The American Journal of Managed Care April 2007
Impact of Chest Radiography Screening on Healthcare Spending
TO THE EDITORS:
Medical evidence suggests that the current technologies used for chest radiography for screening purposes are not cost-effective and may be clinically harmful.1 More surprisingly, a recent metaregression analysis published in the November issue of the Journal by Mauri et al1 found that despite formal recommendations, chest radiography screening is still prescribed by primary care physicians, and prescription trends seem to decrease only slowly over time. This is a very important issue considering the worrisome proportions that healthcare costs–and, specifically, imaging costs–are amassing.2 For this reason, it would be important to be able to evaluate the impact of chest radiography screening on healthcare spending. Unfortunately, from the reported analysis by Mauri et al the impact of this practice on health expenditure cannot be estimated. More specifically, it would be useful if Mauri et al had reported the actual practice of chest radiography screening in the general population and not only the physicians' prescription habits. This is likely to represent a bias, because the rate of prescription of a certain test may be consistently different from its real practice among the general population.3 Given that the same authors, in 2 previous studies, supported that in Greece the rate of prescription of the test by primary care physicians was 3 times higher than its real practice (77% vs 20%),4,5 it is surprising that they did not report this information or comment on this issue, which constitutes a possibly unnecessary limitation in the work they present.
Lorenzo Pesce, PhD
The University of Chicago
1. Mauri D, Kamposioras K, Proiskos A, et al. Old habits die hard: chest radiography for screening purposes in primary care. Am J Manag Care. 2006;12:650-656.
2. Iglehart JK.The new era of medical imaging–progress and pitfalls. N Engl J Med. 2006;354:2822-2828.
3. Montano DE, Phillips WR. Cancer screening by primary care physicians: a comparison of rates obtained from physician self-report, patient survey, and chart audit. Am J Public Health. 1995;85:795-800.
4. Kamposioras K, Casazza G, Mauri D, et al. Screening chest radiography: results from a Greek cross-sectional survey. BMC Public Health. 2006;29:113.
5. Proiskos A, Loukidou E, Kamposioras K, et al. Screening chest radiography in primary care: an underestimated belief. Eur J Gen Pract. 2005;11:76-77.
Prescribed chest radiography for screening purposes (S-CRx) is not a cost-effective test–in any setting considered. Its practice may still be harmful because its positive predictive value is low, and further evaluation of false-positive findings might be associated with increased cost and risk from additional diagnostic/therapeutic interventions. To assess whether S-CRx recommendation by primary care physicians changes over time, a systematic review of literature was recently published. As healthcare costs continue to climb to a worrisome proportion, and more specifically the costs that imaging are amassing,1 critics observed that test prescription may be consistently different from its real practice among the general population,2-4 and consequently, our study5 did not provide relevant data for the calculation of expenditure related to S-CRx implementation among the population. It was thus suggested that the lack of analyses of S-CRx practice patterns was a limitation of the study. We agree with this criticism. In December 2005, a systematic review of literature was conducted to retrieve relevant peer-reviewed studies evaluating the rate of S-CRx practice among the population. Studies investigating both patients' desire and actual practice were regarded as eligible.
An electronic search resulted in 23 528 hits (PubMed/MEDLINE 23 184 hits, Thompson Scientific library 304 hits, and Cochrane library 40 hits). Potentially eligible studies were selected by abstract/title, and 203 full-paper manuscripts were thereafter retrieved. The Panhellenic Association for Continual Medical Research archive for the related literature was further perused.
We found 5 suitable studies2,6-9 but only 3 of them were reporting the actual practice of S-CRx2,7,8; consequently, we did not proceed to statistical analysis.
In the Montano and Phillips study,2 the actual S-CRx practice was 37% for smokers and 32% for nonsmokers, while patients' perception was that they underwent S-CRx at higher rates (45% and 39%, respectively). It is worth mentioning that physicians underestimated their performance of S-CRx; 10% for nonsmokers and 33% for smokers.
In the Woo et al study,6 the actual rate of S-CRx performed was double the expected rate based on physicians' recommendations. Patients' educational status seemed to be an independent correlation factor, because only 30% of patients with post-high school education desired a yearly S-CRx compared with 94% of patients without post-high school education (P <.001). In the Lynch and Prout study,7 40% of smokers or patients with occupational risk underwent SCRx in the past 2 years, while in the Mandel et al study,8 the patient-years per test rate was only 9%.
It is obvious that data from literature are not enough to help us estimate the actual practice of S-CRx. Indeed, to our knowledge, only 4 studies2,3,7,8 had addressed this issue, still including our report published in 2006 (Table).3 Further survey studies are therefore needed to reveal the actual impact of this avoidable screening tool in health economy.
Konstantinos Kamposioras, MD
Davide Mauri, MD
Panagiota Tsekoura, MD
Antonis Valachis, MD
Maria Tsappi, MD
Nikolaos P. Polyzos, MD
Panhellenic Association for Continual Medical Research
1. Iglehart JK.The new era of medical imaging–progress and pitfalls. N Engl J Med. 2006;354:2822-2828.
2. Montano DE, Phillips WR. Cancer screening by primary care physicians: a comparison of rates obtained from physician self-report, patient survey, and chart audit. Am J Public Health. 1995;85:795-800.
3. Kamposioras K, Casazza G, Mauri D, et al. Screening chest radiography: results from a Greek cross-sectional survey. BMC Public Health. 2006;6:113.
4. Proiskos A, Loukidou E, Kamposioras K, et al. Screening chest radiography in primary care: an underestimated belief. Eur J Gen Pract. 2005;11:76-77.
5. Mauri D, Kamposioras K, Proiskos A, et al. Old habits die hard: chest radiography for screening purposes in primary care. Am J Manag Care. 2006;12:650-656.
6.Woo B, Woo B, Cook EF, Weisberg M, Goldman L. Screening procedures in the asymptomatic adult. Comparison of physicians' recommendations, patients' desires, published guidelines, and actual practice. JAMA. 1985;254:1480-1484.
7. Lynch GR, Prout MN. Screening for cancer by residents in an internal medicine program. J Med Educ. 1986;61:387-393.
8. Mandel IG, Franks P, Dickinson JC. Screening guidelines in a family medicine program: a five-year experience. J Fam Pract. 1982;14:901-907.
9. Zemencuk JK, Feightner JW, Hayward RA, Skarupski KA, Katz SJ. Patients' desires and expectations for medical care in primary care clinics. J Gen Intern Med. 1998;13:273-276.