A new study cautions that people undergoing a full-body computed tomography (CT) scan in order to find tumors and other disease as early as possible may be raising their risk for getting cancer. According to findings published in the September issue of the journal Radiology, the radiation from a full-body CT scan can be similar to that experienced by victims of the atomic bombs dropped during World War II. The radiation from one scan is equal to roughly 100 mammograms. "The radiation dose from a full-body CT scan is comparable to the doses received by some of the atomic-bomb survivors from Hiroshima and Nagasaki, where there is clear evidence of increased cancer risk," said David Brenner, PhD, co-author of the study and director of the Center for Radiological Research at Columbia University (New York).

CT, also called computerized axial tomography scanning, involves collecting a series of X-rays. Computer software and multiple angles produce a higher-quality cross-sectional images than a traditional flat X-ray. But since these procedures use X-ray, the scans differ from magnetic resonance imaging scans, which do not expose the body to radiation.

A 45-year-old person who gets one full-body CT scan would have a lifetime cancer death risk of about 0.08%, which would produce a cancer-related death in one in 1,200 people, the researchers estimated. But another 45-year-old who has annual full-body CT scans for 30 years would accrue a lifetime cancer mortality risk of about 1.9%, or about a one-in-50 chance of dying of cancer, according to Brenner's findings. "That is comparable to your risk of dying in a road accident," he said. That risk may be worth it, however, for someone who knows he or she has a high probability of cancer, Brenner added.

According to figures released by Brenner and his colleagues, the risk from one CT scan increases your chance of dying of cancer by 0.08%. The risk, however, is cumulative. Brenner said young people are at the greatest risk since radiation-induced cancer takes a long time to develop. Older individuals are more likely to die from other causes during this period. In addition, the younger a person is, the greater the number of dividing cells he or she has because dividing cells are more sensitive to the effects of radiation. The study found that one scan exposes the patient to about 12 millisieverts of radiation. Atomic-bomb survivors in the low-dose range received 5 millisieverts-100 millisieverts and showed a statistically significant increase in risk of solid tumors, such as cancers of the lung and digestive system.

Elective CT scans are promoted as being able to find hidden diseases – such as cancer – at an early stage of development. Costs of the scans can range from $500 to $1,500. Most insurance companies refuse to cover the cost of an elective scan. An estimated 65 million CT scans are performed in the U.S. each year, though the total number of elective procedures is not known.

A separate study released in May by the Yale University School of Medicine (New Haven, Connecticut) found that only 7% of patients having a CT scan were informed about the possible risks and benefits of the procedure, and that patients, emergency department physicians and radiologists were "unable to provide accurate estimates of CT doses, regardless of their experience level."

According to the FDA, the benefit of whole-body CT screening is "currently uncertain." And the agency has said that the benefit may not be great enough to offset the potential harm such screening could cause. "For a person without symptoms, CT screening is unlikely to discover serious disease, and the potential harm to the individual may be greater than presumed benefit," the FDA said in a statement. The FDA has not approved, cleared or certified any CT system specifically for use in screening for people without symptoms. According to the agency, "no manufacturer has ever demonstrated to the FDA that their CT scanner is effective for screening for any disease or condition."

Organizations such as the American College of Radiology (ACR, Reston, Virginia), the American Association of Physicists in Medicine (College Park, Maryland), the American College of Cardiology (Bethesda, Maryland) and the American Heart Association (Dallas) all recommend against CT screenings.

In a statement posted on its web site, ACR said it does not believe there is sufficient evidence to justify recommending total body CT screening for patients with no symptoms or a family history suggesting disease. "To date, there is no evidence that total body CT screening is cost efficient or effective in prolonging life. In addition, the ACR is concerned that this procedure will lead to the discovery of numerous findings that will not ultimately affect patients' health but will result in unnecessary follow-up examinations and treatments and significant wasted expense."

Device useful in vacuum-assisted deliveries

The threat of medical malpractice suits resulting from injuries and deaths to babies during vacuum-assisted deliveries has both Canadian and U.S. physicians championing a new device that monitors the procedure. The Vacuum Birth Safeguard, or VacuLink, developed by Victor Vines, MD, of Medical City Hospital (Dallas), is an electronic gauge that can be incorporated into standard vacuum delivery devices producing real-time tracing of vacuum pressure to help physicians make critical decisions during delivery. "In the heat of an emergent situation, what seems like five minutes is actually one minute or what seems like five minutes might have actually been 10 or 15 minutes," Vines told The BBI Newsletter. "So what this device does is give the doctor and nurse an objective basis upon which to make decisions about either continuing or abandoning vacuum delivery."

The Canadian doctor who conducted a study of the VacuLink agreed the device provides a "useful tool" for accurately documenting vacuum-assisted deliveries. Dr. Tom Baskett, professor of obstetrics and gynecology at Dalhousie University (Halifax, Nova Scotia), told BBI that this device may help doctors and nurses avoid post-operative disputes about what occurred during vacuum-assisted births and when. "What this does is give you an objective measure that's right there. There's no arguing with it," he said.

Vines said he set about developing the device after he was asked to appear as an expert witness in a lawsuit four years ago. Prior to the scheduled court date, Vines found inconsistencies between the doctor's and nursing staff's medical notes and the appearance of the infant following vacuum-assisted delivery. What his review also showed him, he said, is that poor documentation during the procedure might enable doctors and nurses to demonstrate accountability for their decisions in the delivery room. "In this case, what became clear was that when you have a delivery with a bad outcome, there's the opportunity for the notes to be made to be whatever the doctor and nurse want them to be. That's because all of the vacuum monitoring, the vacuum documentation, is done in arrears, i.e., after the delivery is completed."

During vacuum-assisted deliveries, doctors must be aware of how long a vacuum cup has been attached to an infant's head and at what intensity, how many pulls have been administered to deliver the baby and how many times the vacuum cup pops off the head. Recording this information is critical to delivery outcome. Typically, fetal heart rate and uterine pressure are recorded as positive values on a millimeter scale from zero to 100 mm at the maternal-fetal monitors at bedside. Vacuum pressure, however, is negative pressure.

Study: Hospital billing practices causing crisis

Pricing practices are causing a healthcare crisis in the U.S., according to a report released last month by the California Nurses Association (CNA; Oakland). The second annual study, commissioned by CNA and compiled by the Institute for Health and Socio-Economic Policy (IHSP; Orinda, California), looked at pricing practices at more than 4,100 hospitals in the U.S. and argues that huge markups in charges to patients – especially for prescription drugs, medical supplies and surgeries – are "a major factor in exacerbating the nation's healthcare crisis and the pricing scandal that has prompted hearings, lawsuits and a growing public outcry." The report includes a listing of the 100 most expensive and least expensive hospitals, the top 10 most expensive hospitals by state, and the 40 hospitals that charge the most for operating room services, prescription drugs, and medical supplies.

Charles Idelson, spokesperson for CNA, told BBI that though his organization represents registered nurses, its goal is "to try to secure quality healthcare and access for everyone." Part of that process, he said, "is to understand the institutional barriers created by a market-driven healthcare system and how that impacts access to care and availability of quality care for everyone. As part of that process we began looking at the various factors that create the healthcare crisis. At the top of that list are the outrageous pricing practices of hospitals and the other components of the healthcare industry."

The study's findings are based on the list prices charged by hospitals. Typically, Medicare as well as HMOs and other large third-party payers will negotiate discounts on final payment. But high charges also prompt higher payments by Medicare and the other payers, a fact increasingly recognized in the current national debate on charges, according to CNA and IHSP. The list price, however, is the charge demanded of the uninsured, which the report cites as one reason for the widespread scrutiny and lawsuits over hospital billing practices.

Idelson said that hospitals in the U.S. are run as big business and not public-service institutions. "Their primary goal is not the provision of care but the accumulation of profits or net revenues," he said. According to the IHSP, the research is based on federal cost reports with aggregated data for over 30 million patient discharges in fiscal years 2002 and 2003, filed for all patient services and other financial categories. Overall, according to the study, the country's 100 most expensive hospitals marked up gross charges an average of 673% more than their costs. This means that a hospital in that category would charge $673 for a patient's case where the actual costs were $100.

The national average for all 4,184 hospitals surveyed was a 232% markup, a 13% increase in the national average from last year's IHSP report. The increase was even greater for the 100 most expensive hospitals, a 28% rise compared to figures released in 2003. According to the study results, among the highest markups were in what have become the major profit centers for hospitals – charges to patients or health plans for prescription drugs, medical supplies or operating room services.

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