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Ordering of US Hospital Imaging Tests Remains the Same with or Without Knowing the Cost

By MedImaging International staff writers
Posted on 07 Feb 2013

In a study designed to determine if physicians who are informed of the precise cost of expensive medical testing such as magnetic resonance imaging (MRI) in advance would order less of them, US investigators found out that the answer is no.

In a report published online January 2, 2013, in the Journal of the American College of Radiology, the researchers discovered that revealing the costs of MRI scans and other imaging modalities up front had no impact on the number of tests doctors ordered for their hospitalized patients.

“Cost alone does not seem to be the determining factor in deciding to go ahead with an expensive radiographic test,” said the study’s senior author, Daniel J. Brotman, MD, an associate professor of medicine at the Johns Hopkins University School of Medicine (Baltimore, MD, USA), and director of the hospitalist program at The Johns Hopkins Hospital. “There is definitely an over-ordering of tests in this country, and we can make better decisions about whether our patients truly need each test we order for them. But when it comes to big-ticket tests like MRI, it appears the doctors have already decided they need to know the information, regardless of the cost of the test.”

Earlier studies suggest that much of the expense of medical imaging, laboratory tests, and prescription drugs is unknown or concealed from providers and patients at the time of ordering, leaving financial considerations chiefly out of the healthcare decision-making process and likely push up costs, Dr. Brotman noted.

Other studies have shown that clinicians ordered fewer laboratory tests in some cases when they were given the price right away. However, Dr. Brotman noted that imaging tests appear to be “a different animal.” There are built-in disincentives to ordering many major tests if they are not necessary, such as the potential danger of radiation used in some, Dr. Brotman noted. In addition to making physicians more sensitive to the costliness of unnecessary testing, he noted, they need to learn how to explain to patients why they may not need them.

For the study, Dr. Brotman and his colleagues identified the 10 imaging tests most frequently ordered for patients at The Johns Hopkins Hospital. Dividing the tests into two groups, they made sure prices were attached to one group over a six-month period, from November 2009 to May 2010. Dr. Brotman and his colleagues kept out the pricing data for the other group over the same time period. Prices are not typically shared with physicians or patients in most medical settings.

When the researchers compared the ordering rates to the rates from a six-month period a year earlier, when no costs were displayed at all, they found no considerably difference in ordering patterns. Dr. Brotman noted that he might have been worried if there was a large decrease in ordering expensive tests, as there are many instances when the expensive test is justified. For example, when a patient appears to have had a sub-acute stroke, an MRI is often justified “regardless of cost,” he said. “When a key diagnosis is needed in imaging, there are limited options for comparison shopping.”

That is not to say there are not times when physicians need to look more closely at whether too many imaging tests are being ordered, according to Dr. Brotman. Patients in a hospital intensive care unit (ICU), for instance, who are on a ventilator and not able to tell physicians how they are feeling may not need a daily chest X-ray to scan for potential problems. Dr. Brotman reported that there is evidence that outcomes are not compromised if radiographs are ordered only when the patient’s condition appears to be deteriorating. MRI scans are also ordered too frequently for lower back pain, according to Dr. Brotman.

“For too long, there has not been enough attention paid to the bottom line in healthcare,” Brotman said. This is not about allocating care to hold down costs, he noted, but about choosing tests a little more wisely. “There are financial consequences for the choices we make, and for too long we haven’t considered them,” he said.

Although price transparency did not influence the way physicians ordered imaging tests in his study, according to Dr. Brotman, financial considerations may play a role in other circumstances if tied to clinical evidence. For example, when clinical programs began to compare the amount of blood products used by surgeons, those who were using far more than their peers (and with similar patient outcomes) took notice and decreased their dependence on transfusions, which are not only costly but also carry risks. If a provider is ordering four times as many computed tomography (CT) scans as a colleague whose patients have similar outcomes, it could change the decision-making calculus for the better, according to Dr. Brotman.

“Cost transparency must be part of the solution to solving fiscal challenges in medicine,” Dr. Brotman concluded. “Providers have no idea how much they’re spending. Patients don’t know either. Having everyone understand more of the economics of health care is a great place to start cutting costs in medicine.”

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56 (525.95138549805): SELECT dp.*, ch.title as channel, exp.name as author_name, exp.specialization as author_specialization, exp.images as author_photo FROM jos_deeppockets_archive as dp LEFT JOIN jos_experts as exp ON exp.id = dp.author LEFT JOIN jos_deeppockets as ch ON dp.fid = ch.id WHERE 1=1 AND dp.cat=10 AND dp.id=294744687 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

57 (!!!!! 1365.9000396729): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294744687 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294744687 AND published='1' LIMIT 1

58 (73.19450378418): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294744687 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294744687 AND published='1' LIMIT 1

59 (117.06352233887): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294744687 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294744687 AND published='1' LIMIT 1

60 (61.03515625): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294744687 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294744687 AND published='1' LIMIT 1

61 (97.990036010742): select cover from jos_number where journalid in (5) and cover is not null order by left(issue,2)+right(issue,2)*12 desc limit 1

62 (550.98533630371): SELECT fid FROM jos_deeppockets WHERE id=294744687 AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE id=294744687 AND published='1' LIMIT 1

63 (313.99726867676): SELECT id,name,sponsor_text FROM jos_deeppockets dp left outer join jos_channel_sponsor cs on dp.id=cs.fid WHERE cat=10 AND TYPE='file_folder' AND published=1 AND id=215 ORDER BY `ordering`

64 (48.160552978516): select jos_twitters.link from jos_twitters where cat=10

65 (34.093856811523): select jos_facebook.link from jos_facebook where cat=10

66 (37.908554077148): select jos_google_plus.link from jos_google_plus where cat=10

67 (52.928924560547): select jos_linkedin.link from jos_linkedin where cat=10

68 (38.14697265625): SELECT fid FROM jos_deeppockets WHERE id=294744687 AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE id=294744687 AND published='1' LIMIT 1

69 (37.908554077148): SELECT id,name,sponsor_text FROM jos_deeppockets dp left outer join jos_channel_sponsor cs on dp.id=cs.fid WHERE cat=10 AND TYPE='file_folder' AND published=1 AND id=215 ORDER BY `ordering`

70 (299.93057250977): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=294744687 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

71 (286.81755065918): SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294744687 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

72 (47.922134399414): SELECT id,name,title FROM jos_deeppockets WHERE cat=10 AND TYPE='file_folder' AND published=1 AND id != 294743300 AND id != 294743301 AND id != 294743302 AND id != 294743303 AND id != 294743304 AND id != 294743305 AND id != 294743306 AND id != 294743307 AND id != 294743308 AND id != 294743309 AND id != 294743310 AND metakey != 'aacc' ORDER BY `ordering`

73 (56.028366088867): SELECT show_live FROM jos_com_show_setting LIMIT 1

74 (35.04753112793): SELECT show_live FROM jos_com_show_setting LIMIT 1

75 (31.948089599609): SELECT show_live FROM jos_com_show_setting LIMIT 1

76 (30.994415283203): SELECT show_live FROM jos_com_show_setting LIMIT 1

77 (30.040740966797): SELECT show_live FROM jos_com_show_setting LIMIT 1

78 (30.994415283203): SELECT show_live FROM jos_com_show_setting LIMIT 1

79 (30.994415283203): SELECT show_live FROM jos_com_show_setting LIMIT 1

80 (30.040740966797): SELECT show_live FROM jos_com_show_setting LIMIT 1

81 (29.802322387695): SELECT show_live FROM jos_com_show_setting LIMIT 1

82 (30.994415283203): SELECT show_live FROM jos_com_show_setting LIMIT 1

83 (28.848648071289): SELECT show_live FROM jos_com_show_setting LIMIT 1

84 (31.948089599609): SELECT show_live FROM jos_com_show_setting LIMIT 1

85 (37.908554077148): SELECT show_live FROM jos_com_show_setting LIMIT 1

86 (31.948089599609): SELECT show_live FROM jos_com_show_setting LIMIT 1

87 (45.061111450195): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=294744687 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

88 (33.140182495117): SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294744687 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

89 (38.14697265625): SELECT id,name,title FROM jos_deeppockets WHERE cat=10 AND TYPE='file_folder' AND published=1 AND id != 294743300 AND id != 294743301 AND id != 294743302 AND id != 294743303 AND id != 294743304 AND id != 294743305 AND id != 294743306 AND id != 294743307 AND id != 294743308 AND id != 294743309 AND id != 294743310 AND metakey != 'aacc' ORDER BY `ordering`

90 (54.836273193359): SELECT show_live FROM jos_com_show_setting LIMIT 1

91 (34.093856811523): SELECT show_live FROM jos_com_show_setting LIMIT 1

92 (31.948089599609): SELECT show_live FROM jos_com_show_setting LIMIT 1

93 (30.994415283203): SELECT show_live FROM jos_com_show_setting LIMIT 1

94 (30.994415283203): SELECT show_live FROM jos_com_show_setting LIMIT 1

95 (33.855438232422): SELECT show_live FROM jos_com_show_setting LIMIT 1

96 (82.015991210938): SELECT show_live FROM jos_com_show_setting LIMIT 1

97 (34.093856811523): SELECT show_live FROM jos_com_show_setting LIMIT 1

98 (30.994415283203): SELECT show_live FROM jos_com_show_setting LIMIT 1

99 (30.994415283203): SELECT show_live FROM jos_com_show_setting LIMIT 1

100 (30.994415283203): SELECT show_live FROM jos_com_show_setting LIMIT 1

101 (41.961669921875): SELECT show_live FROM jos_com_show_setting LIMIT 1

102 (30.994415283203): SELECT show_live FROM jos_com_show_setting LIMIT 1

103 (30.994415283203): SELECT show_live FROM jos_com_show_setting LIMIT 1

104 (80.108642578125): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294744687 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294744687 AND published='1' LIMIT 1

105 (56.028366088867): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294744687 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294744687 AND published='1' LIMIT 1

106 (69.141387939453): SELECT dp.*, ch.title as channel, exp.name as author_name, exp.specialization as author_specialization, exp.images as author_photo FROM jos_deeppockets as dp LEFT JOIN jos_experts as exp ON exp.id = dp.author LEFT JOIN jos_deeppockets as ch ON dp.fid = ch.id WHERE 1=1 AND dp.cat=10 AND dp.id=294744687 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

107 (61.03515625): SELECT dp.*, ch.title as channel, exp.name as author_name, exp.specialization as author_specialization, exp.images as author_photo FROM jos_deeppockets_archive as dp LEFT JOIN jos_experts as exp ON exp.id = dp.author LEFT JOIN jos_deeppockets as ch ON dp.fid = ch.id WHERE 1=1 AND dp.cat=10 AND dp.id=294744687 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

108 (111.10305786133): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294744687 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294744687 AND published='1' LIMIT 1

109 (59.843063354492): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294744687 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294744687 AND published='1' LIMIT 1

110 (73.909759521484): SELECT dp.*, ch.title as channel, exp.name as author_name, exp.specialization as author_specialization, exp.images as author_photo FROM jos_deeppockets as dp LEFT JOIN jos_experts as exp ON exp.id = dp.author LEFT JOIN jos_deeppockets as ch ON dp.fid = ch.id WHERE 1=1 AND dp.id=294744687 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

111 (473.97613525391): SELECT dp.*, ch.title as channel, exp.name as author_name, exp.specialization as author_specialization, exp.images as author_photo FROM jos_deeppockets_archive as dp LEFT JOIN jos_experts as exp ON exp.id = dp.author LEFT JOIN jos_deeppockets as ch ON dp.fid = ch.id WHERE 1=1 AND dp.id=294744687 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

112 (654.93583679199): SELECT dp.name, dp.id, dp2.name as channel, ex.name as author_name, ex.specialization, ex.images FROM jos_deeppockets as dp LEFT JOIN jos_experts as ex ON ex.id = dp.author LEFT JOIN jos_deeppockets as dp2 ON dp2.id = dp.fid WHERE dp.author != 0 AND dp.cat = 10 AND dp.published = 1 AND ( (dp.fid = 294743300) OR (dp.fid = 294743301) OR (dp.fid = 294743302) OR (dp.fid = 294743303) OR (dp.fid = 294743304) OR (dp.fid = 294743305) OR (dp.fid = 294743306) OR (dp.fid = 294743307) OR (dp.fid = 294743308) OR (dp.fid = 294743309) OR (dp.fid = 294743310) ) ORDER BY RAND() LIMIT 1

113 (469.92301940918): SELECT dp.name, dp.id, dp2.name as channel, ex.name as author_name, ex.specialization, ex.images FROM jos_deeppockets as dp LEFT JOIN jos_experts as ex ON ex.id = dp.author LEFT JOIN jos_deeppockets as dp2 ON dp2.id = dp.fid WHERE dp.author != 0 AND dp.cat = 10 AND dp.published = 1 AND ( (dp.fid = 294743300) OR (dp.fid = 294743301) OR (dp.fid = 294743302) OR (dp.fid = 294743303) OR (dp.fid = 294743304) OR (dp.fid = 294743305) OR (dp.fid = 294743306) OR (dp.fid = 294743307) OR (dp.fid = 294743308) OR (dp.fid = 294743309) OR (dp.fid = 294743310) ) ORDER BY RAND() LIMIT 1

114 (82.015991210938): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294744687 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294744687 AND published='1' LIMIT 1

115 (59.127807617188): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294744687 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294744687 AND published='1' LIMIT 1

116 (58.174133300781): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294744687 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294744687 AND published='1' LIMIT 1

117 (47.922134399414): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294744687 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294744687 AND published='1' LIMIT 1

118 (63.896179199219): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294744687 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294744687 AND published='1' LIMIT 1

119 (50.067901611328): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294744687 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294744687 AND published='1' LIMIT 1

120 (51.975250244141): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294744687 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294744687 AND published='1' LIMIT 1

121 (50.067901611328): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294744687 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294744687 AND published='1' LIMIT 1

122 (329.97131347656): SELECT * FROM trending_articles WHERE `journal_id` = 10 AND `timestamp` <= NOW() + INTERVAL 7 DAY ORDER BY `order`

123 (!!!!! 106661.08131409): SELECT * FROM jos_deeppockets WHERE jos_deeppockets.cat = 10 AND jos_deeppockets.type = 'deeppockets_item' AND jos_deeppockets.published = 1 AND jos_deeppockets.created + INTERVAL 14 DAY >= NOW() ORDER BY jos_deeppockets.hits DESC LIMIT 7

124 (!!!!! 1600.980758667): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=294744687 AND type='deeppockets_item' AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294744687 AND type='deeppockets_item' AND published='1' LIMIT 1

125 (!!!!! 23659.944534302): ( SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.video != '' AND dp.video_source != '' AND dp.cat = 10 AND dp.published = 1 AND dp.type != 'deeppockets_item_link' ORDER BY created DESC LIMIT 3 ) UNION ( SELECT dpa.id, dpa.name, dpa.title, dpa.video, dpa.video_source, dpa.created FROM jos_deeppockets_archive AS dpa WHERE dpa.video != '' AND dpa.video_source != '' AND dpa.cat = 10 AND dpa.published = 1 AND dpa.type != 'deeppockets_item_link' ORDER BY created DESC LIMIT 3 ) ORDER BY created DESC LIMIT 3

126 (257.01522827148): ( SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.video != '' AND dp.video_source != '' AND dp.cat = 10 AND dp.published = 1 AND dp.type != 'deeppockets_item_link' ORDER BY created DESC LIMIT 3 ) UNION ( SELECT dpa.id, dpa.name, dpa.title, dpa.video, dpa.video_source, dpa.created FROM jos_deeppockets_archive AS dpa WHERE dpa.video != '' AND dpa.video_source != '' AND dpa.cat = 10 AND dpa.published = 1 AND dpa.type != 'deeppockets_item_link' ORDER BY created DESC LIMIT 3 ) ORDER BY created DESC LIMIT 3

127 (144.00482177734): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.id = 294803337 LIMIT 1

128 (45.061111450195): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.id = 294803337 LIMIT 1

129 (385.99967956543): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.id = 294803276 LIMIT 1

130 (59.127807617188): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.id = 294803276 LIMIT 1

131 (514.03045654297): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets_archive AS dp WHERE dp.id = 294803276 LIMIT 1

132 (219.10667419434): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets_archive AS dp WHERE dp.id = 294803276 LIMIT 1

133 (42.915344238281): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.id = 294802958 LIMIT 1

134 (347.85270690918): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.id = 294802958 LIMIT 1

135 (!!!!! 3863.0962371826): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294744687 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

136 (550.0316619873): SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294744687 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

137 (!!!!! 1022.8157043457): SELECT name FROM jos_deeppockets WHERE id=215

138 (56.982040405273): SELECT name FROM jos_deeppockets WHERE id=215

139 (724.07722473145): SELECT *, DATE_FORMAT(publish_up,'%d %b %Y') AS date_publish_up, DATE_FORMAT(publish_down,'%d %b %Y') AS date_publish_down FROM jos_events WHERE state=1 AND publish_up > NOW() and extra_info REGEXP '((;)|(^))215((;)|($))' AND catid IN (0,110) ORDER BY publish_up ASC LIMIT 3

140 (590.08598327637): SELECT *, DATE_FORMAT(publish_up,'%d %b %Y') AS date_publish_up, DATE_FORMAT(publish_down,'%d %b %Y') AS date_publish_down FROM jos_events WHERE state=1 AND publish_up > NOW() and extra_info REGEXP '((;)|(^))215((;)|($))' AND catid IN (0,110) ORDER BY publish_up ASC LIMIT 3

141 (114.91775512695): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294744687 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294744687 AND published='1' LIMIT 1

142 (61.988830566406): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294744687 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294744687 AND published='1' LIMIT 1

143 (!!!!! 9046.0777282715): TRUNCATE TABLE jos_trademed_module

144 (95.844268798828): SELECT dp.*, ch.title as channel, exp.name as author_name, exp.specialization as author_specialization, exp.images as author_photo FROM jos_deeppockets as dp LEFT JOIN jos_experts as exp ON exp.id = dp.author LEFT JOIN jos_deeppockets as ch ON dp.fid = ch.id WHERE 1=1 AND dp.cat=10 AND dp.id=294744687 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

145 (71.048736572266): SELECT dp.*, ch.title as channel, exp.name as author_name, exp.specialization as author_specialization, exp.images as author_photo FROM jos_deeppockets_archive as dp LEFT JOIN jos_experts as exp ON exp.id = dp.author LEFT JOIN jos_deeppockets as ch ON dp.fid = ch.id WHERE 1=1 AND dp.cat=10 AND dp.id=294744687 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

146 (!!!!! 1020.9083557129): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294744687 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

147 (67.949295043945): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294744687 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

148 (77.009201049805): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294744687 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294744687 AND published='1' LIMIT 1

149 (109.91096496582): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294744687 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294744687 AND published='1' LIMIT 1

150 (!!!!! 1420.0210571289): SELECT jos_item.* FROM jos_item INNER JOIN jos_number ON jos_item.numberID=jos_number.id WHERE 1=1 AND (jos_item.imgMini<>'') AND jos_item.type='L' AND jos_item.numberID= ( SELECT jos_number.id FROM jos_number WHERE jos_number.journalID IN (10) and jos_number.id in (select distinct jos_number.id from jos_number join jos_item on jos_item.numberid=jos_number.id where jos_item.type='P') ORDER BY (CONVERT(SUBSTRING(issue,1,2),SIGNED) + (CONVERT(SUBSTRING(issue,3,2),SIGNED)*100)) DESC LIMIT 0,1 ) ORDER BY RAND() DESC LIMIT 6

151 (70.095062255859): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294744687 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294744687 AND published='1' LIMIT 1

152 (60.081481933594): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294744687 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294744687 AND published='1' LIMIT 1

153 (44.107437133789): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=294744687 AND type='deeppockets_item' AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294744687 AND type='deeppockets_item' AND published='1' LIMIT 1

154 (40.054321289062): select distinct links.* from jos_textlinks links join jos_textlinks_placement placement on links.id=placement.link_id where journal_id=(10) and (channel_id=215 or channel_id is null)

155 (37.908554077148): select distinct links.* from jos_textlinks links join jos_textlinks_placement placement on links.id=placement.link_id where journal_id=(10) and (channel_id=215 or channel_id is null)

156 (39.100646972656): SELECT livesite FROM jos_dp_categories WHERE id=10 AND published='1' LIMIT 1

157 (125.88500976562): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294744687 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294744687 AND published='1' LIMIT 1

158 (61.03515625): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294744687 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294744687 AND published='1' LIMIT 1

159 (40.054321289062): select jos_twitters.link from jos_twitters where cat=10

160 (34.093856811523): select jos_facebook.link from jos_facebook where cat=10

161 (35.04753112793): select jos_google_plus.link from jos_google_plus where cat=10

162 (33.855438232422): select jos_linkedin.link from jos_linkedin where cat=10

163 (299.93057250977): update jos_bannersmanager_banner set impmade=impmade+1 where id in(14202,14203)

164 (!!!!! 3546.9532012939): insert into jos_banners_delta values (14202,'2025-06-23 15:02:04','216.73.216.120','view'),(14203,'2025-06-23 15:02:04','216.73.216.120','view')

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