Last month signified a victory for high-value care with the approval of a new patient safety metric, Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography in Adults. Starting in 2025, the measure will be integrated into the Centers for Medicare and Medicaid Services (CMS)’s Merit-based Incentive Payment System (MIPS) and Hospital Inpatient and Outpatient Quality Reporting Programs, with the goal of regulating patients’ exposure to radiation during computed tomography (CT) scans. 

This new measure of radiation quality sheds light on an important potential harm of imaging overuse. Here’s what it means for the future of provider accountability and patient safety.

Radiation exposure during CT scans

Each year, it is estimated that more than 80 million CT scans are performed in the United States. The computerized x-ray imaging procedure has the power to inform diagnostic decisions for everything from tumors and lesions to heart disease and pneumonia. 

While CT scans are an essential diagnostic tool in doctors’ medical toolkits, it’s important they be used carefully. Each time a CT scan is performed, the patient is exposed to ionizing radiation, which is required to produce an internal image for the physician to review and make diagnostic and treatment-related decisions. However, in large doses, exposure to such radiation can damage genetic and cellular material, increasing the risk for mutations and consequently, cancer. 

“Many patients still routinely receive radiation doses two or three times what they should. That will lead to cancer in a small percentage of patients, approximately thirty-six thousand cancers every year. This means that CT causes two percent of annual cancers, and we can reduce that risk substantially without reducing the value of the scans.”

Dr. Rebecca Smith-Bindman, UCSF

Given how common CT scans are and the potential risks of radiation exposure, it seems obvious that there would be standard measures for how much radiation doctors can use. But in fact, the amount of radiation that a patient gets in a CT scan varies widely, largely due to differences in the ways in which physicians use CT machines across institutions. The results of studies exploring the implications of this are alarming, with one citing a 13-fold mean variation between the lowest and highest dosages used across different CT scans. 

Measuring what matters in imaging

To tackle the widespread variation and lack of regulation surrounding CT radiation dosage, UCSF Professor in Residence Dr. Rebecca Smith-Bindman and her team developed a new measure, Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography in Adults. The measure sets lower and upper thresholds for radiation dose based on patient characteristics and type of CT scan. The radiation dose floor ensures that enough radiation is used to create an image of acceptable quality, while the ceiling prevents over-radiation that could increase cancer risk. 

Here’s an example from researchers at UCSF:

The measure is implemented through software that links to providers’ electronic health records, so clinicians can get real-time feedback on their performance. CMS will evaluate providers based on “the percentage of CT exams that are out-of-range based on having either excessive radiation dose or inadequate image quality.”

The future of overuse metrics

The new radiation quality metric is a great example of how overuse measures can help improve quality and reduce patient harm. CMS estimates this measure could prevent nearly 14,000 cancers among Medicare beneficiaries and save as much as $5 billion to Medicare each year.

This overuse metric is one of many that deserve broader use among providers. Through our research on the Lown Hospitals Index, we’ve seen how common unnecessary imaging and procedures can be in U.S. hospitals. For example, a Lown Institute report from October 2023 found that US hospitals delivered nearly 230,000 unnecessary coronary stents from 2019-2021– that’s a rate of one every seven minutes. The Lown Hospitals Index for Social Responsibility evaluates hospitals on 11 other low-value services, including unnecessary imaging like CT scans for fainting and procedures like spinal fusion for lower back pain. We look forward to incorporating the new metric of CT radiation quality into the Index as data becomes available. 

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Low-value care and equity

Given the health risks of overuse, it’s important to understand the impact of low-value care on health equity. Are people of color at higher risk of overuse than white patients, or vice versa? The evidence on this so far is mixed. A systematic review of studies looking at low-value care by race found that white patients were more likely to receive unnecessary care, but another more recent study found higher rates of overuse for certain low-value services in Black and Hispanic patients, such as feeding tubes for dementia. Clearly, there is a lot more to be studied on this issue.

Cue a new analysis from Harvard Medical School professor Dr. Ishani Ganguli and colleagues in The BMJ. This study looked at rates of 40 low-value services in nearly 10 million Medicare patients across 595 health systems. Ganguli and colleagues compared the likelihood of receiving low-value care between Black and white Medicare patients, including a comparison of patients within the same health system. Low-value services measured included screening tests, diagnostic tests, monitoring tests, drugs, and procedures.

Here are key takeaways from their study:

• There were significantly different rates of low-value care for 29 of the 40 services measured, although most of the differences were small. Black patients had higher rates of nine low value services and white patients had higher rates of 20 low-value services. 
• White Medicare patients were more likely to receive low-value screening tests such as prostate-specific antigen testing in men over 75 (31% v 26%) and cardiac screening (5% v 2%), as well as treatments such as antibiotics for cold or ear infection (37% v 33%), and vertebroplasty (5% v 3%) which is an injection of cement into the backbone.
• Black Medicare patients were more likely to receive feeding tubes for advanced dementia (9% v 2%), two or more concurrent antipsychotic medications (8% v 5%), and certain low-value acute diagnostic tests, like imaging for uncomplicated headache (7% v 3%).
• Differences in low-value care remained even when comparing patients within the same health system. That’s important, because it indicates differences in the way patients of different races are treated by the same providers–rather than just differences in culture between the health providers they frequent. 

Drivers of disparities in low-value care

What could explain these differences? The study authors suggest some potential reasons why Black patients could be more likely to receive low-value diagnostic tests:

“Mistrust in the healthcare system because of historical and present day racism might contribute to Black adults being more receptive to diagnostic testing when acutely ill—in this scenario, it is possible that a tangible test is more reassuring than a clinician’s words and might serve to lessen valid concerns about undertreatment.”

The authors also point out that structural barriers to care for Black patients can make it hard to access care earlier and result in them arriving to the ER sicker, which could prompt low-value testing. Additionally, if patients are more likely to seek care in the ER or urgent care as opposed to primary care, they may be subject to more low-value testing from doctors who don’t know them well. Why does this matter? Low-value diagnostic testing exposes patients to radiation exposure, out-of-pocket spending, and additional follow-up testing and procedures (known as “care cascades”).

Black patients were also more likely to receive feeding tubes in the setting of advanced dementia, a practice that does not help patients live longer, and is not recommended for these patients. Differences in rates of feeding tube usage may reflect lack of trust and communication between clinicians and patients; one study found that 14% of family members of patients with feeding tubes reported that there was no discussion about feeding tube insertion, and 42% reported a discussion that was shorter than 15 minutes.  

On the flip side, why are white patients more likely to receive certain low-value screenings and treatments? The authors suggest that white patients could be more likely to request these services, or clinicians might be more likely to offer them, perhaps because of implicit biases. Black patients are less likely than white patients to receive certain cancer screenings that are considered high-value, such as age-appropriate colonoscopies and mammograms, so it makes sense that they are also less likely to receive low-value ones. 

This study provides valuable information on the intersections between health equity and value, but there’s still much more to learn. The authors suggest that health systems measure use of low-value services stratified by racial group and sex, to identify potential disparities. “These results invite further exploration of differential access by race to routine, high value primary care, patient-clinician concordance, and trust,” they write.

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