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Elizabeth Cooney is a health reporter for the Worcester Telegram & Gazette.
Boston Globe Health and Science staff:
Karen Weintraub, Deputy Health and Science Editor, and Gideon Gil, Health and Science Editor.
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Tuesday, October 30, 2007
Specialist referrals for imaging vary with who does the test, Mass. General study says
Doctors who send their patients for imaging tests to someone in their own specialty order diagnostic imaging more frequently than doctors who refer their patients to radiologists, Boston researchers report.
The reason for the difference may be financial, radiologist Dr. G. Scott Gazelle of Massachusetts General Hospital said in an interview about his article in the November issue of Radiology.
But that's impossible to know from the study's results, Dr. Nicholas DiNubile, a spokesman for the American Academy of Orthopedic Surgeons, responded in an interview, saying numbers of MRIs, CT scans, and X-rays alone can't determine whether they are ordered too often or not enough.
Looking at a national database of outpatient visits for such conditions as heart problems, broken bones, joint pain or suspected stroke, Gazelle and his team from the Institute for Technology Assessment at Mass. General found that physicians ordered imaging tests up to twice as often if they referred patients to doctors in their own specialty such as cardiology, orthopedics or neurology, compared with doctors who sent their patients to radiologists.
Previous research has indicated that doctors may order more scans when referring patients to a facility they own, but the authors of the new study decided to look at same-specialty referrals overall, rather than only referrals doctors made to imaging facilities they own. Gazelle said the authors made that choice in light of laws intended to curb self-referral that restrict some Medicare payments to doctors who refer patients to themselves.
"People are much more clever about it now," said Gazelle, who is on the board of chancellors of the American College of Radiology. "Same-specialty referral is in my view a proxy for self-referral."
All imaging has grown rapidly over recent years, but imaging done by non-radiologists has grown faster than imaging by radiologists, the study notes.
"I don't have a problem if a cardiologist or an orthopedist interprets imaging studies if they are qualified and do a good job," Gazelle said. "I do have a problem with the financial motivation to overuse it."
DiNubile, a knee specialist in Havertown, Penn., whose 25-surgeon group has its own imaging center staffed by a radiologist, said there is a turf war between specialists and radiologists who want to get back their business. He faults the study for not saying who owned the imaging facility where patients are being sent.
"The real question is whether that increases referrals when the physician owns his own shop," he said.
A better way to evaluate utilization rates would be to examine the imaging tests themselves to see if they were ordered appropriately, DiNubile said. Too many normal readings would suggest that too many tests are being ordered, for example.
"You always want to be sure to do the right thing," DiNubile said. "Is the right thing more utilization or less?"
Gazelle said the study was not intended to measure the quality of the imaging tests.
"The issue is we are using societal resources to pay for healthcare," he said. "We all ought to be ordering studies for the same reason."