Overuse of Diagnostic Imaging for Work-Related Injuries

Abstract

Overuse of health care in the United States is a growing concern. This article addresses the use of diagnostic imaging for work-related injuries. Diagnostic imaging drives substantial cost for increases in workers’ compensation. Despite guidelines published by the American College of Radiology and the American College of Occupational Medicine and the Official Disability Guidelines, practitioners are prematurely ordering imaging sooner than recommended. Workers are exposed to unnecessary radiation and are incurring increasing costs without evidence of better outcomes. Practitioners caring for workers and submitting workers’ compensation claims should adhere to official guidelines, using their professional judgment to consider financial impact and health outcomes of diagnostic imaging including computed tomography, magnetic resonance imaging, nuclear medicine imaging, radiography, and ultrasound.

Overuse of diagnostic imaging (i.e., computed tomography [CT], nuclear imaging, magnetic resonance imaging [MRI], radiography, and ultrasound) in the United States is a growing concern (Malone et al., 2012). Advanced imaging techniques allow for earlier diagnosis of injury and illness but not without costs (e.g., excessive radiation exposure and excessive financial burden on the health care system; Smith-Bindman et al., 2012). Computed tomography and nuclear imaging expose individuals to potentially damaging ionizing radiation. Yet, according to a 15-year study ending in 2010, the use of CT has nearly tripled. Although MRI does not expose workers to potential cancer-inducing radiation, the cost of imaging is estimated at US$100 billion annually (Smith-Bindman et al., 2012).

The Problem

Occupational health professionals (e.g., physicians, nurse practitioners, and registered nurses) provide evidence-based care to the working population, affecting both workers and employers. In workers’ compensation cases, health care utilization is driven in part by the need to return employees to work while protecting the fiscal interest of the employer (Roberts et al., 2016). To streamline the health care delivered to workers, workers’ compensation cases often include an interdisciplinary team of physicians, nurse practitioners, case managers, registered nurses, physical therapists, and adjusters. All members of this team have a vital role to protect workers and employers from the harms of inappropriate use of health care technology.

Background and Epidemiology

The most expensive workers’ compensation cases include sprains and strains of the back, knee, and shoulder (Bureau of Labor Statistics [BLS], 2015). Workers’ compensation insurance pays 100% of direct costs such as health care expenses (48.4%) and indirect costs including indemnity benefits (51.6%), totaling US$454.7 billion annually (BLS, 2015).

Clinical practice guidelines (CPG) are recommendations intended to optimize client care. Published guidelines use a systematic review process of current evidence, considering the benefits and harms of alternate care options (Institute of Medicine, 2011). Clinical practice guidelines, such as those published by the American College of Radiology (ACR) and American College of Occupational and Environmental Medicine (ACOEM), and the Official Disability Guidelines assist providers in determining when to order diagnostic imaging for occupational injuries (Graves, Fulton-Kehoe, Jarvik, & Franklin, 2014). Although guidelines are available, health care providers are often ordering diagnostic imaging sooner than recommended, driven by improvements in technology, client- and physician-generated demand, defensive health care practices, and diagnostic uncertainty (Smith-Bindman et al., 2012)

Review of Research

Between 1996 and 2010, MRI examinations quadrupled (10% annual growth), ultrasound doubled (3.9% annual growth), and CT examinations tripled (7.8% annual growth; Smith-Bindman et al., 2012). Exposure to CT imaging and nuclear medicine is estimated to contribute to 2% of future cancers. The general population receives 1.18 diagnostic tests per person per year; 35% of these tests are CTs, MRIs, nuclear medicine imaging, or ultrasounds (Smith-Bindman et al., 2012).

Computing tomography imaging allows three-dimensional visualization of the anatomy, improving detection of musculoskeletal injuries; these images are not without potential harm (ACR, 2016). Radiation exposure is measured in millisieverts (mSv), which is a measure of the health effect of ionizing radiation on the body. Computing tomography scans result in exposure of 1 to 10 mSv; 20% of individuals receive very high doses (>50 mSv). According to the ACR (2016), exposure to 10 mSv increases the risk of future cancer. The benefits of detailed imaging may outweigh harms of potential radiation exposure. Nonetheless, providers ordering CT imaging should thoroughly understand the use of imaging and whether the results will affect the overall outcome of injury care.

In contrast, MRI does not expose workers to ionizing radiation. However, workers are at risk due to increased utilization of this imaging technique. A study examining non-adherence to CPGs for acute low back pain found an increase in the cost of workers’ compensation cases associated with early use of MRI (Graves et al., 2014). Nineteen percent of health care providers ordering MRIs were non-adherent to CPGs resulting in a 50% increase in physical therapy and occupational therapy, an 18% increase in chiropractic care, a 30% increased likelihood of lumbosacral injections, and an 18% increased likelihood of surgery. The total cost for clients receiving early MRIs nearly quadrupled compared with conservative care recommended by the CPGs (US$22,151 compared with US$6,640; Graves et al., 2014).

Likewise, Ivanova et al. (2011) found that non-adherence to CPGs resulted in cost of care 3 times greater than controls. X rays are the most commonly ordered diagnostic imaging with at least 50% of imaging received on the day of injury (Ivanova et al., 2011).

Not only does early diagnostic imaging increase costs for workers’ compensation, workers who receive MRIs prematurely without a clear indication have greater incidence of more complex care such as surgery. The natural history of acute low back pain improvement may take more than 4 weeks. Webster, Bauer, Choi, Cifuentes, and Pransky (2013) found that despite CPG availability, 37% of MRIs are ordered prematurely and without a clear indication. Of the individuals receiving early MRIs, more than 20% endure surgery costing employers US$13,000 more than following conservative treatment guidelines (Webster et al., 2013).

Although MRIs are useful in confirming musculoskeletal disease, MRIs are not always necessary to establish definitive diagnoses (Babbel & Rayan, 2012). Clinical diagnoses agreed with MRI diagnoses only 37% of the time in workers’ compensation cases. Walton et al. (2011) studied the validity of MRI use in lateral epicondylitis. The researchers found that MRI findings did not correlate with workers’ symptoms, so diagnostic imaging can lead to over treatment.

Day et al. (2010) compared the course of treatment of hand and wrist disorders between workers’ compensation insurance and standard insurance. The study found almost twice as many workers with workers’ compensation receiving electrodiagnostic testing than workers covered by standard insurance. The study suggests that the use of diagnostic imaging is not standardized throughout the health care system.

Implications for Practice

Although the article does not go into an extensive review of CPGs for occupational injuries, use of CPGs published by ACR and ACOEM and the Official Disabilty Guidelines published by the Work Loss Data Institute may be used to determine the need for diagnostic imaging. Evidence-based guidelines such as the Ottawa Rules assist practitioners in deciding when to order x rays after acute trauma to the neck, knee, ankle, or foot (ACR, 2016). In the absence of red flags (i.e., evidence of fracture, dislocation, infection, tumor, inflammation, progressive neurological deficit, or vascular compromise), musculoskeletal injuries are usually self-limiting and respond to conservative treatment in 4 to 6 weeks. Limiting unnecessary use of diagnostic imaging reduces direct and indirect costs and iatrogenic consequences of early imaging and has favorable return to work outcomes.

Summary

Although guidelines are available to drive quality care and conserve costs associated with work-related injuries, practitioners are still overusing diagnostic imaging resulting in higher costs, increased use of other health care services such as surgery and steroid injections, delayed return to work, and higher disability compensation (Graves et al., 2014).