Appropriateness of Imaging in Canada

During my fellowship training at a large academic centre in the United States, I (J.F.) remember being amused at a Nike logo sticker that had been placed on the computed tomography (CT)multiviewer that read ‘‘Just do it.’’When I asked one of the radiology residents about the logo, he informedme that, because the department had purchased 4 new state-of-the-art CT scanners, this had become the department’s unwritten motto. Residents were not to ask too many questions about the indications for studies or give any resistance with the justification that it was better for patients to get the studies performed and interpreted correctly than to go to the competition down the street where the quality of the work was questionable. In case after case, I struggledwith the dubious indications for these high-cost CTandmagnetic resonance imaging (MRI) examinations, most of which would be laughable in our resource-limited Canadian context. This experience definitely tainted my views regarding the appropriate use of imaging resources in the very competitive environment of the United States, but I often wonder, what do we really know about appropriateness in Canada, and can we be certain of the rate of inappropriate imaging? In a timewhen financial pressures on governments are at an all time high, it is not surprising that all aspects of health care spending are under intense scrutiny. The Canadian Institute of Health Information reports that, between 2010 and 2011, 1.6 million MRIs and 4.3 million CTs were performed on Canadian patients [1]. Annual operating costs for imaging alone are estimated to exceed $2.2 billion [2].With these large numbers, elimination of even a small percentage of inappropriate examinations could significantly impact the cost-effectiveness of the delivery of imaging services in Canada. In addition, we know that the most appropriate imaging examination provided at the most appropriate time can save costs in unnecessary additional investigations, shorten hospitalizations, and reduce the need for costly invasive procedures. It is no wonder that there is great interest in this topic by governments and health economists. Cost-effectiveness, however, cannot be the only consideration; quality and patient safety are also important factors related to the appropriate use of imaging resources. An imaging examination can be deemed inappropriate for a number of reasons, including its inability to contribute to patient management, the performance of an examination at the wrong time, or failure to obtain imaging when it is indicated. There are several reasons why referring physicians order inappropriate or unnecessary examinations [3]. Because of the rapid advances in the techniques of diagnostic imaging, it is difficult