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CT, MRI Use in Emergency Departments Soaring
A study on the increased use of imaging in the emergency department raises questions about how to best provide quality, cost-effective care to patients, and at least one expert sees implications for comparative-effectiveness research and value-based insurance design (VBID).
The use of CT and MRI scans for injury-related ED visits in the United States tripled between 1998 to 2007, but there was no commensurate increase in the prevalence of the diagnosis of certain life-threatening, trauma-related conditions. The research, which used data from the National Hospital Ambulatory Medical Care Survey, appeared in the October 6 issue of JAMA.
The widespread availability of CTs and MRIs and their ability to identify significant injuries "have made these tools important in the evaluation of patients presenting to emergency departments," the authors write. Nevertheless, the increased use of these tools is associated with higher costs, greater exposure to ionizing radiation, and more time spent in the ED.
What drives this increased use? The researchers cite a variety of possible factors, including the superiority of CT scans over x-rays for diagnosing conditions such as cervical spine fractures, availability of CT scanners, and concerns about malpractice lawsuits over a missed diagnosis.
More work is needed to understand these factors: "The role of evidence-adoption strategies such as computerized decision support and audit and feedback in promoting adherence to decision rules for imaging needs to be further understood," the authors conclude.
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Comments are moderated. Please be patient.
cgutbezahl (10/8/2010 at 10:03 AM)
An alternative interpretation of the results is not concern that greater use hasn't improved diagnostic rates, but that increased use has not degraded the value of the test. Often when a new technology gains widespread use, the original benefits are lost as the technology is spread to a less well defined patient population. In this case, wider use was associated with a slightly improved yield rate. Another interesting finding is that comparing this data with reports that claim that the cost of defensive medicine is low. There could be many reasons for the discrepancy but most significantly is that the data showing increased usage in EDs is objective claims based, while the report that claims that defensive medicine costs are low relies on subjective interpretation rather than quantifiable data.
Donald (10/8/2010 at 9:57 AM)
Most doctors I know would say an acceptable "miss rate" is 0%. So when is a miss acceptable? When it isn't you being missed. That's the problem with evidenced-based research - it sounds good, but oddly enough, those who advocate for it are also more likely to believe health care is a right - that's some pretty strong cognitive dissonance. Just can't have it both ways. If health care is a right, then no room exists for a miss rate.