Use of Diagnostic Imaging Studies and Associated Radiation Exposure for Patients Enrolled in Large Integrated Health Care Systems, 1996-2010 | JAMA | JAMA Network
[Skip to Navigation]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address Please contact the publisher to request reinstatement.
 Statement of Glenn M. Hackbarth, Chairman, Medicare Payment Advisory Commission: Options to Improve Medicare's Payments to Physicians. Accessed May 22, 2012
 Report to congressional requesters: Medicare Part B imaging services: rapid spending growth and shift to physician offices indicated need for CMS to consider additional management practices [GAO-08-452]. Government Accountability Office. Accessed May 16, 2012
Winter A, Stensland J. Introduction: expert panel on new research on use of imaging services [presentation to Medicare Payment Advisory Commission, September 5, 2008]. Accessed May 17, 2012
Iglehart JK. Health insurers and medical-imaging policy: a work in progress.  N Engl J Med. 2009;360(10):1030-103719264694PubMedGoogle ScholarCrossref
Board of Radiation Effects Research, Division on Earth and Life Sciences, National Research Council of the National Academies.  Health Risks from Exposure to Low Levels of Ionizing Radiation: BEIR VII Phase 2. Washington, DC: National Academies Press; 2006
Preston DL, Ron E, Tokuoka S,  et al.  Solid cancer incidence in atomic bomb survivors: 1958-1998.  Radiat Res. 2007;168(1):1-6417722996PubMedGoogle ScholarCrossref
Berrington de González A, Mahesh M, Kim KP,  et al.  Projected cancer risks from computed tomographic scans performed in the United States in 2007.  Arch Intern Med. 2009;169(22):2071-207720008689PubMedGoogle ScholarCrossref
Brenner DJ, Hall EJ. Computed tomography: an increasing source of radiation exposure.  N Engl J Med. 2007;357(22):2277-228418046031PubMedGoogle ScholarCrossref
Bhargavan M, Sunshine JH. Utilization of radiology services in the United States: levels and trends in modalities, regions, and populations.  Radiology. 2005;234(3):824-83215681686PubMedGoogle ScholarCrossref
Levin DC, Rao VM, Parker L. Physician orders contribute to high-tech imaging slowdown.  Health Aff (Millwood). 2010;29(1):189-19520048376PubMedGoogle ScholarCrossref
Fazel R, Krumholz HM, Wang Y,  et al.  Exposure to low-dose ionizing radiation from medical imaging procedures.  N Engl J Med. 2009;361(9):849-85719710483PubMedGoogle ScholarCrossref
Graham S. Imaging is everything: diagnostic imaging took off a few years ago: get ready for the next wave of growth. Baltimore Business Journal. February 28, 2005. Accessed May 17, 2012
Hackbarth G, Reischauer R, Mutti A. Collective accountability for medical care: toward bundled Medicare payments.  N Engl J Med. 2008;359(1):3-518596270PubMedGoogle ScholarCrossref
Shortell SM, McCurdy RK. Integrated health systems.  Stud Health Technol Inform. 2010;153:369-38220543254PubMedGoogle Scholar
Lieu TA, Hinrichsen VL, Moreira A, Platt R. Collaborations in population-based health research: the 17th annual HMO Research Network Conference, March 23-25, 2011, Boston, Massachusetts, USA.  Clin Med Res. 2011;9(3-4):137-14022090515PubMedGoogle ScholarCrossref
Hornbrook MC, Hart G, Ellis JL,  et al.  Building a virtual cancer research organization.  J Natl Cancer Inst Monogr. 2005;(35):12-2516287881PubMedGoogle Scholar
Smith-Bindman R, Miglioretti DL, Larson EB. Rising use of diagnostic medical imaging in an integrated health plan.  Health Aff (Millwood). 2008;27(6):1491-150218997204PubMedGoogle ScholarCrossref
Lee C, Lodwick D, Hurtado J, Pafundi D, Williams JL, Bolch WE. The UF family of reference hybrid phantoms for computational radiation dosimetry.  Phys Med Biol. 2010;55(2):339-36320019401PubMedGoogle ScholarCrossref
Lee C, Kim KP, Long D,  et al.  Organ doses for reference adult male and female undergoing computed tomography estimated by Monte Carlo simulations.  Med Phys. 2011;38(3):1196-120621520832PubMedGoogle ScholarCrossref
 The 2007 Recommendations of the International Commission on Radiological Protection: ICRP publication 103.  Ann ICRP. 2007;37(2-4):1-33218082557PubMedGoogle ScholarCrossref
Murray IPC, Ell PJ, Van der Wall H. Nuclear Medicine in Clinical Diagnosis and Treatment. 2nd ed. New York, NY: Churchill Livingstone; 1998
Hendrick RE, Pisano ED, Averbukh A,  et al.  Comparison of acquisition parameters and breast dose in digital mammography and screen-film mammography in the American College of Radiology Imaging Network digital mammographic imaging screening trial.  AJR Am J Roentgenol. 2010;194(2):362-36920093597PubMedGoogle ScholarCrossref
Graubard BI, Korn EL. Predictive margins with survey data.  Biometrics. 1999;55(2):652-65911318229PubMedGoogle ScholarCrossref
Levin DC, Rao VM, Parker L, Frangos AJ, Sunshine JH. Bending the curve: the recent marked slowdown in growth of noninvasive diagnostic imaging.  AJR Am J Roentgenol. 2011;196(1):W25-W2921178027PubMedGoogle ScholarCrossref
Studdert DM, Mello MM, Sage WM,  et al.  Defensive medicine among high-risk specialist physicians in a volatile malpractice environment.  JAMA. 2005;293(21):2609-261715928282PubMedGoogle ScholarCrossref
Redberg RF, Walsh J. Pay now, benefits may follow: the case of cardiac computed tomographic angiography.  N Engl J Med. 2008;359(22):2309-231119038877PubMedGoogle ScholarCrossref
Douglas PS. Improving imaging: our professional imperative.  J Am Coll Cardiol. 2006;48(10):2152-215517113005PubMedGoogle ScholarCrossref
 Medicare: trends in fees, utilization, and expenditures for imaging services before and after implementation of the Deficit Reduction Act of 2005: September 26, 2008 [GAO-08-1102R]. Government Accounting Office. Accessed May 18, 2012
Levin DC, Bree RL, Rao VM, Johnson J. A prior authorization program of a radiology benefits management company and how it has affected utilization of advanced diagnostic imaging.  J Am Coll Radiol. 2010;7(1):33-3820129269PubMedGoogle ScholarCrossref
Parker L, Levin DC, Frangos A, Rao VM. Geographic variation in the utilization of noninvasive diagnostic imaging: national Medicare data, 1998-2007.  AJR Am J Roentgenol. 2010;194(4):1034-103920308507PubMedGoogle ScholarCrossref
Shuryak I, Sachs RK, Brenner DJ. Cancer risks after radiation exposure in middle age.  J Natl Cancer Inst. 2010;102(21):1628-163620975037PubMedGoogle ScholarCrossref
 Ionizing radiation exposure of the population of the United States [NCRP Report No. 160]. National Council on Radiation Protection and Measurements. Accessed March 5, 2009
 International basic safety standards for protection against ionizing radiation and for the safety of radiation sources. International Atomic Energy Agency. Accessed May 18, 2012
International Committee on Radiological Protection.  1990 Recommendations of the International Commission on Radiological Protection: ICRP publication No. 60. Oxford, England: Pergamom; 1991
 NRC Regulations (10 CFR) Part 20: standards for protection against risks: subpart C, occupational dose limits. US Nuclear Regulatory Commission. Accessed September 27, 2011
Charles M. UNSCEAR report 2000: sources and effects of ionizing radiation: United Nations Scientific Committee on the Effects of Atomic Radiation.  J Radiol Prot. 2001;21(1):83-8611281539PubMedGoogle ScholarCrossref
Board of Radiation Effects Research, Division on Earth and Life Sciences, National Research Council of the National Academies, Committee on the Biological Effects of Ionizing Radiation.  Health Effects of Exposure to Low Levels of Ionizing Radiation: BEIR V. Washington, DC: National Academies Press; 1990
Smith-Bindman R, Miglioretti DL. CTDIvol, DLP, and effective dose are excellent measures for use in CT quality improvement.  Radiology. 2011;261(3):99922096003PubMedGoogle ScholarCrossref
 Ensuring quality through appropriate use of diagnostic imaging [white paper]. America's Health Insurance Plans (AHIP). Accessed May 22, 2012
Glabman M. Health plans strain to contain rapidly rising costs of imaging. Managed Care magazine. Accessed May 22, 2012
 June 2010: A Data Book: Healthcare spending and the Medicare Program. Medicare Payment Advisory Commission (MEDPAC). Accessed May 22, 2012
Original Contribution
June 13, 2012

Use of Diagnostic Imaging Studies and Associated Radiation Exposure for Patients Enrolled in Large Integrated Health Care Systems, 1996-2010

Author Affiliations

Author Affiliations: Department of Radiology and Biomedical Imaging, Department of Epidemiology and Biostatistics, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco (Dr Smith-Bindman); Group Health Research Institute, Group Health Cooperative and Department of Biostatistics, University of Washington, Seattle (Dr Miglioretti and Messrs Johnson and Vanneman); Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland (Dr Lee); Institute for Health Research, Kaiser Permanente, Denver, Colorado (Dr Feigelson); Department of Radiology, Center for Health Services Research, Henry Ford Health System, Detroit, Michigan (Dr Flynn); Epidemiology Research Center, Marshfield Clinic Research Foundation, Marshfield, Wisconsin (Drs Greenlee and Kruger); Center for Health Research/Kaiser Permanente Northwest, Portland, Oregon (Drs Hornbrook and Weinmann); Center for Health Research/Kaiser Permanente Southeast, Atlanta, Georgia (Dr Roblin); HealthPartners Research Foundation, Minneapolis, Minnesota (Dr Solberg); and Center for Health Research/Kaiser Permanente Hawaii, Honolulu (Dr Williams).

JAMA. 2012;307(22):2400-2409. doi:10.1001/jama.2012.5960

Context Use of diagnostic imaging has increased significantly within fee-for-service models of care. Little is known about patterns of imaging among members of integrated health care systems.

Objective To estimate trends in imaging utilization and associated radiation exposure among members of integrated health care systems.

Design, Setting, and Participants Retrospective analysis of electronic records of members of 6 large integrated health systems from different regions of the United States. Review of medical records allowed direct estimation of radiation exposure from selected tests. Between 1 million and 2 million member-patients were included each year from 1996 to 2010.

Main Outcome Measure Advanced diagnostic imaging rates and cumulative annual radiation exposure from medical imaging.

Results During the 15-year study period, enrollees underwent a total of 30.9 million imaging examinations (25.8 million person-years), reflecting 1.18 tests (95% CI, 1.17-1.19) per person per year, of which 35% were for advanced diagnostic imaging (computed tomography [CT], magnetic resonance imaging [MRI], nuclear medicine, and ultrasound). Use of advanced diagnostic imaging increased from 1996 to 2010; CT examinations increased from 52 per 1000 enrollees in 1996 to 149 per 1000 in 2010, 7.8% annual increase (95% CI, 5.8%-9.8%); MRI use increased from 17 to 65 per 1000 enrollees, 10% annual growth (95% CI, 3.3%-16.5%); and ultrasound rates increased from 134 to 230 per 1000 enrollees, 3.9% annual growth (95% CI, 3.0%-4.9%). Although nuclear medicine use decreased from 32 to 21 per 1000 enrollees, 3% annual decline (95% CI, 7.7% decline to 1.3% increase), PET imaging rates increased after 2004 from 0.24 to 3.6 per 1000 enrollees, 57% annual growth. Although imaging use increased within all health systems, the adoption of different modalities for anatomic area assessment varied. Increased use of CT between 1996 and 2010 resulted in increased radiation exposure for enrollees, with a doubling in the mean per capita effective dose (1.2 mSv vs 2.3 mSv) and the proportion of enrollees who received high (>20-50 mSv) exposure (1.2% vs 2.5%) and very high (>50 mSv) annual radiation exposure (0.6% vs 1.4%). By 2010, 6.8% of enrollees who underwent imaging received high annual radiation exposure (>20-50 mSv) and 3.9% received very high annual exposure (>50 mSv).

Conclusion Within integrated health care systems, there was a large increase in the rate of advanced diagnostic imaging and associated radiation exposure between 1996 and 2010.