DALLAS – On average, 22% of the CTs and MRIs ordered by emergency physicians are "medically unnecessary," based on responses by 435 emergency physicians participating in a national survey.
"The overwhelming majority of physicians in our sample recognized the issue of overimaging in the ED, and it’s not just something they felt was going on among others in their group. It’s something they personally acknowledged participating in," Dr. Hemal K. Kanzaria said at the annual meeting of the Society for Academic Emergency Medicine.
Dr. Hemal K. Kanzaria
The two most common reasons for ordering "medically unnecessary" advanced diagnostic imaging studies were fear of missing a diagnosis despite low pretest probability, cited by 69% of respondents, and fear of litigation, cited by 64%, noted Dr. Kanzaria, a Robert Woods Johnson Foundation Clinical Scholar and emergency medicine fellow at the University of California, Los Angeles.
Patient and family expectations were identified as a driving force in ordering medically unnecessary imaging, 40% of respondents said. A mere 1% of respondents cited administrative pressure to increase group reimbursement as a main contributor, he added.
Advanced diagnostic imaging in EDs has increased appreciably in recent years, with little evidence of a resultant improvement in patient outcomes. The trend has drawn scrutiny from health policy experts in light of estimates that the U.S. annually spends $210 billion on unnecessary medical tests, procedures, and services. Yet there are little data on emergency physicians’ perceptions regarding overordering of CTs and MRIs, the causes, and the potential solutions.
"Basically, we need to know what physicians are thinking (about the issue), and that’s why we did this study," Dr. Kanzaria explained.
Two focus groups of multispecialty physicians and expert opinion from physicians who have researched overordering of diagnostic imaging were used to create the questions, which were then revised in response to a pilot study conducted among 16 emergency physicians.
The resulting 19-item survey took about 10 minutes to complete. The survey defined a "medically unnecessary" imaging study as "one you wouldn’t order if you had no external pressure and were only concerned about providing optimal medical care."
The nonrandom sample for the survey included 478 academic and community practice emergency physicians in 29 states; the completion rate was a whopping 91% (435 respondents). Respondents’ average age was 42 years with a mean 14 years in clinical practice; 68% were board-certified in emergency medicine. The pattern of survey responses did not differ based upon physician age, years in practice, or board certification status.
More than 85% of the emergency physicians said they believe too many diagnostic tests are ordered in their own ED. More specifically, a similarly lofty percentage believe medically unnecessary CTs and MRIs are ordered in their ED under common clinical scenarios described in the survey, such as head CTs for nontraumatic headaches and pan scans for trauma patients. Fully 97% of EPs acknowledged ordering medically unnecessary CTs and MRIs.
More than 50% of respondents identified as "extremely or very helpful" proposed solutions to "medically unnecessary" advanced imaging in the ED.
Topping the options was tort reform, which 79% of emergency physicians thought would make a major difference. However, Dr. Kanzaria called malpractice reform necessary but not sufficient to change practice. "Recent studies on tort reform efforts have not actually shown subsequent significant effects on cost reduction or a change in test-ordering behavior."
A more promising option may be shared decision making with patients regarding diagnostic testing for low-probability outcomes, he said. "The literature on shared decision making is still in its infancy, but what’s out there [indicates this option] is really promising as an avenue to improve communication and potentially to reduce overuse. So, I think we should consider ways to incorporate shared decision making into emergency care," Dr. Kanzaria said.
Another popular suggestion was to provide feedback to emergency physicians regarding their own test ordering behavior compared to that of their peers, something Dr. Kanzaria called "incredibly simple to do."
Education aimed at steering patients, families, and referring physicians away from the prevailing "no miss" attitude in favor of greater understanding of the probabilistic limits of diagnostic testing was also widely endorsed by the survey respondents.
Dr. Kanzaria’s research is funded by the Robert Wood Johnson Foundation Clinical Scholars Program. He reported having no financial conflicts.