Pandemic Imaging Higher Among Older, Male, Non-White Patients

Over the past seven months, imaging utilization has ridden a rollercoaster across the nation. Changes to outpatient, inpatient, and emergency imaging have varied across the country, but it has also fluctuated across socioeconomic groups.

In a study published this week in the Journal of the American College of Radiology, a team of investigators from Northwell Health examined who used more imaging and who used less throughout the initial phases of the outbreak. Their results highlighted some distinct differences and could be helpful in future scenarios where imaging resources might be scarce.

“Identifying socioeconomic health disparities related to imaging utilization is an initial step towards understanding the need for imaging resources in specific patient groups during the COVID-19 pandemic and subsequent recovery,” said the team led by Jason J. Naidich, M.D., MBA, Northwell senior vice president and regional executive director. “In the time of a healthcare crisis, it is important to understand socioeconomic factors related to imaging utilization to direct imaging resources in order to ensure adequate access and availability.”

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A great deal of time and research has been devoted to studying the impact of the pandemic on imaging levels and how those volumes have rebounded. However, very little is known about how the virus affected imaging use by different socioeconomic groups. In this study, Naidich’s team analyzed patient-level imaging data to evaluate these factors based on patient service location – outpatient, inpatient, or emergency department.

To make these determinations, they retrospectively reviewed radiology invoices from Jan. 1 to May 31 in both 2019 and 2020, dividing the studies into pre-COVID (Jan. 1 – Feb. 28) and post-COVID (Mar. 1 – May 31) time frames. They stratified the data by age, sex, race, insurance status, and income level in order to reveal any trends.

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For the post-COVID period, they reviewed 526,128 exams from 2019 and 348,539 studies from 2020. The composition mix for the 2020 studies was 42 percent emergency department, 33 percent inpatient, and 25 percent outpatient. For 2019, the mix was 39 percent emergency department, 37 percent outpatient, and 24 percent inpatient.

Based on their analysis, the team discovered that older patients (ages 60 to 79 years) men, and non-white racial groups (African American, Asian, other, and unknown) received significantly more medical imaging during the pandemic than they did during the same time period the year prior. Additionally, imaging levels were higher among lower-income patients (less than $80,000), as well as Medicaid-insured and uninsured patients. This pattern was particularly true in the emergency and inpatient environments, the team said, because COVID-19 was prevalent in these group, and they typically sought care in the emergency department prior to a hospital admission.

Conversely, patients with higher incomes (more than $80,000) and private insurance underwent less imaging. Lower utilization rates were also identified in patients who were younger (less than 18 years and between 40 and 49 years), white, lower income (less than $60,000), and higher income (more than $120,000).

“One possible explanation for this decline in the use of outpatient imaging services,” the team said, “is that these patient groups were delaying their care during the COVID-19 pandemic as a consequence of the Centers for Medicare & Medicaid Services recommendation to limit non-essential and non-urgent medical care.”

Such mandates led to a steep drop-off in cancer screenings. Usage declines could also be the result of higher unemployment rates that led to a loss of medical insurance, they said.

Ultimately, Naidich's team concluded, these findings can help inform utilization decisions in future times of scarcity.

“Understanding the impact of the decline in the utilization of imaging services for specific patient groups is important to better guide heath policy during and after the pandemic to ensure imaging needs are met,” they said. “If this issue is not addressed proactively, it may potentially result in widening of existing disparities in radiology in the post-pandemic era that includes access to outpatient imaging services, especially cancer screening programs.”

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