Saturday, October 29, 2011

Guru of Sports Medicine Finds MRIs Vastly Overused

If you want to find a reason for the high costs for health care, look no further than the overuse of MRIs, says Dr. James Andrews, the doctor who revolutionized sports medicine.

He did a study where he looked at MRI scans of healthy athletes, and found that the scans picked up abnormalities nearly all the time.
“An M.R.I. is unlike any other imaging tool we use,” Dr. Sangeorzan said. “It is a very sensitive tool, but it is not very specific. That’s the problem.” And scans almost always find something abnormal, although most abnormalities are of no consequence.

“It is very rare for an M.R.I. to come back with the words ‘normal study,’ “ said Dr. Christopher DiGiovanni, a professor of orthopedics and a sports medicine specialist at Brown University. “I can’t tell you the last time I’ve seen it.”

In sports medicine, where injuries are typically torn muscles or tendons or narrow cracks in bones, specialists like Dr. Andrews and Dr. DiGiovanni say M.R.I.’s often are not needed — they usually can figure out what is wrong with just a careful medical history, a physical exam and, sometimes, a simple X-ray.

M.R.I.’s are not the only scans that are overused in medicine but, in sports medicine, where many injuries involve soft tissues like muscles and tendons, they rise to the fore.

In fact, one prominent orthopedist, Dr. Sigvard T. Hansen, Jr., a professor of orthopedics and sports medicine at the University of Washington, says he pretty much spurns such scans altogether because they so rarely provide useful information about the patients he sees — those with injuries to the foot and ankle.

“I see 300 or 400 new patients a year,” Dr. Hansen says. “Out of them, there might be one that has something confusing and might need a scan.”

The price, which medical facilities are reluctant to reveal, depends on where the scan is done and what is being scanned. One academic medical center charges $1,721 for an M.R.I. of the knee to look for a torn ligament. The doctor who interprets the scan gets $244. Doctors who own their own M.R.I. machines — and many do — can pocket both fees. Insurers pay less than the charges — an average of $150 to the doctor and $960 to the facility.
MRI machines are a profit center for doctors and those operating the scanners. The machines, which can cost upwards of $250,000 a piece, have utility for certain kinds of illnesses and injuries, but are being overused. When an individual scan can cost $1,000 or more - these costs add up over time.

Indeed, the news report highlights the need for doctors to take a careful and detailed personal history and physical examination rather than relying on scans alone. In one instance, several doctors claimed that a patient had a torn ACL, but if they took a detailed history, they would have known that the patient continued skiing after the apparent injury, which is something that would not have been possible had the ACL truly been torn. It turns out that the patient had a broken bone in his leg.

And patients and defensive medicine plays a significant role in why these MRI scans are being ordered:
Dr. DiGiovanni did a similar study with foot and ankle patients, looking back at 221 consecutive patients over a three-month period, 201 of whom did not have fractures. More than 15 percent arrived with M.R.I.’s obtained by doctors they had seen before coming to Dr. DiGiovanni. Nearly 90 percent of those scans were unnecessary and half had interpretations that either made no difference to the patient’s diagnosis or were at odds with the diagnosis.

“Patients often feel like they are getting better care if people are ordering fancy tests, and there are some patients who come in demanding an M.R.I. — that’s part of the problem,” he said.

Some doctors might also feel they are providing better care if they order the scans, Dr. DiGiovanni said, and doctors often feel that they risk malpractice charges if they fail to scan a patient and then miss a diagnosis.
This is exhibit A as to why health costs are soaring.

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