Indications for the use of low-osmolar contrast agents.

The recent introduction of low-osmolar contrast agents for use in radiology procedures presents a dilemma for health care managers concerned about cost and quality. The new agents are reported to be safer and are better tolerated by patients, but they are very costly. Earlier this year, a survey was sent to hospital-based members of the American College of Physician Executives to determine what policy existed for the use of these agents. As a result of the survey, we have a better picture of the indications for low-osmolar contrast agents being used in clinical practice throughout the United States.

Health care managers are increasingly faced with cost versus quality decisions. Very often, these decisions are made with little or no evidence of improved efficacy, such as in the case of recent, widespread usage of very expensive thrombolytic agents for treating coronary thrombosis. At Lourdes Hospital, Binghamton, N.Y., a 277-bed acute care community hospital, increased costs related to the use of new low-osmolar contrast agents have been estimated to be at least $600,000 per year.

Radiologists at the hospital favor use of the new contrast media whenever there is the slightest question of a complication. Management, in an era of cost constraints, is concerned about overuse of a costly material to avoid rare complications. Management believes that contraindications to the use of traditional contrast materials should be evaluated more costly. Evaluation of indications for the use of low-osmolar contrast agents, management believes, can assist in establishing a prototype protocol for dealing with these cost versus quality decisions, which are going to become increasingly necessary and frequent.

A review of the current literature was of little help in analyzing the situation. Through March 1989, there have been a number of articles on the subject, but the indications for the use of the new contrast agents are very ill-defined.

In order to facilitate analysis, a questionnaire was developed, using as a guide the current indications for the use of low-osmolar agents by the Lourdes Hospital Radiology Group. The questionnaire was mailed to 2,113 members of the American College of Physician Executives. There were 325 returns (15 percent). In addition, 33 protocols were received.

As can be seen in the table on page 25, in more than 50 percent of the responses, a history of renal disease, allergies, diabetes, asthma, or heart disease was considered to be an indication for use of the new contrast agents. Age 65 or older was reported as an indication in only 31 percent of the responses. Some respondents used the age of 50, 60, or 70 as the indicator. In addition, in 5 percent of the responses, an age of less than one year was used as the indicator. Some respondents used two years or three years of age as the indicator.

Other indications included a history of a previous reaction to a contrast material (21 percent of the responses), unstable angina (19 percent), and elevated BUN or Creatinine (9 percent). Nineteen percent of the respondents used particular procedures, such as angiography or venography, as indications. Four percent used myelography, and one percent used urography.

Under "other condition," one respondent, perhaps playfully, listed all lawyers.

Other respondents recommended using the new contrast agent for all patients or giving all patients an opportunity to chose the new contrast agent, for which they would be required to cover the additional cost. The conditions for use of the agent are clearly defined in the consent form.

As can be seen from the table, the indications are relatively diffuse, although there is agreement by over 50 percent of the respondents on the use of low-osmolar contrast agents in patients with histories of renal disease, allergies, diabetes, asthma, or heart disease.

On the basis of the results of the survey, the management of Lourdes Hospital considered, with the radiologists, the following options:

* Continue the current protocol.

* Develop a more restrictive protocol based on the responses.

* Continue the current protocol and share with the radiologists the incremental cost of using low-osmolar agents.

* Use a conventional contrast medium, but require premedication with steroids and antihistamines to reduce complications.

It was decided to develop a more restrictive protocol. Accordingly, new guidelines were adopted for the use of low-osmolar contrast agents at the hospital: