Radiologists must engage with Choosing Wisely initiative

The Choosing Wisely campaign from the American Board of Internal Medicine (ABIM) Foundation is now widespread, and because it clearly targets radiology as a specialty whose services are often overused or unnecessary, radiologists must respond, according to a presentation given at the recent RSNA 2013 meeting.

Dr. Vijay Rao.Dr. Vijay Rao.
Dr. Vijay Rao.

The ABIM Foundation announced the Choosing Wisely initiative in April 2012, with the goal of curbing the use of tests or procedures that are considered overused and/or unnecessary. Nine medical organizations, including the American College of Radiology (ACR), signed on as charter members, and each selected five tests it felt were overused.

More than a year later, the list of member organizations has grown, said presenter Dr. Vijay Rao of Thomas Jefferson University.

"When we conducted our research in March, the ACR and 26 other national medical societies had joined," she said.

By studying the Choosing Wisely website and other materials, Rao and colleagues tallied how many of the 135 tests listed as overused or unnecessary related to imaging. The group then categorized the exams by body system and modality.

Twenty-one of the 26 nonradiology societies chose at least one imaging exam for its list of overused procedures, and of the 135 tests/procedures listed, 61 were related to imaging (45%), Rao said. Because there was some redundancy among the various societies, Rao and colleagues eliminated duplicates, leaving a total of 49 separate imaging tests identified as overused or unnecessary.

Six of these were echocardiography exams, which are rarely performed by radiologists, leaving 43 imaging tests commonly performed by radiologists, according to Rao.

Choosing Wisely imaging tests by body system and modality
Body system No. of imaging tests Modality No. of imaging tests
Cardiac 11 CT 16
Head and neck 10 Nuclear medicine, including PET 11
Pediatric 5 Ultrasound 8
Musculoskeletal 4 X-ray 4
Abdomen/pelvis 4 MRI 3
Vascular 4 Any imaging at all 1
Chest 2  
Breast 2
Whole body 1

Rao listed some examples of imaging tests that Choosing Wisely member societies said should not be performed:

  • Annual stress imaging after coronary revascularization
  • Coronary CT angiography in high-risk emergency department patients presenting with acute chest pain
  • Brain CT or MRI in children with simple febrile seizures
  • Carotid artery imaging for simple syncope without neurologic symptoms
  • CT of the head or brain for sudden hearing loss
  • MRI of peripheral joints to monitor inflammatory arthritis
  • Echocardiography for preoperative assessment in patients without cardiac history or symptoms
  • Routine bone scans in patients with low-risk prostate cancer
  • Predischarge echocardiography after cardiac valve replacement surgery
  • Re-imaging of deep vein thrombosis in the absence of a clinical change
  • Stress echocardiography to assess cardiovascular risk in patients without symptoms and with low risk for coronary disease

As of November, 10 more societies had joined Choosing Wisely, bringing the membership list to 37. And five of these 10 new members had suggested imaging-related tests or procedures, boosting the number of unnecessary or overused exams to 48, according to Rao.

Most radiologists are still unfamiliar with the initiative, and that has to change, she told session attendees.

"As the recognized stewards of imaging during a time when great effort is being made to reduce costs, radiologists need to engage with this initiative," she said. "We need to become familiar with the list of studies that are perceived to be overused, and then either refute the allegations of overuse or take steps to limit their use."

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