Low-Osmolar Contrast Agents: Why Their Rise Is Important

In the 1990s, the radiology market introduced low-osmolar contrast agents (LOCAs). This new product met a need by providing a less painful CT experience for patients. However, Medicare deemed it appropriate only for high-risk patients and kept reimbursement levels low, creating a moral dilemma for many radiologists. Would they continue to use high-osmolar contrast agents which cause greater discomfort, but for which they would be reimbursed, or would they take the financial hit and use a more expensive, patient-friendly product?

In a recent issue of the American Journal of Roentgenology, Saurabh Jha, MBBS, MRCS, assistant professor of radiology at University of Pennsylvania School of Medicine, explored the reasons behind the eventual increased use of LOCAs and how it impacted the overall use of CT. Diagnostic Imaging spoke with Jha about why it’s important to understand the rise of LOCAs and how this knowledge can be applied in the future.

Why was it important to analyze the changes in use and cost of low-osmolar contrast agents?

We’re getting to an era where there’s going to be a lot more science focused on how to use new technologies, and these new technologies will have to prove themselves as not only being effective but also more cost efficient than older technologies. I wanted to see how right we, in radiology, have been when deciding between older and newer technologies.

The most ubiquitous choice for imaging is low-osmolar contrast agents (LOCAs). They are particularly intriguing for two reasons. First, I wanted to see whether the economic analysis done when the agents first came out was accurate in its prediction of price range and efficiency. And second, I wanted to see if there could be some blind spots when we look at any particular usage of a particular technology. We’ve seen that it’s impossible to predict the future of how medical agents will be used. Take aspirin, for instance. No one knew the major use would be with heart attacks. It’s a very interesting era to see in health care how new technology is judged, what we end up doing with that judgment, and how correct we are.

What happened with the cost of LOCAs?

When you look at the cost effectiveness of new technologies, there is a sense of static observation. But, cost doesn’t always stay the same. When we looked historically, we saw the cost of LOCAs fell precipitously once patents expired, and it fell further once competing agents entered the market. This isn’t surprising.

The problem with static looks is you end up saying, “This is the range in which this agent is cost effective,” and there is no inertia to re-investigate those calculations. When the price of LOCAs fell, it became more and more utilized by the radiology community, but reimbursement didn’t change. Several years after that, the American College of Radiology wrote to Medicare and made a case for its reimbursement. Prior to that, radiologists only received reimbursement for LOCAs when it was used with patients deemed to be high risk, such as those with diabetes or kidney problems. This was an example of smart advocacy where an organization, certainly with a vested interest in contrast agents, continued to lobby for a change that was backed up by solid reasoning and solid fact. It was an instructional moment.

What messages can be learned from your study?

LOCAs and their widespread use spurred the growth of CT technology. The reason was that high-osmolar contrast agents (HOCAs) had a higher rate of pain when injected at high rates. You could almost see the radiologists being drawn to newer agents because they were so much more comfortable in their quality and safety. If LOCAs hadn’t been adopted in a widespread manner - if the recommendations of the economic analysis had been taken - then we would perhaps be in a situation where the arterial application of CT technology was never realized.

LOCAs, the advent of power-injection, and CT angiograph worked in concert. If LOCAs had been stopped, the message is fairly sobering. It’s a trade-off between the reasoned imposition of standards on new technologies and convergence and development of other technologies due to unforeseen benefits. We need some wiggle room for serendipity - to tinker a bit more.

The second message is that we should be a little more clairvoyant with the drop in prices. We live in an ecosystem where vendors and pharmaceutical companies that are investing in research and development naturally want their patents to survive. But, there is a point in time after they expire, that prices of technologies drop dramatically. So, policymakers should be more generous with their analyses, taking into consideration that future prices are likely to drop.

As a third message, in the 80s and 90s, when the LOCAs first came out, radiologists adopted them despite the low reimbursement. This is a very interesting point because there is so much of the feeling that we do things because we’re reimbursed for it. Fee-for-service is “do more, get paid more.” This is an example where radiologists took something up despite Medicare not providing additional payment for it. They did that because they clearly saw the benefits of using LOCAs. Any physician would’ve been in the ethical dilemma: Do they use a cheaper agent with more toxic side effects and risk a real injury, or do they use the more expensive, but safer agent?

What are the clinical lessons to be learned from the evolution of LOCAs?

When LOCAs came out, vendors began thinking about reducing the toxicity of contrast agents because of renal injuries. Radiologists also saw that using LOCAs wasn’t as painful for the patient. Using this product really did make a difference with something that had been troubling them: discomfort to the patient during CT. From that, we learn what we really want to be doing is having radiologists and all physicians articulate what is most troubling for them because the things that trouble us trouble the patient, as well. This is also where vendors are good at responding to industry needs.

Is there a lesson here for how to make health policy decisions?

It’s a fact that the entirety of benefits from new technologies can’t be predicted. It must be emphasized and cautioned that there is a definite need to be smart and reasoned with technology adoption.

However, we also need to do more empirical research on how prices for various pharmaceutical products and imaging technologies have fallen from the point at which they made it to market; it will make for a fairer analysis of the technology. If that had happened in the 90s when LOCAs emerged, the argument for its universal use would’ve been a lot stronger.

We’re now in the same position with hybrid imaging of PET/CT or MR/PET - all these emerging technologies will be put to the same economic and clinical tests. Academic radiology is very well suited to create these analyses through partnerships with vendors.

My advice is to, by all means, have these analyses and use them. But allow for a certain degree of power for them to be tinkered around a bit. We need to tinker around to create advances in medicine, science, and imaging.