The creation of the Ottawa Ankle Rules, a milestone in Canadian medicare, began with a simple question: Why were X-rays being performed on nearly every patient who hobbled into a hospital’s emergency department with a swollen ankle?
Many of the scans were a waste of time and money, detecting no fracture. The number of ankle X-rays could be cut dramatically, Ottawa doctor Ian Stiell concluded, if emergency physicians followed a few basic guidelines, such as checking for bone tenderness and whether patients could walk four steps.
These simple rules, crafted two decades ago and now posted in hospitals worldwide, have transformed how doctors deal with ankle pain, but in many other areas of medicine, the astronomical growth of diagnostic testing – some of it unnecessary or questionable – remains a significant challenge for Canada’s financially strained health system. A 15-member expert panel in cash-strapped Ontario is reviewing how exams such as X-rays, ultrasounds and MRIs are handled and whether testing facilities outside hospitals should be required to have some kind of accreditation.
The panel was assembled after the government put on hold a controversial plan to halve fees paid to doctors who order tests for patients at their own clinics, known as self-referral.
Ontario doesn’t regulate self-referral exams, but most other provinces do, deeming them a potential conflict of interest. Ontario Health Minister Deb Matthews contends that studies show physicians who have a financial interest in testing equipment are much more likely to order exams, some unnecessarily. But many medical specialists say the 50-per-cent payment reduction is not the solution, warning the proposed cut would drive up wait times, hurt patient care and prompt some doctors to ditch their diagnostic machines. The debate is heated, but data on unnecessary testing is hard to come by. The studies Ontario and others cite focus mainly on the United States.
The Canadian Association of Radiologists estimated in 2009 that as many as 30 per cent of CT scans and other imaging procedures were inappropriate or contributed no useful information. At the same time, the growth of diagnostic tests has been substantial, in part because technology and medicine have improved, more machines are available, and patients are asking for tests they’ve read about on the Internet. Last year, Canadians had 1.6 million MRI exams and 4.3 million CT tests, nearly double the number performed in 2003, according to the Canadian Institute for Health Information.
“Utilization of services has gone up significantly, but health outcomes haven’t really changed that much,” noted John Abbott, chief executive officer of the Health Council of Canada, an advisory body created by the federal and provincial governments. “That then draws you back to that question, ‘Well, are all of these services appropriate in the first instance?’”
The Canadian Association of Radiologists recently updated its test-referral guidelines, but changing practices in a vast health system that varies from province to province is not easy. James Fraser, the association’s president and a cardiac radiologist in Nova Scotia, believes the guidelines – which help address the issue of unnecessary testing – would be followed more closely if they were part of an electronic test-ordering system all doctors were required to use.
“The biggest problem has been putting [the guidelines] in place so that it’s easy for the referring physician to use them on a day-to-day basis,” Dr. Fraser said. “We haven’t really been able to get the provinces or the authorities to invest into that infrastructure to make that happen.”
In many parts of Ontario, particularly in small communities, diagnostic and imaging clinics established by doctors have greatly reduced wait times for vital tests and hastened treatment. Under the proposed changes unveiled in May, specialists would be required to send patients back to their family doctor to get the exam order if they want to get full payment for a test. If this step is skipped, the specialist would receive only half the payment.
Physicians opposed to the cut argue that requiring family doctors to order exams in cases where ongoing monitoring is needed will add costs to the health system and burden patients. Consider high-risk pregnancies, which often involve women with low incomes or serious medical conditions such as diabetes. The extra doctor appointments could deter them from getting the care they need, noted Jon Barrett, head of maternal fetal medicine at Sunnybrook Health Sciences Centre in Toronto.
“Think of the cost, and the transfer and the travel of somebody taking time off work,” Dr. Barrett said. “They’ve got to go see another doctor to come back again for an ultrasound. It just doesn’t make any sense in our situation.”
Dr. Barrett and seven other heads of maternal fetal medicine at hospitals from Windsor to Ottawa have come together to ask the expert panel and the province to exclude their group from self-referral rules. The panel is expected to complete its review by the end of September, reporting its recommendations to the health minister.