Abstract
Several articles have, increasingly in recent years, discussed and questioned the increasing use of high-tech imaging (1). It has been used as an example of overuse of medical technology. I assure you, it isn’t. My honest opinion is that these articles have a “stop-the-world” philosophy, and are not based on factual data. The innovations and technological advances seen within imaging have given us more effective, more accurate, less harmful, and more accessible diagnostic procedures.
I shall remind older readers and enlighten younger readers of one of the most significant of many revolutions within radiology: the introduction of computed tomography (CT). When I started my radiology career, CTs were in common use. However, I’m old enough to have performed angiography to find traumatic hemorrhages in the liver and spleen. This was a method demanding on resources and with uncertainties. These diagnostic uncertainties would lead to surgery if in doubt. First, CT gave us possibilities of intracranial diagnoses not possible earlier, shortly after it replaced angiography for trauma and tumor diagnoses. So what? CT was better, faster, and a lot cheaper than performing angiograms. It was cheaper per examination and with fewer complications to the patient; in addition, it was easily accessible. If you get access to a better procedure that will give you more accurate diagnoses with fewer complications, then it will be used, and the overall use will thus increase (2,3). Should patients be denied access to better and less harmful examinations and treatment because the overall costs rises? The reality is that few new technologies come close to the CT with regard to added value to so many.
Healthcare costs
Costs for healthcare as a percentage of GDP.
A few examples of the expenditure for healthcare (OECD.Stat 2015).
It is difficult to find the exact share of costs induced by imaging. In most surveys and national statistics, it is combined with other areas, such as laboratories or pathology; this varies from one country to another. One Swedish health economist once said that all our radiology is paid for by increasing the level for treating high blood pressure with 5 mmHg, but I have not been able to confirm that. My analyses of national statistics in Scandinavia and the USA resulted in estimates of the costs for all radiology to be around 5% of total health costs in Scandinavia and 10% in the USA.
Computer technology and radiology
What has happened with the personal computer from approximately 1980 until today? Most readers will remember this evolution. Quite a lot of the development in radiology follows this. It may be characterized by describing the development of ultrasound. From compound scanners, where one wonders if anybody saw anything, to top notch scanners that had a cost of US$500,000 in the late 1990s, to better, simpler scanners costing less than US$100,000 today. It is now possible to buy reasonably good cheap ones for US$20,000. For magnetic resonance imaging (MRI) and CT it is approximately the same, more institutions having better and better equipment without paying more. You do recognize the development of computers, don’t you? What has happened with computers? From being a rather rare commodity, it is now common for everyone to have at least one computer. It is all a part of the same development: data equipment has been constantly developed as more have been sold, and with increasing production the price lowers and development increases. As computer technology represents such a large part of modern radiology equipment, the two are part of the same evolution.
With a price of US$20,000, a general practitioner may buy his own ultrasound equipment. He will then discover more real and false-positive disease, which will lead to higher use of CT and MRI in order to find the real positives, which then again will lead to more patients being in need of treatment. The latter is probably the most expensive part of this chain. The added value to the patients will, in the end, be better and earlier treatment. When one discusses high-tech medicine, such obvious associations are rarely mentioned.
The spiraling cost of medicine and spiraling use of modern imaging
With the exception of the USA the cost of medicine is not spiraling. Most European countries have costs representing 7–10% of their gross national budget, and it has been like this for quite a number of years (OECD.Stat, WHO Health statistics). The costs have risen, a lot, but so have most costs in our societies. We do most likely face a future increase in costs, but this will be a result of an aging population and a demand to take care of our elderly. As I have shown, the costs for healthcare have not really spiraled, neither has the use of radiology. It has partly been so in the USA (Table 1), but elsewhere it has risen with the new innovations giving new possibilities without large increases in costs. The use of modern radiology has increased every time we have received innovations improving diagnostic and interventional work; such as real-time ultrasonography, CT and later multi-detector CT, MRI and improvements in MRI, and improvements both in X-ray systems and catheter systems enhancing interventional radiology and minimal invasive therapy. This has given large groups of patients better medical treatment and often reduced the need for longer hospital stays and surgical procedures, thus reducing overall costs in the hospitals.
Overdiagnosis or overtreatment?
Several articles have raised a question on whether or not we have come too far in our technological development (1). And certainly, many have been concerned about the increased use of imaging (4,5). Does our modern technology lead to overdiagnosis as it is capable of finding pathology not in need of treatment? An example used in several articles is CT in detecting lung emboli (6): “The CT is capable of detecting lung emboli that would be better off not treated”. Read it again and think it through thoroughly, and most likely you’ll find that this statement is nonsense. First, it is not an overdiagnosis; it is a diagnosis, a diagnosis that will, with high accuracy, tell the clinician that the patient has an embolus, where it is, and the size of it. If the clinician then chooses to treat too many patients, it is overtreatment, but not overdiagnosis. Does anyone think that the clinicians would like to go back to a time with scintigraphy giving lower accuracy, pulmonary angiography with possibilities for complications, and CT not having any proper sensitivity for an embolus? The present CT is not only a better alternative, it is even cheaper than the alternatives.
The increased ability to detect even smaller tumors and metastases, given by CT, MRI, and PET-CT, has given the oncologists improved possibilities to monitor treatment. This symbiosis has led to a sort of spiraling costs, as controls come more frequent and changes in cancer therapy (with expensive drugs) become more frequent. It has also been a necessary part of the development of new cancer drugs. This has been the reason for better survival for large groups of cancer patients, and is an example of added value of technological development.
During the last 20 years, but especially during the last 5 years, several nations, societies, and hospitals have developed routines for appropriateness of diagnosis and treatment, as well as recommendations on proper procedures. These are overall routines to improve quality of care, but will inevitably see to that overtreatment are reduced.
Conclusion
We need more technology, not less, in order to improve medical treatment without increasing the costs. We need higher accuracy in our diagnostic work to avoid overtreatment and we need smart high-tech solutions to take care of our increasing number of older citizens. All we have seen of radiological development during the last 40–50 years indicates that new innovations in technology have given us better medical treatment for more patients given pretty much the same costs. The future with even better imaging and innovations in molecular imaging will probably give us smarter and more effective diagnostic imaging. This will probably lead to more accurate treatment with less complications and lower cost per procedure. It is difficult to predict the future, but if I shall have to try, I would guess that the increasing age of the population and the increasing demands of the younger will lead to more imaging.