CT overuse, length of stay dictated by hospital financing, Joanne Lynn, MD, on end-of-life care

January 7, 2016

In order to bring you more of the news you want to read, RightCare Weekly summarizes and interprets three important articles and provides headlines linking to the many other articles and editorials you’ll find interesting. As always, RightCare Weekly presents articles related to moving our healthcare system toward the right care for all patients.

Join the conversation: Post your comments in our section at the bottom of this page.




The use of computed tomography, or CT scans, in the United States has grown from 3 million in 1980 to more than 85 million in 2011, as many as half of which may be medically unnecessary, says the FDA. A piece in The Washington Post this week calls attention to risks associated with the ionizing radiation in CT scans, which can cause DNA damage and cancer. (MRIs and ultrasound do not involve radiation.) The $100 billion-a-year spent on CT scans is partly driven by patients who may not be aware of the risks and continue asking for what they believe is “cutting edge care.” While the debate regarding actual risks continues (one study says up to 2 percent of future cancers may be caused by CT scans), so too does a lack of standardization of how CTs should be used. There are no national standards for the techs who administer them, and some states don’t require they be licensed. Children undergoing CTs, may be particularly vulnerable.  Some specialists and surgeons require patients undergo CTs before a patient is seen. New Medicare rules may soon bring about the change that is needed, thanks to appropriateness criteria being developed by the American College of Radiology. Says Rebecca Smith-Bindman, MD, a professor of radiology at the University of California at San Francisco, “Radiology has become an enormous profit center [for hospitals]. The amount we get paid is very high.” For now, patients should ask questions when a CT is ordered, such as how the results will affect treatment and whether another imaging technology could be used in its place.


In 1980 the average length of a hospital stay was 7.3 days. Today it’s around 4.5. Austin Frakt, MD, in The New York Times this week says the decrease in length of stay is not necessarily because the average patient needs less time to recover. According to Frakt, “today’s patients are older and sicker.” Lengths of stay have decreased in large measure because of financial incentives that encourage hospitals to discharge patients as soon as possible. For example, Medicare implemented the Diagnosis-Related Group, or DRG, a system of classifying and paying for hospital cases that was introduced to rein in out-of-control Medicare spending on hospitalization. In the seventies and eighties, lengths of stay were often longer than necessary because Medicare paid hospitals a day rate. The pendulum may have swung too far. Today, evidence indicates that shorter lengths of stay are linked to higher rates of readmission. The bottom line: Care decisions are affected by hospital financing and incentives must be realigned to promote right care. Will global budgets for hospitals help them find the happy medium for lengths of stay?


Joanne Lynn, MD, Director of Altarum’s Center for Elder Care and Advanced Illness is a champion of better care for the frail elderly. She spoke at the 2013 Lown Conference on the importance of addressing social determinants at the end of life. This year, at the 2016 Lown Conference, Lynn will deliver a keynote address on the many problems in elder care and the necessity of “putting people in charge of their own treatment and giving them honesty about their options” in order to minimize overuse, underuse, misuse, and yield more prudent care. Her messages are echoed in a piece by Rachael Bedard, MD, in The New York Times about treating incarcerated patients at the end of life. Bedard recounts her experience caring for a patient dying from liver cancer. He was not allowed to know about his care plan or when he was being moved to different facilities. His wife and daughters had to apply for special permission to visit him. He was jailed in a prison two hours away from his family. He was alone when he died. And his wife eventually lost her job for having spent so much time with him. Bedard chides, “Our aging, ill prisoner population is both a humanitarian crisis and an economic challenge that demands the collaborative attention of physicians, corrections officials, legislators and advocates who can devise national guidelines for medical parole.”



  • We are pleased to offer the second annual RightCare Vignette Competition. We are seeking clinical vignettes written by trainees that describe harm or near harm caused by medical overuse. To learn more or to submit a vignette, visit our RightCare Vignette Competition page.


  • Registration is now open for the 4th Annual Lown Institute Conference. We have great keynotes scheduled: John P.A. Ioannidis, MD, Joanne Lynn, MD, Rita Redberg, MD, Jeff Brenner, MD and Gordon Guyatt, MD. Learn more about the conference and register here.










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RightCare Weekly is made possible through the generous support of the Robert Wood Johnson Foundation.