Nationally, when a patient shows up at a hospital for medical imaging for a chest or abdominal malady, the chances that he or she will need a “combination” CT scan, which entails an excess radiation risk, are slim: 5 percent in the case of chest scans, and 19 percent for abdominal scans.
Not so at UConn’s John Dempsey Hospital, where 48 percent of all patients who received CT scans of the chest were subjected to combination scans—nearly 10 times the national average—according to data collected by the federal Centers for Medicare & Medicaid Services [CMS]. And more than 72 percent of patients who were sent for CT scans of the abdomen received double scans. The data, from 2008, is the most recent available.
Combination scans have come under scrutiny because they may unnecessarily expose patients to excess radiation. Standards of quality care say that most patients who get a CT scan of the chest should be given a single CT scan, rather than a double study. “Combination scans are usually not appropriate for the chest,” CMS guidelines say.
Similarly, with abdominal scans, a rate of double scans that is higher than the national average – 4 times higher, in Dempsey’s case – may indicate that “too many patients are being given a double scan when a single scan is all they need,” CMS says. “Combination scans involve additional radiation exposure and risks associated with use of contrast.”
Combination CT scans mean that a patient gets two scans – one regular scan, and a second with a substance called “contrast” that is put into the patient’s body before the scan begins, to help make parts of the body stand out more clearly on the x-rays.
For chest scans, a patient’s radiation exposure from a double scan is 700 times higher than from a simple chest X-ray. For abdominal scans, the radiation dose is comparable to that of approximately 400 chest X-rays.
The data collected by CMS’ “Hospital Compare” system shows that Dempsey, part of the UConn Health Center, has the highest rate of double chest and abdomen scans among all hospitals in the state, most of which are in line or have lower rates than national averages.
Dr. Douglas Fellows, chair of radiology at the UConn Health Center, said this week that he was “absolutely staggered” by the rates recorded by the federal government. “To be 10 times higher than the national average is astounding,” he said.
But he said his own internal review last year had flagged a high incidence of the multiple scans – a trend that the hospital is now addressing through a number of steps. Clinicians with expertise in abdominal and chest imaging are working with physicians to encourage single scans, he said. And in cases where outpatients come to Dempsey with orders for double scans, Fellows’ staff is contacting doctors to push for single scans.
Also, when double scans are clearly warranted, Dempsey radiologists are using a lower-dose radiation on the initial non-contrast study, Fellows said.
“Radiation safety is very high on our list of concerns,” he said. “We’re working very hard on this, in terms of changing policies and talking to physicians to reduce the orders for double scans.”
Statewide, most hospitals—including Bristol, Danbury, Stamford, Waterbury, St. Francis in Hartford and St. Raphael in New Haven—are well-below the national average for combination scans. Only Hartford Hospital, Norwalk Hospital and Charlotte Hungerford in Torrington are higher than national average for double chest scans; only MidState Medical Center in Meriden and Bridgeport and St. Vincent hospitals are higher for abdominal scans. But all are significantly lower than Dempsey in both categories.
Overall, the state’s average for double scans is lower than the national average.
A report to the state Office of Health Care Access filed by Dempsey shows the hospital did more than 17,000 CT scans in the 2009 fiscal year, up 3 percent over the prior year. Double scans are more expensive than single scans – nearly 60 percent higher in cost, according to average Medicare reimbursement rates.
Questions about the double scans come as state officials grapple with news that the UConn Health Center won’t be receiving a much-anticipated $100 million federal grant that officials were counting on to help pay for a massive renovation and improvement project. The Center, including the hospital, has faced financial trouble in recent years and has required millions of dollars in state bailouts. But the hospital also has been recognized in recent years with several quality and patient care awards.
While CT scans are a steady revenue source for hospitals, a number of recent studies have pointed to potential risks from radiation exposure.
A November study published in the journal Radiology found that emergency department use of CT scans had increased nearly six-fold since 1995 and showed no signs of tapering off.
In 2007, the scans were used in 16.2 million emergency room visits—a huge increase from 1995’s figure of 2.7 million. By the end of the study period, the top complaints among those who underwent CT scans were abdominal pain, headache, and chest pain.
The study noted that CT scans to investigate abdominal pain carry a higher radiation dose than CT exams used to determine the cause of a headache. The study found that overall, the use of scans that typically involve a higher radiation dose grew faster than those with a lower radiation dose. In 1995, a patient visiting the emergency room with chest pains rarely received a CT exam. But by 2007, chest pain was the third most common complaint in the ER associated with CT imaging, according to the study.
The American College of Radiology [ACR], with more than 30,000 members, has expressed concerns about the unnecessary use of scans. The group recommends that hospitals adopt “decision support systems” for clinicians, using a set of clinical findings to produce a list of possible diagnoses and evaluation measures – a step that the ACR believes could cut down on unnecessary scans.
“We do feel that there’s unnecessary scanning being done out there, and we would like to see steps being taken to address that,” said Shawn Farley, a spokesman for the ACR.
Other studies also have sparked concerns about the technology’s possible overuse and the resulting radiation exposure and significant costs. Two recent reports in the Archives of Internal Medicine found that doses of radiation from the commonly performed procedure vary widely and may contribute to tens of thousands of future cancer cases.
“While CT scans can provide great medical benefits, there is concern about potential future cancer risks because they involve much higher radiation doses than conventional diagnostic X-rays,” the authors of one report wrote.
Last year, the FDA took up the issue, announcing an initiative to reduce unnecessary CT scans and limit patients’ exposure to “radiation that can increase a person’s lifetime cancer risk.” The agency said it wants to ensure that safeguards are built into the design of the machines, that practitioners are appropriately trained, and that patients are better informed about their radiation exposure and risks.
The “Hospital Compare” database compiled by CMS also includes a measure that looks at whether hospitals perform unnecessary MRI (magnetic resonance imaging) tests on patients complaining of lower back pain. In most cases, the pain resolves on its own and does not require an MRI for diagnosis, Medicare officials say. The MRI scans can be expensive and stressful, but do not expose the patient to radiation.
In its data, CMS looked at the percentage of patients with back pain who probably did not need an MRI but got one before trying other treatments. The national average is 33 percent.
Two Connecticut hospitals—New Milford and Windham Community – exceeded the national average on such MRIs. Some other hospitals also had high rates, but the patient count was not large enough to be sure how well the hospitals were performing. Dempsey’s rate for unnecessary MRI’s was lower than the state and national averages.