Laurie Barclay, MD

October 15, 2013

On October 14, the American College of Emergency Physicians (ACEP) issued a list of 5 tests and procedures that may not be cost-effective in some situations. The ACEP announced this list, which reflects its participation in the ABIM Foundation's Choosing Wisely campaign, at the opening session of their annual meeting in Seattle, Washington.

To lower healthcare costs and improve patient care, ACEP recommends that clinicians avoid these interventions when appropriate, after discussing that decision with patients and educating them regarding the rationale.

"ACEP needed a strategy to determine what emergency physicians could do to improve efficiency and reduce cost without affecting the quality of care we deliver," ACEP Cost Effectiveness Task Force Chair David Ross, MD, an emergency physician in Colorado and medical director for more than 50 emergency medical services agencies in Colorado Springs, said in a news release. "The challenge also was to identify real cost savings, but also to develop consensus among emergency physicians."

The ACEP board of directors approved the following 5 Choosing Wisely recommendations for patients seen in the emergency department:

  1. For patients with minor head injury who are deemed to be at low risk for skull fractures or hemorrhage, based on validated decision rules, clinicians should avoid head computed tomography scans. The majority of minor head injuries do not result in brain hemorrhage.

  2. For stable patients who can urinate on their own, clinicians should avoid placing indwelling urinary catheters for either urine output monitoring or patient or staff convenience.

  3. For patients likely to benefit from palliative and hospice care services, clinicians should not delay in engaging such services when available. Early referral from the emergency department can improve quality, as well as quantity, of life.

  4. For patients with uncomplicated skin and soft tissue abscesses successfully treated with incision and drainage, clinicians should provide adequate medical follow-up but avoid antibiotics and wound cultures.

  5. For children with mild to moderate, uncomplicated dehydration, clinicians should avoid giving intravenous fluids before a trial of oral rehydration therapy.

"Emergency physicians are dedicated to improving emergency care and to reducing health care costs," ACEP President Alex Rosenau, DO, said in a news release. "These recommendations are evidence-based and developed with significant input from experts."

An expert panel of emergency physicians and the ACEP board of directors reviewed pertinent research and input, including a survey of all ACEP members, before developing the recommendations.

In its Choosing Wisely campaign, the ABIM Foundation aims to facilitate discussion among physicians and patients about appropriate use of tests and treatments and avoidance of these interventions when the harms may outweigh the benefits.

More than 80 national, regional, and state medical specialty societies and consumer groups have joined Choosing Wisely since the campaign began in April 2012, but ACEP held off until February 2013. The delay resulted from potential conflicts of the Choosing Wisely strategy with the unique goals of emergency medicine and from concerns that the campaign does not advocate for medical liability reform.

"Overuse of medical tests is a serious problem, and health care reform is incomplete without medical liability reform," said Dr. Rosenau. "Millions of dollars in defensive medicine are driving up the costs of health care for everyone. We will continue to encourage the ABIM Foundation and its many partners in this campaign to lend their influential voices to the need for medical liability reform."

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