When More Information Doesn't Equal More Cost-Effective Care
By Ishani Ganguli, MD, MPH
September 18, 2020
Imaging tests like X-rays and MRIs can be useful diagnostic tools. But they often show incidental findings or abnormalities that may seem alarming yet are not medically important. For instance, if you took spine images of 100 20-year-olds with no symptoms of back pain, up to 37 of them would show “spine degeneration” – so-called abnormalities that are just part of normal aging. Though such findings are usually harmless, they can propel cascades of downstream tests, treatments, costs and worry for patients and clinicians alike.
So I was intrigued by a rigorously designed, pragmatic trial published in JAMA Network Open testing a simple potential way to prevent those unintended cascades of concern. The researchers, led by Jeffrey G. Jarvik, randomized nearly 250,000 patients across four health systems who had X-Rays, CT scans or MRIs of their lower backs to receive either the usual radiologist’s report or one that explained how common any discovered abnormalities are among similarly-aged people without back pain. The researchers then tallied how many spine-related medical services (like visits, tests and treatments) patients in each group received in the following year.
Disappointingly, patients who got the enhanced reports had no fewer spine-related medical services. But researchers did see a decrease within one specific group — patients who received a CT scan. And they found a tiny but statistically significant decrease in all patients’ likelihood of getting an opioid prescription from their doctor, a potentially meaningful win given the opioid epidemic. It’s also possible the intervention had other benefits the study didn’t capture, like easing patients’ anxiety about their test results.
Despite the tepid outcome, I thought this study was a great example of how to test a commonsense, low-cost approach to educating patients and clinicians in a real-world setting.
Ishani Ganguli is a primary care physician, health services researcher and assistant professor of medicine at Harvard Medical School and a member of the 2021 Tradeoffs Research Council. She studies medical decision-making and delivery and payment innovation in ambulatory care.