National Council on Radiation Protection and Measurements, 7910 Woodmont Ave., Suite 400, Bethesda, MD 20814 (Schauer)International Society of Radiology, 7910 Woodmont Ave., Suite 400, Bethesda, MD 20814 (Linton)
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In 2006, Americans were exposed to more than seven times as much ionizing radiation from medical procedures as was the case in the early 1980’s, according to a new report on population exposure released March 3, 2009, by the National Council on Radiation Protection and Measurements (NCRP) at its annual meeting in Bethesda, Maryland. In 2006, medical exposure constituted nearly half of the total radiation exposure of the U.S. population from all sources.The increase was primarily a result of the growth in the use of medical imaging procedures, explained Kenneth R. Kase, senior vice president of NCRP and chairman of the scientific committee that produced the report. “The increase was due mostly to the higher utilization of computed tomography (CT) and nuclear medicine. These two imaging modalities alone contributed 36 percent of the total radiation exposure and 75 percent of the medical radiation exposure of the U.S. population.” The number of CT scans and nuclear medicine procedures performed in the United States during 2006 was estimated to be 67 million and 18 million, respectively.NCRP Report No. 160, Ionizing Radiation Exposure of the Population of the United States, provides a complete review of all radiation exposures for 2006. The following Fig. 1 and Table 1 summarize the changes that have occurred from the 1980’s to 2006.Some causes and consequences of this significant increase in medical radiation exposure are the focus of this editorial.According to James Thrall, chairman of the American College of Radiology’s Board of Chancellors and Radiology at Massachusetts General Hospital, “Imaging has literally become the guiding hand of medical practice.”BENEFITSVivian Ho of Rice University wrote an editorial in Medical Care (Ho 2008) in which she asserted that, “An overall increase in advanced diagnostic imaging is likely justified.” She pointed out that non-invasive imaging has revolutionized medical practice by leading to early, more precise, and much less morbid diagnosis. She offered two examples: CT and magnetic resonance imaging (MRI) have replaced exploratory laparotomy for diagnosing abdominal problems, and CT angiograms are much less invasive than coronary angiography.ISSUES TO BE CONSIDEREDSelf-referralKouri et al. (2002) reported that 60 to 90% of non-hospital radiography is the result of self-referral. Self-referral originally consisted of physicians who are not imaging specialists (or a non-physician provider, such as a podiatrist or chiropractor) directing patients to their onsite imaging services. It now also includes physicians referring their patients to outside facilities in which the physicians have a financial interest. This “joint venture” type of self-referral has been targeted by federal legislation.In an article titled Turf Wars in Radiology: The Overutilization of Imaging Resulting from Self-Referral, David Levin and Vijay Rao of Jefferson Medical College estimated that as much as $16 billion per year is spent by our health care system to cover the cost of unnecessary (i.e., unjustified), self-referred, non-invasive diagnostic imaging, not including the costs of image-guided invasive procedures (Levin and Rao 2004).In 2008, Jean Mitchell of Georgetown University reported findings that suggest that physician self-referral arrangements and independent diagnostic testing facilities seem to be contributing to a greater use of advanced imaging, especially for MRI and positron emission tomography (PET).Mitchell concluded that, “Use of highly reimbursed advanced imaging, a major driver of higher health care costs, should be based on clear clinical practice guidelines to ensure appropriate use” (Mitchell 2008).