Imaging More Wisely-Already At Work-Reply.

Letters (ARIC) cohort (adjusted hazard ratio [HR], 1.33; 95% CI, 1.01- 1.74) and Geisinger Health System (adjusted HR, 1.12; 95% CI, 1.06-1.17). Excluding baseline estimated glomerular filtration rate from the adjusted model also demonstrated similar results in both cohorts (ARIC: adjusted HR, 1.50; 95% CI, 1.15-1.96; and Geisinger Health System: adjusted HR, 1.20; 95% CI, 1.15-1.26). Thus, we believe that the conclusions of our study 1 remain unchanged. Poesen et al and Fusaro et al present plausible hypotheses of potential mechanisms that may explain the observed association between PPI use and CKD. We welcome further research investigating these hypotheses. Bibb Allen Jr, MD Author Affiliation: Grandview Medical Center, Birmingham, Alabama. Corresponding Author: Bibb Allen, Jr, MD, Department Of Radiology, Grandview Medical Center, 3690 Grandview Pkwy, Birmingham, AL 35243 (bibb@mac.com). Conflict of Interest Disclosures: None reported. Benjamin Lazarus, MBBS Josef Coresh, MD, PhD Morgan E. Grams, MD, PhD 1. Smith-Bindman R, Bindman AB. Imaging more wisely. JAMA Intern Med. Author Affiliations: Department of Epidemiology, Johns Hopkins University, Baltimore, Maryland (Lazarus, Coresh, Grams); Division of Medicine, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia (Lazarus); Department of Medicine, Johns Hopkins University, Baltimore, Maryland (Coresh, Grams). Corresponding Author: Morgan Grams, MD, PhD, Department of Medicine, Johns Hopkins University, 2024 E. Monument St, Baltimore, MD, 21205 (mgrams2@jhmi.edu). Conflict of Interest Disclosures: None reported. 2. Harvey L. Neiman Health Policy Institute Neiman Almanac. CMS Physician/Supplier Procedure Summary Master File. http://www.neimanhpi.org /almanac/series-select/#category-25. Accessed January 5, 2016. 3. Institute for Clinical Systems Improvement. Decision Support for Ordering Appropriate High-Tech. Diagnostic Imaging Scans at the Point-of-Order. http: //cdn.medicexchange.com/images/whitepaper/icsi%20decision%20support %20white%20paper%202010.pdf. Accessed January 5, 2016. 4. Sistrom CL, Dang PA, Weilburg JB, Dreyer KJ, Rosenthal DI, Thrall JH. Effect of computerized order entry with integrated decision support on the growth of outpatient procedure volumes: seven-year time series analysis. Radiology. 1. Lazarus B, Chen Y, Wilson FP, et al. Proton pump inhibitor use and the risk of chronic kidney disease. JAMA Intern Med. 2016;176(2):238-246. 5. American College of Radiology (ACR) Appropriateness Criteria. Sinonasal Disease. Updated 2012. http://www.acr.org/~/media/ACR/Documents /AppCriteria/Diagnostic/SinonasalDisease.pdf. Accessed January 5, 2016. Imaging More Wisely—Already At Work 6. MITA Smart Initiative. MITA Smart Dose CT. http://www.medicalimaging.org /policy-and-positions/mita-smart-dose. Accessed January 5, 2016. To the Editor The American College of Radiology (ACR) has for decades worked to reduce unwarranted imaging and lower ra- diation dose. We wish to update the information in a recent editorial by Smith-Bindman and Bindman. 1 The reference cited on growth of computed tomography (CT) use includes data only through 2010. Since 2010, Medi- care CT use is actually down overall in the outpatient, inpa- tient, and office settings. 2 Institute for Clinical Systems Improvement 3 and Partners Healthcare 4 studies have proven that appropriateness criteria-based clinical decision support (CDS) reduces imaging growth, radiation exposure, and costs. The ACR Appropriateness Criteria are evidence-based, in- corporating more than 6000 scientific references, most from nonradiology journals, and the criteria are also constantly up- dated. The ACR criteria for imaging in Acute Sinonasal Disease 5 care states that most of these patients do not need imaging. The 5 rating for CT would apply only if the imaging provider felt atypical factors compelled them to consider the exam. The Protecting Access to Medicare Act that will require Medicare imaging providers to consult CDS systems now re- quires that most CT scans be performed on scanners that meet the MITA Smart Dose standard. 6 The ACR Dose Index Registry enables dose optimization by allowing facilities to compare their dose levels with other facilities’ and national benchmarks. The cost for registry participation is typically less than $500 per scanner, and national average doses for each examination are publicly available. The Image Wisely and Image Gently initiatives that predate Choosing Wisely by 2 and 5 years, respectively, have raised aware- ness and provided materials to help imaging providers optimize dose; the ACR proudly participates in Choosing Wisely, whose recommendations closely follow ACR appropriateness criteria. Physicians and patients need up-to-date information to optimize the discussion of imaging benefit vs risk. Policy makers need this information to work with imaging provid- ers to create effective medical imaging policies. In Reply We are pleased that the American College of Radiology (ACR) “has worked for decades” to reduce unwarranted imaging and lower radiation dose, but given the substantial rise in unnec- essary tests, 1,2 and the dramatic variation in the radiation doses used in performing them even when patients are evaluated for the same clinical questions, 3,4 it appears that the ACR’s strategy is not working. Perhaps the problem would be even worse with- out the efforts of the ACR, but the current situation cannot be con- sidered acceptable. An independent assessment of the ACR’s ap- propriateness criteria determined that they had no effect on the use of imaging or the appropriateness of imaging when tested among more than 3900 imaging providers across 8 states. 5 This finding is consistent with what has been found in many other as- pects of clinical care. Voluntary guidelines are a weak lever to change physician practice behavior 6 especially if the guidelines are not based on clear and convincing evidence 7 or if they rely upon biased evidence or evidence perceived to be biased. 8 We applaud the ACRs engagement with the issue of un- necessary imaging and excessive radiation doses, but if these efforts are to become more than window dressing they need to be aligned and refined by evidence, and their effects need to be assessed by independent researchers. As was reflected in the title of our editorial, we believe that existing evidence is not being used to ensure the wisest recommendations about when to use imaging. Rebecca Smith-Bindman, MD Andrew B. Bindman, MD JAMA Internal Medicine June 2016 Volume 176, Number 6 (Reprinted) jamainternalmedicine.com Copyright 2016 American Medical Association. All rights reserved. Downloaded From: http://jamanetwork.com/pdfaccess.ashx?url=/data/journals/intemed/935316/ by a UCSF LIBRARY User on 04/27/2017