones to publish radiation safety information.

"They're in business just like the insurance companies are in business, to make money, not to take care of patients," said Rebecca Jaffe, MD, a family physician in Wilmington, Del. "If they can dissuade someone, it's more money in their pocket."

Money aside, Dr. Frush said the problem with AIM's site is that it does not talk about legitimate reasons a patient should have a scan. "What can't be overemphasized is things like CT scans are tremendous diagnostic tools, and far more lives are saved using CT than are ever going to be lost by the [accompanying] risk of cancer."

He said the radiation exposure figures on American Imaging Management's Web site were at least in the ballpark but said there was no "readily apparent" reason the company should be the one providing it to patients.

Dr. Frush suggested that the company might instead support the efforts of an unbiased third party.

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Aiming at radiation

American Imaging Management recently introduced a "Patient Safety Tool" on its Web page, featuring an interactive radiation dose calculator it says can determine if an imaging procedure is safe. But doctors and others aren't so sure of AIM's intentions. Among the procedures:

Computed tomography scans

Bone density
Neck -- soft tissue
Diagnostic virtual colonoscopy
Cervical spine
Thoracic spine
Lumbar spine
Upper extremity
Lower extremity

CT angiographies

Chest (non-coronary)
Aorta with lower extremity runoff
Upper extremity
Lower extremity

Nuclear medicine

Cardiac blood pool imaging
Rest perfusion scan
Stress perfusion scan
Rest and stress perfusion scan

Positron emission tomography scans

Tumor imaging

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External links

American Imaging Management patient exposure tool (link)

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The print version of this story did not correctly report that Richard Morin, PhD, chair of the American College of Radiology Safety Committee, was speaking on behalf of the American College of Radiology. American Medical News regrets the error.

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