The story, from journalists Alex Berenson and Reed Abelson-rich in commentary from physicians, patients, and representatives of third-party payers-has a clear cautionary tilt, presented as a kind of parable on conflicts between the best and the worst of the American healthcare system.
"Increasing use of the scans . . . is part of a much larger trend in American medicine. A faith in innovation, often driven by financial incentives, encourages American doctors and hospitals to adopt new technologies even without proof that they work better than older techniques," the article states. Some groups are calling for supporting evidence, "but the story of the CT angiogram is a sobering reminder of the forces that overwhelm such efforts, making it very difficult to rein in a new technology long enough to determine whether its benefits are worth its costs."
Cardiologists simply practice medicine the way the health system rewards them to. Given the opportunity to recommend a test for which they will make money, the doctors will. This is not greed. . . . This is normal economic behavior. The article leads off with the story of a San Francisco cardiologist who turned down an offer from another practice to become co-owner of a cardiac CT scanner, which had a million-dollar price tag. Cautious of the shortage of supporting evidence and the radiation risk, Dr Andrew Rosenblatt "worried that he and other doctors in his clinic would feel pressure to give scans to people who might not need them in order to pay for the equipment," according to the story. "If you have ownership of the machine," Rosenblatt is quoted as saying, "you're going to want to utilize the machine."
Once the scanner is purchased, the article notes, "doctors and hospitals have every incentive to use the machines as often as feasible. To pay off a scanner, doctors need to conduct about 3000 tests, industry consultants say."
According to Georgetown University economist Jean M Mitchell, "fees from imaging have become a significant part of cardiologists' income-accounting for half or more of the $400 000 or so that cardiologists typically make in this country."
Later, Mitchell notes, "Cardiologists simply practice medicine the way the health system rewards them to. Given the opportunity to recommend a test for which they will make money, the doctors will. 'This is not greed,' she said. 'This is normal economic behavior.' "
Hazards and overuse
CT angiograms also increase healthcare costs by prompting other, often-unnecessary tests-perfusion scans in particular-according to the story. "We're seeing layering of tests on top of each other," Dr Russell Amico, a CareCore executive, says. His company, which reviews treatment and test results for insurers, denies up to 70% of CT-angiography requests, it states.
Cardiac-care consultant John O. Goodman is quoted: "You find a lot of asymptomatic disease. . . . It will put more patients in the cath lab." When that happens, the discovery of stenoses large enough to demand revascularization is so rare that routine use of the imaging technology isn't worth the downsides, according to the story.
Stenoses in general "are not necessarily a threat," says Dr Eric Topol (Scripps Translational Science Institute, La Jolla, CA) in the article, which explains that CT angiography can't usually show when a stenosis is functionally serious and can never predict when a plaque is likely to rupture.
There certainly is this idea that having a test can help you prevent a heart attack, and I don't know where it came from. Dr Rita Redberg (University of California, San Francisco), "a leading critic of the scans," is quoted as saying, "No data suggest that there's any reason for anyone asymptomatic to have a test. . . . There certainly is this idea that having a test can help you prevent a heart attack, and I don't know where it came from."
And Dr Howard C Herrmann, director of interventional cardiology at the University of Pennsylvania, in Philadelphia, says: "I find many patients have CT angiograms who shouldn't be getting CT angiograms."
Unnecessary scans expose patients to considerable radiation, an amount equal to more than 1000 chest X-rays, according to the journalists, whose numbers were estimated based on the scanning session of one patient featured in the story.
"Further, each scan creates an additional lifetime risk of cancer that is somewhere between 1 in 200 and 1 in 5000, said Dr David J Brenner, director of the Center for Radiological Research at Columbia University [New York]," the article states.