Neuroimaging overuse is more common in Medicare compared with the VA

We thank Drs. Johnston and Sartwelle for the continued discussion related to our article. [1]

The application of any test, in any context, requires consideration of how often it leads to false positives, true positives, and the benefits and harms of each. If imaging studies never led to harm, universal imaging would be warranted; everybody would have an MRI of the brain and a full-body MRI too. It is dangerous to assume that the risks of false-positive results after imaging in patients with migraine is zero. While, undoubtedly, many false positive MRIs in patients with migraine do not lead to harm, it is a major leap of faith to assume that this is universally the case. When true positives are exceedingly rare and false positives vastly outnumber them, the theoretical benefits of imaging rapidly evaporate if even a small fraction of false positives lead to harm. If our goal is to first do no harm, then it's hard to argue that wider use of neuroimaging in migraine is warranted without high-quality evidence regarding the potential harms of imaging given how infrequently imaging leads to important changes in clinical management.

1. Burke JF, Kerr EA, McCammon RJ, et al. Neuroimaging overuse is more common in Medicare compared with the VA. Neurology 2016;87:792-798.

For disclosures, please contact the editorial office at [email protected].

We strongly encourage Drs. Burke and Callaghan to reread our comment since it has nothing to do with the number of lawsuits filed, but the number of patients harmed (and claims made and settled before a suit is filed) due to substandard care by the intransigent adherence to outdated guidelines. The recommendation by Burke et al. [1] to limit neuroimaging based on these flawed guidelines is contrary to an acceptable standard of care. There is no reason to fear incidental findings on neuroimaging since these often warrant further evaluation (e.g. stroke), continued monitoring (e.g. aneurysm), or treatment (e.g. arachnoid cyst). Failure to offer patients the option of neuroimaging disregards the ethical mandate of providing informed consent. We hope most neurologists recognize that following outdated flawed guidelines, whether for headache or any other condition, does not translate to "using the best evidence," and will not provide "the best patient outcomes."

1. Burke JF, Kerr EA, McCammon RJ, et al. Neuroimaging overuse is more common in Medicare compared with the VA. Neurology 2016;87:792-798.

For disclosures, please contact the editorial office at [email protected].

Drs. Johnston and Sartwelle's argument that more imaging is needed because misdiagnosis of headache is "the most common diagnostic error" leading to neurology lawsuits is unfounded. Neurologists see 10 million headache visits per year and approximately 0.0005% result in lawsuits. [2-4] Misdiagnoses in headache patients are common causes of lawsuits because headache is ubiquitous and even the best medicine is imperfect, not because neurologists fail to image. If all headache patients were imaged, for every malignant brain tumor diagnosed marginally earlier, more than 100 false positives would be exposed to harm from downstream tests and procedures. Malpractice claims are extremely limited measures of quality of care. [5,6] We should not substitute the logic of courts for evidence based medicine. The 1:200,000 risk of being sued for medical malpractice by using the best evidence to get the best patient outcomes is easily justifiable.

1. Burke JF, Kerr EA, McCammon RJ, et al. Neuroimaging overuse is more common in Medicare compared with the VA. Neurology 2016;87:792-798.

2. Callaghan BC, Kerber KA, Pace RJ, et al. Headache neuroimaging: Routine testing when guidelines recommend against them. Cephalalgia 2015;35:1144-1152.

3. Jena AB, Seabury S, Lakdawalla D, Chandra A. Malpractice Risk According to Physician Specialty. N Engl J Med 2011;365:629-636.

4. Physician Insurers Association of America Neurology Study. In: PIAA Neurology Claims [online]. PIAA; 2004:1-38. Available at: http://vns.aan.com/media/neurology_report_2004.pdf. Accessed September 15, 2016.

5. Localio AR, Lawthers AG, Brennan TA, et al. Relation between malpractice claims and adverse events due to negligence. Results of the Harvard Medical Practice Study III. N Engl J Med 1991;325:245-251.

6. Brennan TA, Localio AR, Leape LL, et al. Identification of adverse events occurring during hospitalization. A cross-sectional study of litigation, quality assurance, and medical records at two teaching hospitals. Ann Intern Med 1990;112:221-226.

For disclosures, please contact the editorial office at [email protected].

In their article, Burke et al. state, "neuroimaging overuse appears to be high in both... populations." [1] This statement, as related to headache, is based on a retrospective analysis with the definition of overuse predicated on the United States Headache Consortium Guidelines which recommended that neuroimaging is not warranted for patients with migraine and a normal neurological examination. [2] These guidelines, in relation to migraine, stem from a meta-analysis of 11 outdated studies with serious methodological flaws underestimating the incidence of intracranial abnormalities in migraine patients with a normal examination. [3,4] Thus, the authors' conclusion that "inappropriate neuroimaging for headache... is relatively common" is simply untenable, and promoting "interventions to curb overutilization" represents a misguided approach that should be avoided until further research delineates relevant guidelines that properly "correlate intracranial abnormalities with individual patient data, headache patterns, underlying diseases, associated conditions, imaging protocols, and related factors." [4] Blind adherence to outdated data remains detrimental to patient care, increases physician liability, and ensures that misdiagnosis of headache will continue its reign as the most common diagnostic error in neurology, leading to increasingly expensive jury verdicts and settlements against unsuspecting neurologists following flawed guidelines.

1. Burke JF, Kerr EA, McCammon RJ, et al. Neuroimaging overuse is more common in Medicare compared with the VA. Neurology 2016;87:792-798.

2. Silberstein SD. Practice parameter: evidence-based guidelines for migraine headache (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2000;55:754-762.

3. Evans RW, Johnston JC. Migraine and medical malpractice. Headache 2011;51:434-440.

4. Johnston JC, Wester K, Sartwelle TP. Neurological Fallacies Leading to Malpractice: A Case Studies Approach. Neurol Clin 2016;34:747-773.

For disclosures, please contact the editorial office at [email protected].