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September 11, 2020

Radiology and Value-Based Health Care

Author Affiliations
  • 1European Society of Radiology, Vienna, Austria
  • 2Mercy University Hospital, Cork, Ireland
  • 3American College of Radiology, Reston, Virginia
  • 4International Society for Strategic Studies in Radiology, Vienna, Austria
  • 5Harvard Medical School, Boston, Massachusetts
  • 6Royal Australian and New Zealand College of Radiologists, Sydney, Australia
  • 7Flinders Medical Centre and Flinders University, Adelaide, Australia
JAMA. 2020;324(13):1286-1287. doi:10.1001/jama.2020.14930

Because health care usage and expenditures have continued to increase in most countries, well in excess of cost-of-living inflation, value-based health care has become an increasingly important concept, aimed at improving patient outcomes without increasing costs. The value-based health care model is founded on the effort to encourage adoption of practices that optimize the ratio between health gained and costs incurred and will inevitably lead to greater scrutiny of how resources are deployed and expended.

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2 Comments for this article
One Part of Clinical Decision Making
Madhureeta Achari, MD | Private Practice
While I agree with the author’s assertions that radiologists should engage in evidence-based guidelines for care and timely communication with referring physicians, I disagree with radiologists discussing results with patients. Without the full clinical picture and established patient-physician relationships, this would cause confusion and may increase anxiety in patients. Rather, explaining to the patient that the results will be communicated to their physician and encouraging follow up would be helpful. Being available to discuss optimal diagnostic tests/procedures with clinical colleagues is also helpful.
Radiology's Benefits Must be Balanced Against Its Adverse Effects
James Dickinson, MB PhD CCFP | Depts of Family Medicine and Community Health Sciences, U of Calgary
The commentary exhaustively describes a wide range of benefits that we derive clinically from radiology services, but the only adverse effect mentioned is the costs of the services. This presents an unduly rosy viewpoint. In practice radiology also produces many harms. Examples include the false positive test, in both screening and diagnostic settings, and the "incidentaloma" that leads to further intervention. Uncertain results lead to recommending repeat studies, or different modalities that may clarify the shadow, but also lead to greater anxiety as well as costs. Recommending frequent repeat monitoring tests to observe whether a cyst or other structure has malignant characteristics is too common. In screening, North American radiologists recommend much earlier and more frequent testing than in other parts of the world, with little evidence of better outcomes. It appears that some radiologists never take any risk and leave high rates of uncertainty in their reports. In doing so they pass risk back to referring physicians, and delay decision-making, not help.

That we cause harm is difficult for us as physicians to accept, but we must do so, and measure its effects. Until then, we are not providing a truly balanced perspective.
CONFLICT OF INTEREST: I have been an unpaid member of screening guideline groups.