Desire for Certainty, Litigation Fears Drive ER Overimaging

Diana Swift

April 07, 2015

Most emergency department physicians order diagnostic imaging tests they know are unnecessary, according to the results of a national survey published online March 23 in Academic Emergency Medicine. A key driver behind these excess scans is the fear of malpractice lawsuits based on missed diagnoses, the researchers found.

"The most striking finding of our study is that the overwhelming majority of the [emergency physicians (EPs)] we asked believed that they and their colleagues order a substantial amount of medically unnecessary imaging," write investigators led by Hemal K. Kanzaria, MD, MSHPM, an EP at the University of California, Los Angeles, and a Veterans Affairs–supported Robert Wood Johnson Foundation Clinical Scholar.

Of the 435 EPs who responded to the survey (478 were invited to participate), 97% acknowledged ordering some advanced imaging scans, such as computed tomography and magnetic resonance imaging, that were not strictly necessary. In addition, more than 85% of responding EPs said too many diagnostic procedures, from blood and urine to scans, were ordered in their departments, suggesting the problem is systemic.

Respondents reported practicing in academic (50.6%), community (49.4%), health maintenance organization (18.9%) emergency departments. Approximately one-third were women (30.8%), 68.4% were board-certified in emergency medicine, and the mean number of years in practice was 13.7 (range, 0.75 - 45 years).

Topping the list of common ("almost always" or "often") reasons for overimaging was the fear of missing even a low-probability diagnosis (68.9%), followed by malpractice concerns (64.3%).

The authors ascribed the former reason to contemporary medicine's low tolerance for incertitude. "We believe that the existing desire in modern U.S. health care, to minimize and even eliminate any diagnostic uncertainty, is a primary contributor to our current, resource-intensive approach," Dr Kanzaria and colleagues write. "While this professional culture may be well-intentioned, in the case of advanced imaging it has not only failed to improve patient outcomes, but has also led to overdiagnosis and overtreatment, resulting in substantial harm."

Respondents said other drivers of excess imaging included patient/family expectations (39.7%), standard practice norms for their group/close colleagues (38.5%), standard emergency medicine practice (34.9%), time saving (23.6%), administrative pressure to increase group reimbursement (1.4%), and increasing personal reimbursement (0.7%).

The multifactorial problem of excess imaging will require multifaceted solutions, according to the authors. The potential solutions most commonly cited by respondents as "extremely" or "very" helpful for reducing unnecessary imaging included the following: malpractice reform to counteract the need for defensive medicine (78.9%), increased patient involvement through education (69.9%) and shared decision-making about tests (55.9%), feedback to physicians on their test-ordering metrics vs peers' (54.8%), and improved physician education on diagnostic testing (50.2%).

Although not considering tort reform alone sufficient to eliminate overimaging, the authors suggest it may be a necessary first step. "As long as the specter of liability is so prevalent, it may be difficult to convince EPs to change their practice patterns," they write. "At the same time, it would be useful to educate EPs that the actual risk posed by legal liability is likely lower than the perceived risk, which may allay these fears."

Other proposals to reduce overimaging included better staffing to boost clinical evaluation (39.7%), voluntary guidelines on when to order tests (37.9%), elimination of financial incentives to order tests (32.7%), computer decision support on testing for clinicians (25.2%), and financial incentives to physicians to order fewer tests (17.5%).

The most frequent (n = 4) additional solution written in by respondents related to encouraging societal change away from a perceived "no-miss" attitude.

Stressing that "inappropriate testing can cause medical harm — not merely in the abstract, but to individual patients," the authors conclude that multiple complex factors as well as several potential high-yield solutions must be simultaneously addressed to curb overimaging in emergency medicine.

This study was financially supported by the Veterans Affairs Office of Academic Affiliations through the Veterans Affairs/Robert Wood Johnson Foundation Clinical Scholars program and the National Heart, Lung, and Blood Institute of the National Institutes of Health. The authors have disclosed no relevant financial relationships.

Acad Emerg Med. Published online March 23, 2015. Abstract

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