Addressing Overutilization in Medical Imaging

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Through this effort, a national strategy to address overutilization should be developed as a reflection of the need for greater accountability by radiology and health care professions in general in their stewardship of the expensive technologies used to improve the health and health care of patients.

The growth in medical imaging over the past 2 decades has yielded unarguable benefits to patients in terms of longer lives of higher quality. This growth reflects new technologies and applications, including high-tech services such as multisection computed tomography (CT), magnetic resonance (MR) imaging, and positron emission tomography (PET). Some part of the growth, however, can be attributed to the overutilization of imaging services. This report examines the causes of the overutilization of imaging and identifies ways of addressing the causes so that overutilization can be reduced. In August 2009, the American Board of Radiology Foundation hosted a 2-day summit to discuss the causes and effects of the overutilization of imaging. More than 60 organizations were represented at the meeting, including health care accreditation and certification entities, foundations, government agencies, hospital and health systems, insurers, medical societies, health care quality consortia, and standards and regulatory agencies. Key forces influencing overutilization were identified. These include the payment mechanisms and financial incentives in the U.S. health care system; the practice behavior of referring physicians; self-referral, including referral for additional radiologic examinations; defensive medicine; missed educational opportunities when inappropriate procedures are requested; patient expectations; and duplicate imaging studies. Summit participants suggested several areas for improvement to reduce overutilization, including a national collaborative effort to develop evidence-based appropriateness criteria for imaging; greater use of practice guidelines in requesting and conducting imaging studies; decision support at point of care; education of referring physicians, patients, and the public; accreditation of imaging facilities; management of self-referral and defensive medicine; and payment reform.

© RSNA, 2010


  • 1 US health care costs. Web site. Accessed June 10, 2010. Google Scholar
  • 2 Congress of the United States. Budget options. Vol 1, Health care. Washington, DC: Congressional Budget Office, 2008. Google Scholar
  • 3 Emanuel EJ, Fuchs VR. The perfect storm of overutilization. JAMA 2008;299(23):2789–2791. Crossref, MedlineGoogle Scholar
  • 4 European Science Foundation. Medical imaging for improved patient care. European Science Foundation Web site. Accessed June 10, 2010. Google Scholar
  • 5 Iglehart JK. The new era of medical imaging: progress and pitfalls. N Engl J Med 2006;354(26):2822–2828. Crossref, MedlineGoogle Scholar
  • 6 America’s health insurance plans: ensuring quality through appropriate use of diagnostic imaging. America’s Health Insurance Plans Web site, 2008. Accessed September 14, 2009. Google Scholar
  • 7 Keehan S, Sisko A, Truffer Cet al.. Health spending projections through 2017: the baby-boom generation is coming to Medicare. Health Aff (Millwood) 2008;27(2):w145–w155. Crossref, MedlineGoogle Scholar
  • 8 Picano E. Sustainability of medical imaging. BMJ 2004;328(7439):578–580. Crossref, MedlineGoogle Scholar
  • 9 Angrisano C, Farrell D, Kocher B, Laboissiere M, Parker S. Accounting for the cost of health care in the United States, January 2007. McKinsey Global Institute Web site. care.pdf. Accessed September 14, 2009. Google Scholar
  • 10 Beever C, Karbe M. The cost of medical technologies: maximizing the value of innovation. McLean, Va: Booz Allen Hamilton, 2003. Google Scholar
  • 11 Brenner DJ, Hall EJ. Computed tomography: an increasing source of radiation exposure. N Engl J Med 2007;357(22):2277–2284. Crossref, MedlineGoogle Scholar
  • 12 National Council on Radiation Protection and Measurements. Ionizing radiation exposure of the population of the United States. NCRP report 160. Bethesda, Md: National Council on Radiation Protection and Measurements, 2009. Google Scholar
  • 13 Fazel R, Krumholz HM, Wang Yet al.. Exposure to low-dose ionizing radiation from medical imaging procedures. N Engl J Med 2009;361(9):849–857. Crossref, MedlineGoogle Scholar
  • 14 Institute of Medicine. Health professions education: a bridge to quality. Washington, DC: National Academy of Sciences Press, 2003. Google Scholar
  • 15 National Priorities Partnership. National priorities and goals: aligning our efforts to transform America’s healthcare. Washington, DC: National Quality Forum, 2008. Google Scholar
  • 16 Levin DC, Rao VM. Turf wars in radiology: the overutilization of imaging resulting from self-referral. J Am Coll Radiol 2004;1(3):169–172. Crossref, MedlineGoogle Scholar
  • 17 Abella HA. Soaring CT-based radiation exposure points to self-referral. Web site. Published March 2, 2009. Accessed September 10, 2009. Google Scholar
  • 18 Massachusetts Medical Society Web site. Accessed September 10, 2009. Google Scholar
  • 19 Lee DW, Foster DA. The association between hospital outcomes and diagnostic imaging: early findings. J Am Coll Radiol 2009;6(11):780–785. Crossref, MedlineGoogle Scholar
  • 20 Pisano ED, Gatsonis C, Hendrick Eet al.. Diagnostic performance of digital versus film mammography for breast-cancer screening. N Engl J Med 2005;353(17):1773–1783. [Published correction appears in N Engl J Med 2006;355(17):1840.] Crossref, MedlineGoogle Scholar
  • 21 Gierada DS, Pilgram TK, Ford Met al.. Lung cancer: interobserver agreement on interpretation of pulmonary findings at low-dose CT screening. Radiology 2008;246(1):265–272. LinkGoogle Scholar
  • 22 Hess BJ, Lynn LA, Holmboe ES, Lipner RS. Toward better care coordination through improved communication with referring physicians. Acad Med 2009;84(10 suppl):S109–S112. Crossref, MedlineGoogle Scholar
  • 23 Sistrom CL. The appropriateness of imaging: a comprehensive conceptual framework. Radiology 2009;251(3):637–649. LinkGoogle Scholar
  • 24 Sistrom CL, Dang PA, Weilburg JB, Dreyer KJ, Rosenthal DI, Thrall JH. Effect of computerized order entry with integrated decision support on the growth of outpatient procedure volumes: seven-year time series analysis. Radiology 2009;251(1):147–155. LinkGoogle Scholar
  • 25 Lee SI, Saokar A, Dreyer KJ, Weilburg JB, Thrall JH, Hahn PF. Does radiologist recommendation for follow-up with the same imaging modality contribute substantially to high-cost imaging volume? Radiology 2007;242(3):857–864. LinkGoogle Scholar
  • 26 Lee TH, Brennan TA. Direct-to-consumer marketing of high-technology screening tests. N Engl J Med 2002;346(7):529–531. Crossref, MedlineGoogle Scholar
  • 27 The Commonwealth Fund. Why not the best? results from the national scorecard on U.S. health system performance, 2008. Commonwealth Fund Web site. Accessed October 13, 2009. Google Scholar
  • 28 Sistrom CL, Dreyer KJ, Dang PPet al.. Recommendations for additional imaging in radiology reports: multifactorial analysis of 5.9 million examinations. Radiology 2009;253(2):453–461. LinkGoogle Scholar

Article History

Received January 9, 2010; revision requested February 17; revision received March 4; accepted April 16; final version accepted April 21.
Published online: Oct 2010
Published in print: Oct 2010