Are CT Angiograms Worth It?

As a medical student preparing to apply for radiology residency programs, I admit I have a bias towards viewing diagnostic tests as beneficial. However, there are many reasons to have some skepticism about this view. The recent passing of Tim Russert has led many to think about how we perform preventive screening for coronary disease. One suggestion is to use a new technology, CT Angiograms, to help screen patients:

A group of cardiologists recently had a proposition for Dr. Andrew Rosenblatt, who runs a busy heart clinic in San Francisco: Would he join them in buying a CT scanner, a $1 million machine that produces detailed images of the heart?

The scanner would give Dr. Rosenblatt a new way to look inside patients’ arteries, enable his clinic to market itself as having the latest medical technology and provide extra revenue.

However, there was a downside to having the technology available:

Although tempted, Dr. Rosenblatt was reluctant. CT scans, which are typically billed at $500 to $1,500, have never been proved in large medical studies to be better than older or cheaper tests. And they expose patients to large doses of radiation, equivalent to at least several hundred X-rays, creating a small but real cancer risk.

Dr. Rosenblatt worried that he and other doctors in his clinic would feel pressure to give scans to people who might not need them in order to pay for the equipment, which uses a series of X-rays to produce a composite picture of a beating heart.

“If you have ownership of the machine,” he later recalled, “you’re going to want to utilize the machine.” He said no to the offer.

Such concerns go beyond one doctor, with proponents of CT angiograms lining up against payers who question their value:

The Centers for Medicare and Medicaid Services had decided to push back.

The agency, which this year will spend more than $800 billion on health care, rarely questions the need to pay for new treatments. But last June, Medicare said it was considering paying for CT heart scans only on the condition that studies be done to show they had value for patients.

Concerned about the overall proliferation of imaging tests, Medicare said it might require a large-scale study to determine the scans’ value.

The plan met with fierce resistance, particularly from a relatively new organization of specialists, the Society of Cardiovascular Computed Tomography. The society has 4,700 physician members and one purpose — to promote CT angiograms.

Needless to say, the group put up intense lobbying pressure, and Medicare eventually gave way. Still, the case is an interesting mix of health economics, medicine, and society. The new technology raises the issue of not only how much benefit it provides, but also whether that benefit is worth the cost. I think there are worthwhile arguments on both sides. On the one hand, you have to have some people "go first" and use the technology in order to see if it is worthwhile, so some funding / market must be there. However, on the other hand, you do not want to blindly enable the technology in general only to later find out that it was of little use. Medicine, it seems, has chosen to err towards the side of trying everything now, and only checking later if it actually worked. Such is modern medicine in the U.S., I guess.

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