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Self-referred Whole-Body Imaging: Where Are We Now?¹

¹ From the Department of Diagnostic Radiology, Yale University School of Medicine, 330 Cedar St, TE-2, New Haven, CT 06510 (G.M.K., H.P.F.); Research Department, American College of Radiology, Reston, Va (M.B., J.H.S.); and Department of Economics, Yale College, and School of Management, Yale University, New Haven, Conn (H.P.F.). Received December 5, 2003; revision requested February 6, 2004; revision received March 5; accepted March 31. Address correspondence to H.P.F. (e-mail: howard.forman@yale.edu).

	ABSTRACT

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES

 
PURPOSE: To identify current patterns and trends of computed tomographic (CT) screening, including geographic data, services provided, facility type, and demographic characteristics.

MATERIALS AND METHODS: In March 2003, self-referred body imaging (SRBI) centers were identified by using the Internet. Data involving geographic location, type of facility, services provided, and demographic characteristics were collected. The 2000 U.S. census data were used to compare center locality demographics with national patterns. Descriptive statistics, t tests, and regression analyses were used to evaluate data. Nonstatistical comparisons were made with results obtained from a previously published analysis.

RESULTS: The number of SRBI centers totaled 161 (vs 88 in a comparative study in 2001), and centers were distributed across 31 states and Washington, DC (vs 21 in 2001). Racial demographics of center localities more closely resembled national averages in the current study, with equal percentages of whites (76.0% vs 77.1% nationally) and Hispanics (11.5% vs 12.5% nationally). Center localities continued to exhibit greater wealth and levels of education, as reflected by higher income per capita and median household income (P < .05), as well as by higher percentages of people with college and advanced degrees (P < .05). Heart scanning was the most commonly offered service (n = 152, 94%), followed by whole-body scanning (n = 135, 84%), lung scanning (n = 126, 78%), and virtual colonoscopy (n = 88, 55%). Centers in the West were more likely to offer whole-body and organ-specific scanning, compared with centers in other regions (P < .001 for virtual colonoscopy, P < .05 for head scanning). Hospital-based centers were less likely to offer services other than heart scanning (P < .001).

CONCLUSION: Compared with results of a prior analysis, SRBI centers have increased and are distributed more widely in areas with a population that more closely resembles national norms. The increased trend to broaden services may suggest possible saturation of the preexisting market.

© RSNA, 2004

Index terms: Computed tomography (CT) • Computed tomography (CT), utilization • Economics, medical • Radiology and radiologists, socioeconomic issues • Self referral

	INTRODUCTION

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The utility, cost-effectiveness, impact, and safety of self-referred body imaging (SRBI) are subjects of major controversy (1–4). Proponents of whole-body screening argue that the potential risks are largely outweighed by the benefits, which include early detection of cancer or coronary disease (1). Although several success stories have been the focus of much media attention (5–7), the medical community has not provided validated evidence in support of whole-body scanning as a screening modality (8,9).

In 2001, Illes et al (10) conducted a World Wide Web–based search for SRBI centers that advertised their services on the Internet. They concluded that most centers were located in a bicoastal distribution in areas where people were more highly educated and were of higher socioeconomic status. The authors raised concerns about the rapid growth and penetration of whole-body screening as a common medical procedure before carefully designed research was conducted to assess its long-term public health impact. Since then, the American College of Radiology has stated that there is little evidence that whole-body screening is cost-effective or prolongs life (9). The clinical utility of targeted screening, such as lung scanning for patients with a history of smoking, coronary calcium scoring for people with cardiac risk factors, and computed tomographic (CT) colonoscopy for individuals who meet current colonoscopy screening criteria, is being investigated by large multicenter prospective trials (8).

As a follow-up to the study by Illes et al (10), the purpose of our study was to identify current patterns and trends of CT screening, including geographic data, services provided, facility type, and demographic characteristics.

	MATERIALS AND METHODS

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Internet Search
Internet searches were conducted during March of 2003. Yahoo and Google, two commonly used Internet search engines, were used as previously described by Illes et al (10). Five search phrases were used in basic mode without using quotation marks or other operative commands—full body scan, total body scan, whole body scan, preventive imaging, and radiological screening. Each uniform resource locator, or URL, was individually viewed by one of the authors (G.M.K.) to (a) validate its association with an active Web site and (b) confirm its representation of a facility with SRBI services. SRBI services were defined as CT scanning of the whole body or sections of the body as requested by the consumer without physician referral. Centers that did not meet these criteria were excluded from this study. In addition, centers that were not located in the United States—as well as centers at which dual x-ray absorptiometry, magnetic resonance (MR) imaging, positron emission tomographic imaging, or mammography were exclusively performed—were excluded. A repeat search was conducted in August 2003. Center Web sites that were not accessible at this time were also eliminated from this analysis.

Site and Demographic Variables
Information in regard to geographic location of and type of facility, as well as services provided by each SRBI center, was obtained directly from the Web sites. When a uniform resource locator returned a company Web site that was associated with more than one center, each facility was analyzed separately. For geographic location, state of location was recorded, and each center was further categorized into one of the following census divisions: (a) eastern states (Connecticut, Maine, Massachusetts, New Hampshire, Vermont, New York, New Jersey, and Pennsylvania); (b) midwestern states (Illinois, Indiana, Michigan, Ohio, Wisconsin, Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, and South Dakota); (c) southern states (Delaware, Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, West Virginia, Alabama, Mississippi, Kentucky, Tennessee, Arkansas, Louisiana, Oklahoma, and Texas) and Washington, DC; and (d) western states (Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Utah, Wyoming, Washington, Oregon, California, Hawaii, and Alaska). The type of facility was categorized according to its affiliation with a hospital or a general outpatient imaging facility, a comprehensive screening center, or a center at which imaging is performed as strictly self referred (hereafter referred to as an exclusive SRBI center). Each uniform resource locator was explored to determine what services were offered. Services were categorized as full body (without head), head, heart, lung, and abdomen and/or pelvis scanning or virtual colonoscopy.

Data from the 2000 census were used in this study to determine demographic characteristics of the geographic location of the SRBI centers. As previously described by Illes et al (10), the census tract street locator and the topographically integrated geographic encoding and referencing system were used to identify the census tract number of each SRBI center. The census tract number was then cross referenced with 2000 census data to determine racial composition, educational attainment, median household income, income per capita, and percentage of households with income below the poverty level of the population in each census tract.

Data from this study were compared with data obtained from a previous analysis by Illes et al (10). Statistical comparisons were not made with primary data.

Statistical Analysis
Descriptive statistics were used to analyze all data. Percentages of facilities offering each service, according to census region and center type, were calculated. These percentages were compared with national averages obtained from 2000 U.S. census data by using t tests of differences in proportions.

Means and 95% confidence intervals for demographic variables were calculated for each census tract and were compared with national averages by using one-sample t tests.

Multivariate regression analyses were used to measure the effect of census region and center type on variation of services provided in a facility and on the probability of the offering of each type of service.

	RESULTS

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The number of uniform resource locators generated for each keyword search ranged from 54 100 to 869 000. A total of 161 SRBI centers were identified, each with a Web site that advertised radiologic screening services that included whole-body CT; abdominal, pelvic, or head CT; cardiac calcium score evaluation; or virtual colonoscopy. Of 161 SRBI centers, 98 (61%) were part of 19 large multicenter corporations that owned more than one screening facility.

Geographic Data
For 160 of 161 centers, the address was listed on the Web site. Centers were distributed across 31 states and Washington, DC, as shown in Figure 1. The greatest numbers were found in California (n = 44, 27%) and Florida (n = 13, 8%). When centers were categorized into larger geographic regions, the numbers of SRBI centers were greatest in the western states (n = 62, 39%) and fewest in the northeastern states (n = 22, 14%), as shown in Figure 2. However, as shown in Table 1, center concentrations were greatest in Arizona (n = 17.5 per 10 million), and then California (n = 13.0 per 10 million), followed by Maryland and Washington, DC, combined (n = 11.9 per 10 million). Analysis of concentration according to geographic region revealed that the greatest concentration of centers was in the western states (9.8 centers per 10 million), followed by the midwestern states (5.3 per 10 million), as shown in Figure 3.

View larger version (17K): [in this window] [in a new window] [Download PPT slide]   Figure 1. Graph shows geographic distribution of SRBI centers according to state and Washington, DC (DC).

View larger version (23K): [in this window] [in a new window] [Download PPT slide]   Figure 2. Graph shows number of SRBI centers according to geographic region.

View larger version (26K): [in this window] [in a new window] [Download PPT slide]   Figure 3. Graph shows concentration of SRBI centers according to geographic region.

View larger version (51K): [in this window] [in a new window] [Download PPT slide]   Figure 4. Graph shows types of SRBI centers. In parentheses, number is the total number of centers of each type, and percentage was calculated on the basis of the total number of centers (n = 161).

View larger version (20K): [in this window] [in a new window] [Download PPT slide]   Figure 5. Graph shows comparison of services provided at SRBI centers.

Demographic Characteristics
Demographic data of the SRBI center localities are outlined in Table 4. Comparisons of the mean percentages of whites and Hispanics in center localities with national averages showed no statistically significant differences. However, the mean percentages of African Americans and American Indians were significantly (P < .05) lower in center localities, while the mean percentage of Asians was higher (P < .05), compared with the national average. Level of educational attainment was higher in SRBI center localities, with significantly higher mean percentages of people who obtained postgraduate degrees (P < .05) and a lower mean percentage of people who did not obtain a college degree (P < .05). Median household income and income per capita were significantly higher in SRBI center localities (P < .05), although the mean percentage of households with income below the poverty level was not different from the national average.

	DISCUSSION

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES

We believe ours is the first follow-up study in which the effects of trends of direct-to-consumer marketing on the SRBI industry are reported since the initial evaluation by Illes et al (10). Within 2 years (2001–2003), the SRBI industry has almost doubled in number of advertised locations. This may represent a greater trend toward consumer-directed health care, coupled with widespread dissemination of success stories by the media (5–7). The emergence of managed care has forced consumers to loosen their grip over health care decisions, thus creating a climate of general distrust of physicians. The Internet makes available a wealth of information for the growing population of people who are preoccupied with health and prolonging life.

In the current study, a smaller proportion of SRBI centers identified were hospitals (11%) and general diagnostic imaging centers (17%), compared with findings in the study of Illes et al conducted in 2001 (49%). This may be a reflection of the lack of support given to whole-body imaging by the medical community (3,4,11). Indeed, the hospital-based centers identified in this study offered fewer screening examinations other than those for coronary calcium scoring. This hesitation in support may be explained by the lack of evidence to suggest that findings from whole-body imaging will prolong or improve life (2), in addition to the ramifications of incidental and false-positive findings, which may lead to several unnecessary follow-up examinations (12). The radiology community generally agrees that scientific data from multicenter randomized trials will eventually clarify questions in regard to the effectiveness of CT scanning as a screening modality. However, results from these studies are estimated to take a decade to obtain (4). In the present study, the total number of centers that were part of an outpatient diagnostic imaging center or a hospital (n = 45 combined) was unchanged since the analysis of Illes et al was conducted in 2001 (n = 43), and this finding suggests that the growth of the SRBI industry was due completely to opening of exclusive SRBI centers. This further supports the view that a dichotomous environment has developed that is composed of critics of SRBI screening who await scientific confirmation and supporters who advocate patient autonomy and unrestrained imaging. Earnest et al (4) and Amis (3) recently suggested that the American College of Radiology and other medical organizations reconsider their policies to facilitate a compromise. These researchers endorsed the use of informed consent to provide information to the patient in regard to the risks and benefits of CT screening, the possibility of false-positive results, and the responsibility of the individual to assume all costs of further tests.

Since the study of Illes et al (10) in 2001, the percentages of centers that offer heart, lung, and whole-body scanning and virtual colonoscopy increased from 70% to 94%, 58% to 78%, 53% to 84%, and 40% to 55%, respectively, as shown by the data in our study. This reflects a trend to broaden services, which could suggest a possible saturation of the preexisting market. In addition, although Illes et al found a tendency for SRBI centers to be located in bicoastal states, the present study findings suggest a shift toward wider geographic distribution, with a larger concentration in the midwestern states. In addition, with the exception of centers located in the West, which were more likely to offer head CT and virtual colonoscopy, in general centers offered the same services with similar frequency, regardless of geographic location. The hypothesis of a possible saturation of the preexisting market is further supported by a relative equilibration of racial demographics in center locations. In this study, the percentages of whites (76.0%) and of Hispanics (11.5%) in center locations did not differ significantly from the national averages (77.1% and 12.5%, respectively). Last, the percentage of people with income below the poverty level in center locations (12.7%) was not significantly different from the national average (12.4%). Indeed, it has recently been reported that exclusive SRBI centers are beginning to scale back services or shut down completely, a development that indicates the beginning of a downturn from the earlier peak of the industry (13).

This study is limited by its reliance on the Internet to search for SRBI centers. For a more comprehensive evaluation, newspapers and radio could be searched for advertisements. However, because the SRBI industry targets educated consumers who are likely to research information in regard to personal health and can furthermore afford the high cost of CT scanning, most centers are likely to advertise on the World Wide Web. Further, because we used methods used in the previous study of Illes et al, we believe that our study results are a representative measurement of change. The 2000 U.S. census data became available after Illes et al (10) conducted their study in 2001, and the 2000 census data were used in the present study. This may have resulted in disparities between demographic variables in center localities and the national averages that were independent of industry trends during the past 2 years (2001–2003).

In conclusion, findings of this study indicate a major increase in SRBI centers during the past 2 years. Growth was seen primarily in exclusive SRBI centers, which we believe reflects the polarity between critics and supporters of SRBI. However, the market seems to exhibit a possible saturation, indicated by a wider geographic distribution of centers, a smaller racial gap between center locations and the national averages, and similar figures for the population with income below the poverty level. Thus, the SRBI industry may have reached its peak, and its future is uncertain. If organ-specific CT scanning is approved by the medical community as a valid screening tool, coverage of these services by insurance companies will increase and may lead to a decline of the whole-body SRBI industry. Last, if the American College of Radiology and other medical organizations revise their policies to adopt the informed-consent approach such that SRBI centers also follow this approach, patients may be deterred from seeking SRBI because of the reality of false-positive results and the attendant costs of follow-up tests.

	ACKNOWLEDGMENTS

 
Stephen R. Baker, MD, Department of Radiology, University of Medicine and Dentistry New Jersey–New Jersey Medical School, Newark, NJ, provided advice and help in the conceptualization of the manuscript.

	FOOTNOTES

 
Abbreviation: SRBI = self-referred body imaging

Authors stated no financial relationship to disclose.

Author contributions: Guarantors of integrity of entire study, H.P.F., G.M.K., J.H.S.; study concepts, H.P.F., J.H.S., G.M.K.; study design, all authors; literature research, G.M.K.; data acquisition, G.M.K.; data analysis/interpretation, all authors; statistical analysis, G.M.K., M.B.; manuscript preparation and revision/review, G.M.K., H.P.F.; manuscript definition of intellectual content, H.P.F.; manuscript editing, H.P.F., J.H.S.; manuscript final version approval, all authors

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