进阶诊断影像检查的使用增加


  【24drs.com】一篇回溯分析发现,整合健康照护系统的进阶诊断影像检查于1996-2010年间持续增加,举例而言,计算机断层(CT)检查的数量在这段期间增加3倍,源自CT的人平均放射线曝露达4倍。
  
  加州大学旧金山分校的Rebecca Smith-Bindman医师等人发表研究结果于6月13日的JAMA。
  
  Smith-Birdman医师指出,研究者想要在一个控制设定下厘清影像检查的使用,我们知道,照护模式付费原则下,影像检查在过去廿年增加许多,比较不清楚的是,这段期间的影像检查模式,以及在整合健康照护系统之下,病患接受的累积放射线剂量。我们想要研究健康维护组织(HMOs)制度下的病患,它们提供了一组病患、在相同制度下进行所有的检查。
  
  作者们回顾了HMO Research Network内的6个大型整合式健康照护制度的电子化纪录,以确认影像检查的使用,排除癌症治疗时进行的检查程序,并评估接受的放射线剂量。作者们排除购买收费服务计划者的资料,以及在未纳入HMO之健康照护计画机构进行治疗的病患。
  
  CT检查的数量在1996-2010年间增加3倍(52/1000投保者vs 149/1000投保者),导致每年增加7.8% (95%信心区间[CI]为5.8% - 9.8%),不过,增加幅度在2007年后趋于平缓。同样地,磁振造影的使用在这15年间增加4倍(1996 年:17/1000投保者,2010年:65/1000投保者),导致每年增加10%(95% CI,3.3% - 16.5%)。
  
  再者,这段研究期间内,超音波影像检查增加约2倍(134/1000投保者vs. 230/1000投保者),导致每年增加3.9% (95% CI,3.0% - 4.9%)。
  
  另一方面,核子医学的使用每年减少3% (95% CI,增加幅度从7.7%降低至1.3%) (32/1000投保者vs 21/1000投保者),不过,正子造影的使用自2004年后每年增加57%(0.24/1000投保者 vs 3.6/1000投保者)。
  
  同时,使用X光(每年增加1.2%)与使用血管摄影/萤光摄影(每年增加1.3%)则是相对稳定。
  
  对于所有影像检查方式,使用率倾向随著病患年纪增加。
  
  医疗影像检查的平均有效剂量每年增加3.2%(95% CI,3.1% - 3.3%),从1996年的4.8 mSv增加到2010年的7.8 mSv。同样地,在这段研究期间,曝露于高(20-50 mSv)或非常高(>50 mSv)剂量的病患比率分别倍增到2.5%与1.4%。
  
  和使用情况方面的结果一样,源自CT的每年人均放射线剂量增加4倍,从1996年的0.38 mSv到2010年的1.58 mSv。血管摄影/萤光摄影的放射线剂量从1996年的0.52 mSv降低到2010年的0.34 mSv。 
  
  曝露于高或非常高放射线剂量的病患比率随年纪而增加。到了2010年,65岁以上投保者分别有11%和7.3%曝露于高和非常高的放射线剂量,0-14岁的投保者则分别是1.3%和0.4%。
  
  Smith-Bindman医师主张更谨慎的使用影像检查,我们需要改变医师实务,需要资助比较效益研究,以帮助我们了解影像检查何时有帮助,以及何时反而可能造成更多伤害。
  
  在一篇相关评论中,波士顿大学医学院的George T. O'Connor医师和哈佛医学院的Hiroto Hatabu博士指出,进阶CT方式降低了病患的离子性放射线曝露,认为可以有后续改善。最近,藉由合并一定量的现代闪烁材料之X光侦测器、重复的物理模型基础重建算法、更加个人化的图象采集协议,或许有可能进一步降低放射线曝露。无放射线曝露的诊断方式,如磁振造影和超音波影像,或许可以取代某些CT扫描。
  
  国家癌症研究院的Amy Berrington de Gonzalez,质疑预警系统可能会改变影像检查方式的使用。Berrington医师表示,一些HMO机构在考量使用情况增加下,会在医嘱使用含离子性放射线时开始发出警讯,这些警讯是否影响使用情况,则值得后续探究。
  
  资料来源:http://www.24drs.com/professional/list/content.asp?x_idno=6854&x_classno=0&x_chkdelpoint=Y
  

Use of Advanced Diagnostic Imaging Increasing

By Joe Barber Jr PhD
Medscape Medical News

June 13, 2012 — A retrospective analysis revealed that the use of advanced diagnostic imaging among members of integrated healthcare systems increased substantially from 1996 to 2010. For example, the number of computed tomography (CT) examinations nearly tripled during that time, and the per capita radiation exposure from CT quadrupled.

Rebecca Smith-Bindman, MD, from the University of California San Francisco, and colleagues published their findings in the June 13 issue of JAMA.

Dr. Smith-Birdman noted that the researchers wanted to clarify the use of imaging in a controlled setting. "While we know that within 'fee for service' models of care, imaging has gone up a lot in the last two decades, little is known of the patterns of imaging over time and cumulative doses of radiation that patients receive within the context of integrated health care systems," Dr. Smith-Birdman told Medscape Medical News by email. "We wanted to study patients in HMOs [health maintenance organizations] as they provided a group of patients where we would know all of the tests they underwent would be in the same system."

The authors reviewed the electronic records of 6 large integrated healthcare systems that participate in the HMO Research Network to determine the use of imaging modalities, excluding procedures done in conjunction with cancer treatment, and assess the delivered radiation dose. The authors excluded the data for members who purchased fee-for-service plans and those for patients who were treated at healthcare plan facilities without being enrolled in the HMO.

Imaging Use Over Time

The number of CT examinations tripled from 1996 to 2010 (52/1000 enrollees vs 149/1000 enrollees), resulting in an annual increase of 7.8% (95% confidence interval [CI], 5.8% - 9.8%), although this increase appeared to flatten after 2007. Similarly, the use of magnetic resonance imaging quadrupled over the 15-year study period (17/1000 enrollees in 1996 to 65/1000 enrollees in 2010), resulting in an annual increase of 10% (95% CI, 3.3% - 16.5%).

Moreover, the use of ultrasonography increased by approximately 2-fold during the study period (134/1000 enrollees vs. 230/1000 enrollees), resulting in an annual growth of 3.9% (95% CI, 3.0% - 4.9%).

On the other hand, the use of nuclear medicine decreased by 3% annually (95% CI, 7.7% decrease to 1.3% increase) during the study period (32/1000 enrollees vs 21/1000 enrollees), although use of position emission tomography increased by 57% annually after 2004 (0.24/1000 enrollees vs 3.6/1000 enrollees).

Meanwhile, the use of radiography (1.2% annual increase) and the use of angiography/fluoroscopy (1.3% annual decrease) were both relatively stable during the study period.

For all imaging modalities, the rate of use tended to increase with increasing patient age.

Radiation Exposure Over Time

The average effective dose of radiation via medical imaging increased by 3.2% annually (95% CI, 3.1% - 3.3%) from 4.8 mSv in 1996 to 7.8 mSv in 2010. Similarly, the proportion of patients exposed to high (20 to 50 mSv) or very high (>50 mSv) doses of radiation approximately doubled during the study period to 2.5% and 1.4%, respectively.

In line with the usage findings, the annual per capita radiation dose delivered by CT increased by 4-fold from 0.38 mSv in 1996 to 1.58 mSv in 2010. The amount of radiation delivered by angiography/fluoroscopy decreased from 0.52 mSv in 1996 to 0.34 mSv in 2010.

The proportion of patients exposed to high and very high doses of radiation increased with increasing age. By 2010, 11% and 7.3% of enrollees aged 65 years or older were exposed to high and very high radiation doses, respectively, compared with 1.3% and 0.4%, respectively, for enrollees aged 0 to 14 years.

Comparative Effectiveness Research Needed

Dr. Smith-Bindman argues for a more prudent use of imaging. "We need to change the way we practice as physicians," Dr. Smith-Bindman told Medscape Medical News. "We need to fund comparative effectiveness research that helps us understand when imaging is helpful and when it may potentially lead to more harm than good."

In a related commentary, George T. O'Connor, MD, MS, from the Boston University School of Medicine in Boston, Massachusetts, and Hiroto Hatabu, MD, PhD, from Harvard Medical School in Boston, noted that advanced CT modalities have reduced the exposure of patients to ionizing radiation and suggested that further improvements can be made. "In the near future, it may be possible to further decrease radiation exposure by an order of magnitude by combining modern scintillation materials for x-ray detectors, iterative physical model-based reconstruction algorithms, and more personalized image acquisition protocols," Dr. O'Connor and Dr. Hatabu write. "Diagnostic modalities without radiation exposure, such as magnetic resonance imaging and ultrasonography, may be able to be substituted for some CT scans."

Amy Berrington de Gonzalez, from the National Cancer Institute in Bethesda, Maryland, questioned whether warning systems could alter the use of imaging modalities. "In some HMOs, they started using warning messages when a physician ordered an imaging procedure that involved ionizing radiation after concerns were raised about the increasing levels of use," Dr. Berrington de Gonzalez told Medscape Medical News by email. "It would be worth investigating further whether these warnings may have impacted the levels of use."

Dr. Hatabu received research grant support from Toshiba Medical, Canon, and AZE. The remaining authors and commentators have disclosed no relevant financial relationships.

JAMA. 2012;307:2400-2409.

    
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