While Congress debates the pros and cons of Obamacare, a silent revolution proceeds apace in American medicine. Actually, it is not totally silent; it is heralded by the low hum of the CT scanner. Studies indicate patients are receiving more CT scans than ever before in emergency rooms, hospitals, and outpatient settings. This burgeoning application of CT scanning, has important implications for individual patients, diagnostically and in terms of radiation exposure, as well as consequences for the country’s overall medical budget.
The CT (computerized tomography) scan is a relatively recent invention, developed serendipitously in the late 1960’s by the British company that coincidentally owned the rights to the Beatles’ music. In large measure, the CT scanner was developed with profits from their recordings. (John Lennon did indeed start a medical “Revolution”). By the late 1970’s, technology had shifted to the United States. CT scans became a routine part of diagnostic medicine.
In the last ten years, the use of CT scans has exploded. In 1980, three million CT scans were performed. The current projection for 2011 is 72 million, nearly 20,000 every day. Between 2000 and 2005 Medicare spending on CT scans more than doubled.
This trend is likely to increase with at least two new applications of CT scanning at hand. President Obama, in his first physical exam as president, received CT colonography, commonly known as “virtual colonoscopy”. This noninvasive procedure will be coming soon to a neighborhood near you. It will supplement, and sometimes replace, the routine colonoscopy recommended for Americans each decade beginning at age 50 (President Obama technically fell outside the colonoscopy guidelines). In addition, an NIH study has demonstrated a 20% reduction in lung cancer deaths when a new Low Dose CT scan is used to screen high-risk patients, of which there are thousands.
This CT explosion has raised questions in medical circles whether radiation associated with CT scanning may result in increased cancer risk, especially in children. The typical CT scan exposes a patient to more radiation than chest X-rays, mammograms, or airport scanners. A full body CT scan for a serious trauma patient delivers a significant fraction of the annual dose limit of radiation exposure for radiation workers.
There is no good epidemiologic data at present but researchers extrapolating exposure from atomic bomb survivors at Hiroshima and Nagasaki have theorized thousands of people may develop future cancers from CT scan radiation. This is not yet a reason for patients to avoid CT scans but it is a reason for physicians to be concerned.
Currently, there is no consensus, even among physicians, about CT scanning. Because they place a premium on rapid information and diagnosing life-threatening conditions quickly, emergency physicians obtain CT scans frequently. Other specialists believe where CT scans are concerned, “less is more”. Many physicians blame defensive medicine and the malpractice environment for the increase but evidence for this is largely anecdotal. Without more reliable information, patients are stuck in CT scanner limbo.
In view of this, the medical community must address several questions:
Are all these CT scans necessary? Can alternative procedures such as MRI and ultrasound substitute more cheaply and with less radiation? Currently, no medical authority or anyone in the Federal Government can say conclusively, based on reliable information, whether we should be doing more or fewer CT scans.
Does radiation exposure from CT scans cause cancer? The World War II experience may not be applicable in medical settings. This means performing long-term epidemiologic studies. From a practical standpoint, every patient’s medical record should include an estimate of how much radiation they have been exposed to from medical procedures. In the 21st Century, this information is at least as important as vaccination history. This collection should begin at birth; the potential implications of CT scan radiation for 80 year-olds are far different than they are for infants.
Are hospitals and radiologists ensuring scanners deliver the minimum amount of radiation necessary without sacrificing diagnostic accuracy? Radiologists can limit radiation exposure by imaging less of the body, especially on follow-up scans. A side benefit is a reduction in the number of incidental findings that often prompt unnecessary further testing.
Can the cost of CT scanning be reduced? Manufacturers, hospitals, free-standing CT centers, and physicians all have a role in reducing the bill for CT scans. In other fields, as new technology disperses, user costs decrease rather than increase. Why is medicine different?
Why is there such a disparity in charges for CT scans nationally? Currently, charges for the same CT procedure vary as much as fourfold across the United States. Imagine paying $15,000 for a new car in Atlanta and $60,000 for the same car in Houston. The costs of CT scanning are fairly uniform everywhere - depreciation of equipment, maintenance, labor, and interpretation by radiologists. No quality factors can account for a fourfold disparity. In addition, providers should make their charges for CT scanning readily accessible to the public.
Within one generation CT scanning has revolutionized medicine, yet its very success has created uncertainty in its precise role in patient care. It’s time to answer these critical questions.
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