Expensive Imaging Tests Are Overused in Emergency Medicine

Lara C. Pullen, PhD

December 31, 2015

An increasing number of emergency department patients are being given computed tomography (CT) scans — even those patients who are unlikely to benefit and are most likely to experience harm from the scan.

"Beyond the risk posed by ionizing radiation, high resolution CT may have unintended downstream consequences related to incidental findings and overdiagnosis, leading to a costly and potentially harmful diagnostic, therapeutic, or interventional cascade," Frank S. Drescher, MD, and Brenda E. Sirovich, MD, from the Geisel School of Medicine at Dartmouth in Hanover, New Hampshire, explain.

The researchers published the results of their trends analysis online December 28 in JAMA Internal Medicine.

They analyzed data collected from 2001 to 2010 in the National Hospital Ambulatory Medical Care Survey and found that during the last 10 years, there has been a fourfold increase in emergency department use of CT scans to evaluate respiratory symptoms (from 2.2% in 2001 - 2002 to 9.4% in 2009 - 2010).

Although the rate of CT scans increased, antibiotic prescription and hospital admission rates did not go up. Instead, an increasing percentage of patients were discharged without a diagnosis during the 10-year study period.

Choosing Wisely

One of the reasons behind the increased use of CT scans may simply be that physicians increasingly rely on imaging for clinical management, suggest Rebecca Smith-Bindman, MD, and Andrew B. Bindman, MD, from the University of California, San Francisco, in an accompanying editorial.However, although imaging can be critical for accurate diagnoses, guiding treatment, and improving patient outcomes, it also can be costly and increase patient exposure to radiation.

In 2012, the American Board of Internal Medicine Foundation created the Choosing Wisely campaign to identify tests, treatments, and procedures that, although useful in some situations, are often used inappropriately. Choosing Wisely has also recognized that certain tests may be preferentially used under fee-for-service payment systems, even if the tests do not provide value to the patient.

The incentivizing of certain procedures is a recognized shortcoming of the fee-for-service model and has led to the development of the Medicare Incentive Payment System, the editorialists report. The system "will soon place Medicare physicians at financial risk for their practice style" by reimbursing on the basis of performance comparisons between physicians, they explain.

The recent analysis by Dr Drescher and Dr Sirovich and the work of others suggest that the problem with imaging is not just a problem of an increasing frequency of unnecessary tests, but also a problem in the variability of the safety of the tests performed, write the editorialists. For example, a typical patient in the United States who is given a myocardial perfusion imaging test receives a radiation dose that averages 20% higher than the average dose of the same test performed in 64 other countries. Similar variation in radiation exposure has been reported for CT scans.

"To date, much of the work in the Choosing Wisely campaign has been done within silos (individual management systems that do not operate with any other system). For example, the Imaging Wisely recommendations were developed within radiology. When it comes to medical imaging tests, it is time for physicians who order the tests to join together with radiologists and other physicians who perform imaging studies to form a consensus guided by patients' values about the pressing need to perform imaging tests more wisely," Dr Smith-Bindman and Dr Bindman write.

The authors and editorialists have disclosed no relevant financial relationships.

JAMA Intern Med. Published online December 28, 2015. Letter extract, Editorial extract

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