Overdiagnosis and overimaging: an ethical issue for radiological protection.

AIMS AND OBJECTIVES: This study aimed to analyse the key factors that influence the overimaging using X-ray such as self-referral, defensive medicine and duplicate imaging studies and to emphasize the ethical problem that derives from it. MATERIALS AND METHODS: In this study, we focused on the more frequent sources of overdiagnosis such as the total-body CT, proposed in the form of screening in both public and private sector, the choice of the most sensitive test for each pathology such as pulmonary embolism, ultrasound investigations mostly of the thyroid and of the prostate and MR examinations, especially of the musculoskeletal system. RESULTS: The direct follow of overdiagnosis and overimaging is the increase in the risk of contrast media infusion, radiant damage, and costs in the worldwide healthcare system. The theme of the costs of overdiagnosis is strongly related to inappropriate or poorly appropriate imaging examination. CONCLUSIONS: We underline the ethical imperatives of trust and right conduct, because the major ethical problems in radiology emerge in the justification of medical exposures of patients in the practice. A close cooperation and collaboration across all the physicians responsible for patient care in requiring imaging examination is also important, balancing possible ionizing radiation disadvantages and patient benefits in terms of care.

Ethics in the Legal and Business Practices of Radiation Oncology.

Ethical issues arise when a professional endeavor such as medicine, which seeks to place the well-being of others over the self-interest of the practitioner, meets granular business and legal decisions involved in making a livelihood out of a professional calling. The use of restrictive covenants, involvement in self-referral patterns, and maintaining appropriate comity among physicians while engaged in the marketplace are common challenges in radiation oncology practice. A paradigm of analysis is presented to help navigate these management challenges.

[Conflicts of interest in nephrology]. / Conflictos de intereses en nefrología.

Since doctors disposed of effective tools to serve their patients, they had to worry about the proper management of available resources and how to deal with the relationship with the industry that provides such resources. In this relation-ship, health professionals may be involved in conflicts of interest that they need to acknowledge and learn how to handle. This article discusses the conflicts of interest in nephrology. Its objectives are to identify those areas where such conflicts could occur; to help to solve them, always considering the best interest of patients; and to help health workers to keep in mind that they have to preserve their autonomy and professional integrity. Conflicts of interest of professionals in the renal area and related scientific societies, with the industry producing equipment, supplies and drugs are reviewed. Dichotomy, payment for referral, self-referral of patients and incentives for cost control are analyzed. Finally, recommendations to help preserve a good practice in nephrology are made.

Conflictos de intereses en nefrología / Conflicts of interest in nephrology

Since doctors disposed of effective tools to serve their patients, they had to worry about the proper management of available resources and how to deal with the relationship with the industry that provides such resources. In this relation­ship, health professionals may be involved in conflicts of interest that they need to acknowledge and learn how to handle. This article discusses the conflicts of interest in nephrology. Its objectives are to identify those areas where such conflicts could occur; to help to solve them, always considering the best interest of patients; and to help health workers to keep in mind that they have to preserve their autonomy and professional integrity. Conflicts of interest of professionals in the renal area and related scientific societies, with the industry producing equipment, supplies and drugs are reviewed. Dichotomy, payment for referral, self-referral of patients and incentives for cost control are analyzed. Finally, recommendations to help preserve a good practice in nephrology are made.

The Maryland self-referral law: history and implications.

Many previous studies have shown that nonradiologist physicians who can refer advanced MRI and CT examinations to themselves or within their practices use these modalities at a much higher rate than those who refer their examinations to unaffiliated radiology facilities. This led Maryland to pass a unique self-referral law in 1993 to directly address self-referred advanced imaging. The authors discuss the politics and economics of self-referral and provide a comprehensive review of the creation, progression, and impact of this landmark law.

Effect of financial relationships on the behaviors of health care professionals: a review of the evidence.

This paper explores the empirical evidence regarding the impact financial relationships on the behavior of health care providers, specifically, physicians. We identify and synthesize peer-reviewed data addressing whether financial incentives are causally related to patient outcomes and health care costs. We cover three main areas where financial conflicts of interest arise and may have an observable relationship to health care practices: (1) physicians' roles as self-referrers, (2) insurance reimbursement schemes that create incentives for certain clinical choices over others, and (3) financial relationships between physicians and the drug and device industries. We found a well-developed scientific literature consisting of dozens of empirical studies, some that allow stronger causal inferences than others, but which altogether show that such financial conflicts of interests can, and sometimes do, impact physicians' clinical decisions. Further research is warranted to document the causal relationship of such changes on health outcomes and the cost of care, but the current base of evidence is sufficiently robust to motivate policy reform.

A medical student perspective on self-referral and overutilization in radiology: application of the four core principles of medical ethics.

There is contention within the medical community surrounding imaging self-referral, in which providers refer patients to imaging facilities from which they receive financial returns. Controversy surrounds the assertion that self-referral leads to overutilization, or the application of imaging resources and services in situations in which patients are unlikely to benefit. Proponents of self-referral claim that the practice provides increased convenience, timelier diagnosis, more expeditious treatment, and decreased cost, while opponents believe that the practice results in the inappropriate ordering of unnecessary imaging studies. Given the importance of this subject and the magnitude of its potential economic impact, it is important to restore objectivity. The 4 core principles of medical ethics--autonomy, nonmaleficence, beneficence, and justice--represent a useful and well-established paradigm. This review article addresses the question of whether self-referral upholds these 4 principles and thus whether it is an ethical practice.

The Stark Law in retrospect.

Considering the ultimate goals of preventing the over-utilization of medical services and protecting the Medicare program, are the numerous phases of the Stark Law and their concomitant regulations effective; or, conversely, has the legislation served to impede entrepreneurialism among physicians to the detriment of innovations and better integration in the delivery of medical treatment? This article endeavors to answer the above question through an analysis of the policy goals behind the legislation; the evolution of its regulations; its effect on competitiveness in the field of medicine; and the ethical considerations implicated by the issue of physician self-referral. It further offers some proposals which attempt to address the problem of physician self-referral abuse while at the same time reducing the complexity and breadth of the Stark law and its regulations. The article concludes by noting that to truly change the practice of inappropriate self-referral as well as the culture of over-utilization, it is necessary not only to target specific relationships and practices prone to abuse, but to realign the financial incentives created by our current payment mechanisms as well.

Laboratory test ordering at physician offices with and without on-site laboratories.

BACKGROUND: Physician self-referral, ordering a test or procedure or referring to a facility in which a physician has a financial interest, has been associated with increased utilization of health care services. OBJECTIVE: To examine the association between on-site laboratories and laboratory test ordering among visits to group-practice physicians. DESIGN: Cross-sectional study using data from the 2005 and 2006 National Ambulatory Medical Care Surveys. STUDY POPULATION: Visits by adults to non-federally-funded, non-hospital-based group practices. Primary analyses focused on visits to physician owners; secondary analyses focused on visits to non-owners. MAIN MEASURES: Ordering of five laboratory tests: complete blood count (CBC), electrolytes, glycoslyated hemoglobin A1c (HbA1c), cholesterol, and prostate-specific antigen (PSA). KEY RESULTS: There were 19,163 visits to group-practice owners with 51.9% to a practice with an on-site laboratory. Visits to primary care physicians were more likely to be to a practice with an on-site laboratory when compared with visits to specialists (64.4% vs. 34.0%, p < 0.001). Among visits to specialist group owners, all five tests were ordered more often if there was an on-site laboratory, even after accounting for patient and practice characteristics: CBC: adjusted odds ratio[OR] = 8.01, 95% Confidence Interval [CI], 5.00-12.82, p < 0.001; electrolytes: aOR = 3.51, 95% CI, 1.93-6.40, p < 0.001; HbA1c: aOR = 4.91, 95% CI, 1.75-13.78, p = 0.003; cholesterol: aOR = 3.32, 95% CI, 1.85-5.93, p < 0.001; and PSA: aOR = 3.84, 95% CI, 1.93-7.65, p < 0.001. This association was not found among visits to primary care physician owners and all practice non-owners (both primary care and specialists). The estimated excess spending on these five tests by specialist owners with on-site laboratories was $75 million per 100 million visits. CONCLUSIONS: In a nationally representative sample of visits to physician-owned group practices, specialist owners with on-site laboratories were more likely to order five common laboratory tests, potentially resulting in millions in excess healthcare spending.