Number of MRIs doubles, but poor getting even less than before: study

TORONTO - An infusion of cash to cut long MRI wait times has doubled the number of the annual diagnostic scans performed in Ontario since 2004, but the increase seems to be benefiting wealthy patients far more than their poorer counterparts, a study has found.

When the study started in April 2002, patients living in the richest one-fifth of the province's neighbourhoods were 25 per cent more likely to receive magnetic resonance imaging than those living in the poorest one-fifth of neighbourhoods.

Yet even after Ontario invested $118 million to shorten wait times, it did little to narrow the gap between rich and poor. In fact, access disparity actually widened over five years, with the wealthiest patients being 38 per cent more likely to get an MRI than the poorest.

"One would hope that if you're investing that significantly that you can double a capacity to do MRI scans, that you would narrow that gap and make some impact on it," said Dr. John You, principal investigator of the 2002-2007 study by the Institute for Clinical Evaluative Sciences (ICES).

"But, in fact, it's the opposite that's happened. And to me, that's the most concerning part of what we've found."

You said people with lower incomes tend to have more health problems, on average, than higher-income folks and they're often of a more serious nature. Yet many studies have shown that those with fewer financial assets also have difficulty accessing health services of all kinds compared to those who are better off.

"The staggering thing is that this is not like it's in the United States where there are big issues around the uninsured," said You. "This is in a country, or a province, with universal health insurance. So why should there be a gap in access when everyone has the same kind of insurance coverage?"

The authors of the study, published in the journal Open Medicine, speculate on a number of potential reasons for the rich-poor disparity.

"It may be that wealthier individuals are more adept at navigating the health-care system," said You. "They're perhaps a little bit more insistent with their care providers that they get the test they think they need. And there's very little incentive for the physician to say no because they're not paying for it and the patient's not paying for it."

Those in lower income brackets may not be quite as aware of how to finesse the system and get what they want or they may not be as educated about MRI scans and their uses, he said. As well, patients of lower socioeconomic status may have other issues that prevent access.

"If you have less flexibility in your schedule, you may be less likely to show up to the doctor in the first place, despite not feeling well, because it's just too costly to miss the time off work or too challenging to get to the doctor's."

The study authors say more research is needed to determine why income seems to make a difference in getting an MRI before attempts can be made to close the access gap.

You said that with increased capacity for testing since 2004 - Ontario invested in more machines and began operating them for longer hours - doctors may be ordering more MRIs that are medically unnecessary or inappropriate.

Strategies are needed to reduce inappropriate overuse of the technology, he said.

For instance, the Canadian Association of Radiologists has a hefty book of scientifically based guidelines that advise doctors when certain symptoms in a particular type of patient call for an MRI or other imaging test - and when they do not.

You suggested that providing the guidelines online would make them easier for doctors to use, and could encourage more sound decision-making when it comes to ordering a test.

Dr. David Vickar, president of the Canadian Association of Radiologists, said the suggestion is a reasonable one and his group supports the idea of disseminating the guidelines in the most applicable form to help doctors make better decisions.

"We know that physicians are no different from other people, that if you give them a book to reference to find information, they may or may not be able to carry that book around or utilize it," said Vickar, a radiologist at Royal Alexandra Hospital in Edmonton.

"But if you can get it to them in an electronic format, that is perhaps the most helpful."

You said the biggest challenge may be changing how the public and doctors view high-tech imaging.

"I think our tendency, myself included, is to get mesmerized by the beautiful pictures that the machines make and the amount of detail you can get from them," he said. "And you kind of forget to look at it in an objective way, to see if the test is actually useful for your patient."

"There is a tendency for many of us to equate really fancy tests or expensive tests with better care. And I just don't think that's always true."