Imaging studies take four of the five slots in a newly unveiled list of unnecessary tests and procedures commonly performed in the emergency department, with CT scans in low-risk trauma cases earning particular censure.
But it’s how the emergency medicine list’s creators developed it that may prove most valuable in future efforts to reduce unnecessary tests throughout medicine.
Several specialty societies have developed Top-5 lists of avoidable tests or procedures to comply with the American Board of Internal Medicine’s Choosing Wisely campaign. The lists are "a new idea to engage clinicians in resource stewardship and to address rising health care costs," said Dr. Jeremiah D. Schuur of the department of emergency medicine, Brigham and Women’s Hospital, Boston, and his associates (JAMA Intern. Med. 2014 [doi:10.1001/jamainternmed/2013.12688]).
Dr. Jeremiah D. Schuur
To create the emergency medicine list, Dr. Jeremiah D. Schuur and his associates took the traditional Choosing Wisely approach, then added a consensus-based twist.
They convened a technical expert panel that included the chiefs of the two academic hospital emergency departments (EDs) and four community hospital EDs in their health care system, which covers more than 320,000 ED visits annually in eastern Massachusetts. The panel also included an emergency physician with expertise in affordability, another with expertise in diagnostic imaging, and a third with expertise in hospital admissions and transfers, as well as a chief resident in emergency medicine.
The panel devised a preliminary list of 64 "low-value clinical decisions that were under the control of emergency clinicians and were thought to have a potential for cost savings."
Then came the twist: A total of 283 frontline emergency clinicians from the health system’s six emergency departments then were invited to complete a Web-based survey tool measuring their opinions of the potential benefit or harm to patients if clinicians discontinued the top 17 potentially avoidable items on the list.
The panel reviewed results from the 174 clinicians who completed the survey, and it then distilled them into a list of the Top-5 unnecessary tests and procedures:
• Do not order CT of the cervical spine for trauma patients who do not meet the National Emergency X-ray Utilization Study (NEXUS) low-risk criteria or the Canadian C-Spine Rule.
• Do not order CT to diagnose pulmonary embolism without first risk stratifying for pulmonary embolism (pretest probability and D-dimer tests if low probability).
• Do not order MRI of the lumbar spine for patients with low-back pain without high-risk features.
• Do not order CT of the head for patients with mild traumatic head injury who do not meet New Orleans Criteria or Canadian CT Head Rule.
• Do not order coagulation studies for patients without hemorrhage or suspected coagulopathy (for example, with anticoagulation therapy or clinical coagulopathy).
Every item on this list "received similar ratings by different groups of ED clinicians, including physicians and midlevel practitioners, clinicians in academic and community-hospital EDs, and practitioners with experience ranging from less than 3 years to more than 10 years," the authors explained. That suggests that emergency health care clinicians in other locations, as well as members of other specialty societies, also can achieve such consensus, Dr. Schuur and his associates noted.
Emergency medicine "is under immense pressure" to improve the value of services, they added.
"Some emergency physicians may be hesitant to embrace stewardship efforts, such as Choosing Wisely, for fear of losing autonomy and the medicolegal risk," the investigators noted. "However, if emergency physicians, who best understand the clinical evidence and unique needs of our patients, do not define measures of overuse for our specialty, others will."