By Kurt Woock

Last year, a few reports, which named unnecessary medical procedures as a potential multibillion-dollar problem, made headlines. Radiology in particular was cited as a specialty in which repeat testing might be reduced. In a new paper, Pam Kassing, MHA, and Richard Duszak, MD, FACR, suggest that future research focusing on repeat testing break the broad term “repeat testing” into its various parts. “We’re looking to advance the dialogue a bit beyond the relatively superficial interpretation that says if it’s repeated, it must be somehow unnecessary and therefore wasteful,” said Duszak, CEO of the Harvey L. Neiman Health Policy Institute. The pair wrote the paper in order to help others begin to think about a classification system with uniform definitions. “Because ultimately, the important piece is not to find out how many tests are repeated, it’s to identify if a repeated test is necessary or unnecessary,” Duszak said.

Rich.Duszak Richard Duszak, MD, FACR & CEO of the Harvey L. Neiman Health Policy Institute

The primary audience for the paper is health policy researchers and, to some extent, policymakers. Duszak said the paper was not written as a critique of past research, but to “push it to the next step.” Duszak said many of these analyses have mined large databases for their findings. While that method is a good start, according to Duszak, the databases can fail to capture the sophistication of repeat imaging. The context of decision to acquire a repeat image is not always expressed in the data. By using precise definitions to categorize imaging, Duszak said research will more accurately express reality.

In order to eliminate much of the ambiguity, Duszak and Kassing subdivide repeat imaging into four subcategories: supplementary imaging, duplicate imaging, follow-up imaging, and unrelated imaging. Each subcategory has nuances that make it dissimilar from other types of repeat imaging. The authors give one such example: A physician might order an ultrasound exam to supplement a CT scan that did not provide definitive information. Compare that to a physician who orders both exams at once in an effort to expedite the diagnostic process. The former situation might be considered a decision that added high value to patient care, while the latter likely added little.

Duszak said these suggestions are not prescriptive. Instead, he hopes they will help guide the design of future research. We put forward a thought paper rather than a research paper,” he said. Analyzing data using refined definitions will yield refined results; results that can inform how to improve patient care and lower cost. Duszak said that by using such a lens in research, some repeat imaging might be found to occur at a rate that is lower than desirable. For example, mammography exams might occur less frequently and disproportionately affect people based on geography, socioeconomic factors, or race.  

Research moves slowly by design, but Duszak said some of the ideas in the paper can be used by radiologists now, even if the ideas take a while to permeate academia and policy circles. “I hope people will start using this as a framework for their own quality improvements,” he said. A larger or multisite hospital might find that more robust or efficient use of EHR could reduce the number of exams that need to be reproduced because of a technological or proficiency gap.