Diagnostic Imaging: State of the Art or Science?

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• Jim king, MA, OTR, River Oaks Imaging, Houston, Tx

Diagnostic imaging is a major part of health care—and utilization of imaging is growing at double-digit rates. Rehabilitation professionals who specialize in treatment of the upper extremity generally encounter images or reports generated from them related to the diagnosis of their patients on a daily basis. Without a doubt, it's far more likely that readers of the Journal of Hand Therapy will require a diagnostic imaging procedure in their lifetime than the services of a hand therapist! If you twist your ankle and it begins to swell, you'll probably go to an emergency room or physician's office for an x-ray. Many of our readers or their children had their first “picture” taken with an ultrasound machine. If you have chronic sinus problems, you will need a computed tomography (CT), and if you are female and over 50 it's recommended you have an annual mammogram. The advances in medical imaging over the last ten years have been truly amazing, and this area of health care will continue to amaze. We'll be able to see smaller structures and pathology and measure metabolism in new ways, with greater clarity, with greater safety, and in less time. The manufacturers of this sophisticated and expensive equipment are highly motivated to develop ever more sensitive technologies, and with them physicians should be able to provide more appropriate and earlier intervention. Access to imaging equipment and professionals is taken for granted by many of us in developed countries.

As an example, in just a short time, computed tomography has advanced to the point that angiography imaging of the heart is now the standard of care for cardiac screening in most cities. With a 64-slice CT, the number of detectors allows the entire heart to be imaged in less than 1 second. Advances in computer reconstruction allow for the heart's movement to be accommodated in the final images produced, giving a clear and detailed image. The information gained without the need for a more invasive catheterization procedure allows the treating physician to appropriately intervene.

For all its scientific grandeur, though, imaging is still not wholly a science—the images produced by these machines require human interpretation. The art of interpreting is practiced by physicians who specialize and even subspecialize in radiology. With the exception of a few computer-aided detection systems such as those for mammography, the value of the interpretation of images is dependent on the quality of the image and the skill of the interpreter. Radiologists and other qualified physicians provide their diagnosis based on an analysis of the patients' history, the anatomic or metabolic phenomena seen in the image, and their knowledge of disease characteristics and trauma. The information sets the stage for treatment.

On the surface, this seems like a relatively simple and noble pursuit: better images and better interpretations lead to better patient care. Unfortunately, the imaging industry is fraught with challenges that are as diverse as the practice settings in which imaging is practiced. Worldwide, access to modern imaging equipment is severely restricted. However, in many areas in the United States, supply exceeds demand and the industry is characterized by “slice wars” or “tesla wars” by hospitals and other providers who are trying to get a “leg up” on the competition and extract a larger share of the health care dollar. While the vast majorities of imaging providers are legitimate, and provide a valuable service, and changes in the industry have been done in the name of “improved quality,” there is the potential for abuse in imaging, which is driven by the medical economic system.

Entrepreneurs moved imaging out of the hospital years ago to provide consumers with convenient, efficient, outpatient centers. However, this practice quickly impacted hospital profitability and those which could have responded with their own outpatient strategy. Many radiologists have jumped on the imaging center bandwagon and not only provide their interpretive services, but also participate in the reimbursement for the technical portion of the service. Some groups of physicians have gone “in-house” with their imaging. “In this city, there's an MRI on every corner,” a colleague of mine quipped recently. Physician profit from self-referral has been cited as one of the key reasons for overutilization and why imaging is viewed suspiciously by government and commercial payers. To compound the problem, many physicians, concerned with liability, unfortunately tend to “over-refer” for imaging results to minimize their exposure in a sue-happy populace.

Headlines touting new technology that decreases patient morbidity and mortality and evidence-based studies supporting imaging as an imperative and revered contributing factor in a cost-effective health care system are not seen in this environment. Indeed, such studies do not exist on a wholesale basis. Instead, overutilization, physicians accused of profiting from self-referral, and kickback schemes dominate the news. Creative mechanisms exist to “get around” the regulations in the few states that do require Certificates of Need. Sadly, while these types of issues are prolific in many metropolitan areas, rural areas of the United States continue to lag behind in access and technology.

Imaging is highly regulated because of the use of ionizing radiation and radioactive materials in many of the procedures and techniques. However, quality is not often measured and only recently have payers demanded standards in the industry. Free-standing centers that wish to bill and collect from Medicare and Medicaid must apply for and receive Independent Diagnostic Testing Facility certification. The American College of Radiology has a voluntary accreditation program for most modalities that sets standards for image quality, and this has been required by some payers to set limits on the number of facilities in their networks. Other payers have required imaging centers to provide a radiologist on-site, three or more modalities, extended hours, and self-assessment standards or have adopted Joint Commission on the Accreditation of Healthcare Organizations standards to assure quality.

The imaging industry desperately needs to develop standards, and research to determine the best and most effective use of imaging procedures. However, there are not universally accepted methods to gauge quality. A radiologist's reputation for accuracy is based on the perception of the referral community as to his or her skills. Measuring the “outcome” of an imaging procedure has typically been focused on surgical confirmation of the accuracy of the read. Some payer and health care systems have undertaken an algorithmic approach to curb the overutilization of imaging procedures. Evidence-based practice studies are only in their infancy, and long-term, comprehensive cost-effectiveness studies do not exist in the imaging industry. There is much work to do.

I am very grateful for the contributing authors' work for this Special Edition issue. In the following pages, readers will have the opportunity to learn more about how imaging interfaces with the surgical and rehabilitation phases of a patient's care. Articles have been assembled that span the spectrum of science and technology to practicality. Marelli and Lindequist have contributed an excellent article that provides an overview of the imaging modalities with emphasis on clinical practice and the future enhancements of these technologies. Susan Weiss and her coauthors present a primer on radiography which will benefit beginning and experienced therapists alike. Our esteemed editors. Flowers and LaStayo, have written a case study in which imaging played an important role in the treatment process. Dr. David Jewell has provided an MRI interpretative course including images from cervical to digits. While not related to imaging of the upper extremity, per se, Dr. Steven Rose has contributed an editorial addressing the current state of breast imaging including mammography, which should provide valuable information for readers of the Journal. In addition, three articles from the JHT archives that had been contributed to past Special Editions have been included.

Diagnostic imaging is a fascinating area of medicine and one upon which we are increasingly dependent both as professionals and as consumers. “State of the Art” is a term that is apropos for the industry, whose practitioners rely on both art and superior technology and science in the provision of their services. Regulatory compliance, access, reimbursement, and quality standards are some of the many issues facing the imaging industry.

Reimbursement is declining and utilization is being managed in imaging. Over ten companies produce high-end imaging equipment today—that number will shrink when they can no longer fund research because new equipment is not being purchased by providers who face reimbursement reductions. Only certain hospitals and imaging centers will be able to afford the best technology and even so, imaging will be a “volume business” if profitability is to be achieved. Access is thus curbed, reimbursement increases, and the cycle starts again. My hope for the diagnostic imaging industry is that growth is ultimately driven by technology, with research addressing imaging's benefits in improving the quality of life and cost-effective patient care, and not an obsession with its economics.