The excesses of image diagnostics

The practice of modern medicine is subject to much pressure from the use of diagnostic imaging technologies, many of which are truly dazzling for the eyes of clinicians and patients and, as a result, health budgets are constantly increasing. This being the case, everyone agrees that more professional debate should be generated to put the matter in its place and avoid the excesses that damage resources, irradiate people and don’t add value to clinical reasoning.

Radiologists and incidental imaging findings

A group of radiologists from several American university hospitals (Massachusetts General, Cleveland, Brigham and Women's, etc.) started a debate in the Journal of the American College of Radiology about the eventuality that radiologists would stop reporting the incidental imaging findings lacking clinical significance. "The traditional role of the radiologist," they say, "is to warn of everything they see, leaving the interpretation of the findings’ relevance to the referring physician”. However, we now open the opportunity to go further, and not just intervene by saying, for example, that an observed abnormality is benign, but also taking the decision not to report the milder ones, given the possibility that our opinion generates confusion and ends up causing excessive medical actions".

Regarding level I renal cysts of the Bosnian classification

The radiologists who authored the article used the findings of renal cysts, which are very frequent with a prevalence of 36% in patients over 80 years of age, in order not to inform of renal cysts of level I of the Bosnian classification in their reports, in accordance with the following criteria: a) the cyst is not the reason for the examination, b) doesn’t generate local problems, c) has no malignant potential, and d) is not likely to generate a polycystic kidney disease.

Overdiagnosis: in relation with pulmonary embolism

The introduction of computed tomographic pulmonary angiography (CTPA) for the diagnosis of pulmonary embolism, according to a study published in JAMA Internal Medicine (US data), has been associated with an increase of 80% in the incidence of pathology (from 62.1 to 112.3 per 100,000 population p<0.001), with a reduction in hospital mortality of 35% (from 12.1% to 7.8% p<0.001), which lamentably only has led to a decrease in mortality rates of 3% (from 12.3 to 11.9 deaths per 100,000 p=0.02) and also lamentably, an increase in presumed complications of anticoagulation therapy of 71% (from 3.1% to 5.3% per 100,000 p<0.001).

In the graph below, taken from the article, you can see the behaviour of the incidence of pulmonary embolism in relation to mortality, both population-based, comparing the 1993-1998 period, prior to the introduction of CTPA, with the subsequent one. The overall incidence (bright blue) includes all patients admitted to the hospital for any medical or surgical circumstance. The percentages represent average increases for each year (APC: Annual Percentage Change).

Diagnostic Imaging: adjusting the indication

Saurabh Jha, a radiologist at the Hospital of the University of Pennsylvania, in an article in New England (From imaging gatekeeper to service provider: a Transatlantic journey) explains that when he undertook MRI in the UK, residents feared the radiologists, not in vain, since one of them known as “Dr. No”. Migrated to the United States, quickly realized that there, the radiologists who were operating and issuing invoices as service providers, were rather “Dr. Yes”. The involvement of the radiologist in clinical reasoning was gone.

There is a widespread perception that the large investments of modern screening equipment are increasing their disproportionate use and the position of the radiologists, many of them involved in investments, is far from the function of gatekeepers, so praised by Dr. Jha. To this effect, it is revealing in a letter published in JAMA Internal Medicine (Overuse of Magnetic Resonance Imaging) about a consensus methodology (Rand Corporation University of California Los Angeles UCLA) to determine the degree of indication of MRI for low back pain and headache cases. The results say that 77% of the experts consulted, for example, believe that the MRI indication for back pain of less than 6 weeks duration is inappropriate or not well founded.