Physicians

NY Times examines CT scans and evidenced-based medicine

The front page of the New York Times Sunday morning had a don’t miss article on the financial incentives behind using CT scans to look for heart disease. Medicare’s decided in March to begin paying for the test despite no evidence that it saves lives (see this GoozNews post). The lobbying campaign by a newly created physicians guild that invests in CT scanning clinics is discussed in the last few paragraphs of the story. That campaign was aided by "entrepreneurial guidelines" touting the procedure, discussed in this GoozNews post.

Here are the two key quotes from the story:

"It’s incumbent on the community to dispense with the need for evidence-based medicine." –Dr. Harvey Hecht, Manhattan cardiologist and CT scan advocate

"There are a lot of technologies, services and treatments that have not been unequivocally shown to improve health outcomes in a definitive manner."–Dr. Barry Straube, chief medical officer, Medicare

Alas, the article does not clearly describe the option that Straube and the Center for Medicare and Medicaid Services rejected in agreeing to pay for the scans. During Mark McClellan’s tenure at the agency, he instituted a "coverage with evidence development" program. That in-between option would require physicians using heart CT scans to send in results and monitor their patients over time, sending that follow-up data into the agency, too. This would create a database that could be analyzed to see if CT scans for heart disease and subsequent follow-up care actually reduced the incidence of heart disease mortality.

"We didn’t need to be talking about registries and the research," said Daniel S. Berman, president of Society of Cardiovascular Computed Tomography, a society of 4,700 physicians whose sole purpose is to promote CT angiograms, according to the article.

We don’t need no stinkin’ evidence. We don’t need no stinkin’ registries. We don’t need no stinkin’ research.

New leadership at CMS in the next administration at a minimum must insist on creating electronic registries for every new technology that it pays for where there is not yet clear cut evidence that it works. It also should set firm deadlines for manufacturers to submit well-controlled clinical trials offering definitive proof — or the payments authorized under the coverage-with-evidence-development policy should be revoked.

Merrill Goozner has been writing about economics and health care for many years. The former chief economics correspondent for the Chicago Tribune, Merrill has written for a long list of publications including the New York Times, The American Prospect and The Washington Post. His most recent book, "The $800 Million Dollar Pill – The Truth Behind the Cost of New Drugs " (University of California Press, 2004) has won acclaim from critics for its treatment of the issues facing the health care system and the pharmaceutical industry in particular. Today he has something to say about a familiar topic : the relationship between public sector R&D investment and innovation in the pharmaceutical and biotech industries. You can read more pieces by Merrill at  Gooznews.com

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Andrew WhitmanCorDocGregory D. Pawelski Recent comment authors
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Gregory D. Pawelski
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Gregory D. Pawelski

Rate cuts in medical imaging do not distinguish between appropriate tests and unneeded ones. Radiology benefits managers such as National Imaging Associates offers a cost control service that evaluates whether physicians are following guidelines when ordering tests and works with doctors if any corrections are needed. A study, published last year in the Journal of the American College of Radiology, found that use of CT scans dropped by about a third after the introduction of pre-authorization based on American College of Radiology guidelines. The process seems tedious at times but it can help to distinguish self-referral arrangements that are corrupting… Read more »

Andrew Whitman
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What struck me in The New York Times article “Weighing the Costs of a CT Scan Inside the Heart” was what the story omitted: peer-reviewed and emerging clinical trial data showing that CTA scans produce cost savings and improve patient outcomes. Also, for a story of this length to leave out any discussion of appropriateness criteria – even though cardiology and radiology medical societies already have programs in place, and both criteria are part of the current policy discussion – is curious. In my estimation, it fails to offer readers balanced information to help inform their decisions. There are numerous… Read more »

Gregory D. Pawelski
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Gregory D. Pawelski

Serial radiographic imaging studies are very expensive tests. In cancer medicine, the idea of their use is to follow the size of the patient’s tumor while the patient is receiving repeated courses of chemotherapy to determine whether or not the treatment is working and whether or not different drugs should be given, instead. This is an entirely unproven benefit, and were appropriate studies ever to be performed, there wouldn’t be any measurable benefit at all, in terms of improving patient response to chemotherapy or patient survival with chemotherapy. No wonder health care costs keep exploding!

CorDoc
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CorDoc

As a former clinical cardiologist who read cardiac CTs for a living, I must comment that both sides have valid arguments. Does everyone need a cardiac CT? NO. Does it save lives? Not necessarily. A cardiac CT provides anatomic information regarding the presence or absence of blockages in coronary arteries. Such findings alone do not determine whether or not a patient requires an invasive procedure such as an angiogram or angioplasty/stent. Such decisions should be based on physiologic indicators such as presence of angina or, more importantly, an abnormal stress test. A cardiac CT by itself will never be proven… Read more »

Gregory D. Pawelski
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Gregory D. Pawelski

Is there evidence that a CT saves lives? No. No diagnostic/laboratory test ever has. This is not what it does. What is the appropriate standard to judge medical tests? 1. Efficacy (use of tests improves clinical outcomes) 2. Accuracy (the test accurately measures what they are purported to measure) Diagnostic/laboratory tests are judged by accuracy and reproducibility and never by their effect upon treatment outcomes. In oncology for instance, most tests used today have comparable “sensitivities” and “specificities.” Pet Scans were not approved because they saved lives in a controlled clinical trial that compared the outcome of patients who received… Read more »