Geographical variations in the use of outpatient diagnostic imaging in Norway 2019.

BACKGROUND: Geographical variations in the use of outpatient imaging can reveal inappropriate use of radiological services. Knowledge about these variations is crucial in the strive for appropriate and improved services. PURPOSE: To investigate the geographical variations in outpatient diagnostic imaging and analyze variations for main groups of examinations and for specific examinations. MATERIAL AND METHODS: Data on outpatient radiological procedures registered at the Norwegian Health Economics Administration in Norway for 2019 were accessed with county-based population rates for age adjustment accessed through Statistics Norway. Age-adjusted rates were used to calculate high/low ratios, means, standard deviations, and coefficients of variation were calculated per 10,000 inhabitants. RESULTS: There is high geographical variation for PET/CT and PET/MRI and moderate variation for neuroradiological outpatient examinations in Norway in 2019. Variations for the musculoskeletal systems and of thorax, abdomen, and vessels are almost 50%. We find high high-to-low ratios in CT-face (9.7), MRI-elbow joint (8.5), CT of the neck, thorax, abdomen, and pelvis (6.5) as well as MRI-prostate (6.2). Comparing with data from 2012-5, we find a reduction in variation for some examinations, such as MRI of the hip and MRI of the entire spine, and an increase in variations for others, such as CT of the face and MRI of the elbow joint. CONCLUSION: Despite much attention to the problem, we demonstrate substantial variations in radiological services in Norway raising concern with respect to appropriateness, quality of care, equity, and justice. The findings provide important input for quality improvement in radiological services.

Impact on radiological practice of active guideline implementation of musculoskeletal guideline, as measured over a 12-month period.

BACKGROUND: An ever-increasing technological development in the field of radiology urges a need for guidelines to provide predictable and just health services. A musculoskeletal guideline was developed in Norway in 2014, without active implementation. PURPOSE: To investigate the impact of active guideline implementation on the use of musculoskeletal diagnostic imaging most frequently encountered in general practice (pain in the neck, shoulders, lower back, and knees). MATERIAL AND METHODS: The total number of outpatient radiological examinations across modalities registered at the Norwegian Health Economics Administration between January 2013 and February 2019 was assessed using an interrupted time series design. RESULTS: A 12% reduction in the total examination of Magnetic Resonance Imaging shoulder and knee, and x-ray lower back and shoulder was found at a significant level (p = 0.05). Stratified analysis (Magnetic Resonance Imaging examination as one group and x-ray examinations as the other) showed that this reduction mainly was due to the reduction in the use of Magnetic Resonance Imaging examinations (shoulder and knee) which was reduced by 24% at a significant level (p = 0.002), while x-ray examinations had no significant level change (p = 0.71). No other statistically significant changes were found. CONCLUSION: The impact of the implementation on the use of imaging of the neck, shoulder, lower back, and knee is uncertain. Significant reductions were demonstrated in the use of some examinations in the intervention county, but similar effects were not seen when including a control group in the analysis. This indicates a diffusion of the implementation, or other interventions or events that affected both counties and occurred in the intervention period.

The ethics of neuromodulation for anorexia nervosa: a focus on rTMS.

OBJECTIVE: Recently there has been emerging clinical and research interest in the application of deep brain stimulation (DBS) and repetitive transcranial magnetic stimulation (rTMS) to the treatment of anorexia nervosa (AN). To our knowledge, few studies have discussed ethical aspects associated with the increased use of neuromodulation in AN, some of which are quite specific to AN, despite the rapid development and dissemination of these new technologies. METHOD: We provide a brief overview of three published rTMS studies for AN and discuss ethical issues involved in the use of neuromodulation for AN. RESULTS: In contrast to neurosurgery or DBS, rTMS is a less invasive technique, with less associated risk, and thus has greater potential to become a more widespread augmentation or add-on therapy for AN. New therapeutic procedures are promising, yet they raise ethical questions regarding informed consent and patient selection. Illness-specific issues surrounding authenticity and autonomy are important to consider, ensuring an ethical approach to treatment for patients with AN. DISCUSSION: We argue that ethical investigations for neuromodulation techniques are timely and important, and discussions should go beyond the immediate goals of patient safety, consent, and risk and benefit, to consider broader ethical concepts such as authenticity and autonomy.

How does kidney transplantation affect the relationship between donor and recipient?

BACKGROUND: There is now a widespread use of kidneys from living donors in Norway. This results in reduced mortality and disease among recipients compared with the use of kidneys from deceased donors. However, there are numerous ethical issues connected with the use of organs from living donors. This article aims to examine how the relationship between recipients and known, living donors is affected by transplantation. MATERIAL AND METHODS: The article is based on a systematic literature search in MedLine. RESULTS: There is little research concerning the direct impact on the relationship between donor and recipient. Most donors report having an improved, or equally good relationship with recipients after transplantation. However, one study shows that when recipients receive a kidney from a parent during adolescence, conflicts frequently arise. The material also shows that good relationships have a tendency to improve, while poor or imbalanced relationships more often deteriorate following transplantation. INTERPRETATION: It is very important to survey the relationship between a recipient and a potential donor before transplantation to avoid relational conflicts.

Commercialization of organs.

The traders are on their way. We should allow the sale of organs. A strictly regulated market for organs can ensure a fair distribution of organs and proper treatment of the donor. Is this true?

Does oral infection cause cardiovascular disease? Oral and moral challenges.

OBJECTIVES: To address three questions: (i) does oral infection cause cardiovascular disease (CVD)? (ii) what kind of uncertainty is there in the relationship between oral infection and CVD? and (iii) how do we handle this uncertainty in practice: what should we do? METHODS: Conceptual analysis with basis in standard methods in philosophy of science and ethics. In particular, the study refers to theories of causality and uncertainty, as well as decision making theory. RESULTS: Whether oral infections cause CVD deeply depends on what we mean by causality. An investigation of the most prominent conceptions of causality suggests that it is far from obvious that oral infection causes CVD. A further analysis reveals that uncertainty occurs as risk, specific uncertainty, ignorance, and indeterminacy, which has implications for how we should handle oral infections. One option is to apply the precautionary principle. Another option is to attribute a cause owing to the strong social commitment to prevent CVD. CONCLUSIONS: A conceptual analysis shows that it is not obvious that oral infections cause CVD and that the question of causality does not only involve descriptive issues of science but also moral matters of society. Hence, whether oral infections cause CVD is an ethical and not only a scientific issue.

What causes increasing and unnecessary use of radiological investigations? A survey of radiologists' perceptions.

BACKGROUND: Growth in use and overuse of diagnostic imaging significantly impacts the quality and costs of health care services. What are the modifiable factors for increasing and unnecessary use of radiological services? Various factors have been identified, but little is known about their relative impact. Radiologists hold key positions for providing such knowledge. Therefore the purpose of this study was to obtain radiologists' perspective on the causes of increasing and unnecessary use of radiological investigations. METHODS: In a mailed questionnaire radiologist members of the Norwegian Medical Association were asked to rate potential causes of increased investigation volume (fifteen items) and unnecessary investigations (six items), using five-point-scales. Responses were analysed by using summary statistics and Factor Analysis. Associations between variables were determined using Students' t-test, Spearman rank correlation and Chi-Square tests. RESULTS: The response rate was 70% (374/537). The highest rated causes of increasing use of radiological investigations were: a) new radiological technology, b) peoples' demands, c) clinicians' intolerance for uncertainty, d) expanded clinical indications, and e) availability. 'Over-investigation' and 'insufficient referral information' were reported the most frequent causes of unnecessary investigations. Correlations between causes of increasing and unnecessary radiology use were identified. CONCLUSION: In order to manage the growth in radiological imaging and curtail inappropriate investigations, the study findings point to measures that influence the supply and demand of services, specifically to support the decision-making process of physicians.